Junto Views From the Summit: Part 1
On June 14th, Junto held its 2018 Summer Summit at Cornell Tech’s newly opened campus on Roosevelt Island. Summits are invite-only events that bring together over 50 senior executives, representing nearly 40 organizations, for a day of knowledge sharing, networking, and collaborative project development. Our Summits reflect our view that many of the problems faced in the healthcare industry today will only be solved by breaking down organizational silos and working with complementary partners.
At each Summit, we ask community members who are doing innovative work within their organizations to share their expertise, with the goal of inspiring, teaching, and cross-collaborating with others in our community. Our speakers share their insights and “how-to” stories; these discussions have proven helpful to industry veterans as well as recent entrants.
To help diffuse the best ideas from our community, we have launched a new series, “Junto Views from the Summit” which will run over the next few weeks. Throughout the series, we will highlight important concepts & actionable tips for you to use in your own organization.
Our first four articles will be detailing the presentations given by Dr. Dodi Meyer, Isaac Kastenbaum, Dr. Mike Swiernik, David Haddad, Ryan Billings, Jonas Thingaard, Lawrence Monoson, Dr. Amir Reuveny, Dr. Niamh O’Hara, and Dr. Neel Madhukar during the 2018 Summer Summit.
How We Did It: Screening for Social Determinants in a Healthcare Setting
Our first speakers at this year’s Summer Summit were Dr. Dodi Meyer and Isaac Kastenbaum from New York-Presbyterian, who shared their experience designing, co-developing, and implementing a comprehensive screening system for social determinants of health (SDOH). They identified 4 key takeaways of their new screening initiative, based on the challenges they faced along the way, which are detailed below.
Dr. Meyer is currently an associate professor of pediatrics at Columbia Medical Center as well as an attending physician at New York-Presbyterian Hospital. Dr. Meyer has received national funding and recognition for her holistic approach in her practice which includes understanding each patient’s biology, family, and community to provide context for treatment.
She has recently partnered with Isaac Kastenbaum, the Director of Population Health at New York-Presbyterian, who oversees new delivery systems in to the hospital as well as community initiatives for the 90,000 Medicaid patients the hospital treats every year. Both Dr. Meyer and Kastenbaum have dedicated large parts of their careers to providing quality healthcare to New York-Presbyterian’s patient community.
During their presentation, Dr. Meyer and Kastenbaum discussed the importance of screening patients for social determinants of health (SDOH) within the hospital setting. Identifying social determinants is a crucial element of any treatment plan because, as Dr. Meyer stated, “healthcare isn’t only about treating people who are sick, but also keeping healthy people healthy.” Monitoring SDOH helps clinicians spot potential health risks before they become acute.
Under Dr. Meyer and Kastenbaum, New York-Presbyterian has undertaken a large public health initiative to screen for SDOH in their hospital. In the current pilot program, funded by the Accountable Health Communities Grant, each patient is handed an iPad upon check-in. A tablet-based software program then guides the patient through a SDOH questionnaire.
These questions are designed to specifically address key risk drivers of SDOH including housing instability, domestic violence, lack of transportation, and food insecurity. The patient’s survey responses are saved in his or her medical record in real time, allowing clinicians to address SDOH during their appointment, rather than waiting for the problem to manifest itself later.
A wide range of detailed information is necessary to see each patient within the context of their family. While it may seem intensive, Dr. Meyer said, these determinants can have a significant impact on a child’s overall health and should be incorporated into any care plan.
Before the current implementation, this screening program went through many iterations, as the team experimented with the tool’s UI/UX. Dr. Meyer and Kastenbaum highlighted the 2 things to continuously check-up on, named “to-dos,” when rolling out a program and 2 "must-haves" that are necessary for running a successful program.
To-Do 1: Tough Tradeoffs When Designing the Tool
The biggest question raised in the early phase: what social determinants should we screen for?
Online questionnaires that ask about sensitive social determinants are more effective than in-person interviews, so the team was tempted to ask as many questions as possible. However, they had to balance this temptation with real-world consequences of asking sensitive questions.
For certain sensitive information, such as domestic violence, Kastenbaum detailed how a different workflow was necessary for the safety and privacy of the patient. Unlike other determinants such as food insecurity or housing, domestic violence disclosures are incredibly sensitive and it can be difficult to ask about someone’s present situation in a safe manner. For instance, if the perpetrator of the violence is present during the screening, asking certain triggering questions could put patients at greater risk of harm.
This is just one of the examples of inherent tension between gathering all information possible during these screenings and protecting the individual being screened from unnecessary exposure. While there is no one right way to pick questions to include and not include into the screening tool, both Dr. Meyer and Kastenbaum claimed that by the end of the trial period they had found, what they believe to be, the right balance for what the program needs now.
Must Have 1: Funding and Support From a Large Institution
Like any new initiative within a 250-year-old institution, the SDOH screening rollout relied on the buy-in from colleagues across New York-Presbyterian.
To generate this buy-in, Dr. Meyer and her team invested significant time & energy speaking with internal stakeholders about the importance of SDOH screening and how it connects to New York-Presbyterian’s core clinical mission. According to Dr. Meyer and Kastenbaum, this process simply cannot be rushed.
Another challenge of an organization as large as New York-Presbyterian—with 900 clinicians and 2,478 beds—was securing the funding to design and implement a new initiative. Thankfully, New York Presbyterian understood the importance of SDOH in their care delivery, and largely supported Dr. Meyer and Kastenbaum as they developed & launched the program.
Must Have 2: Recruiting Necessary Third Party Pieces
Dr. Meyer stressed that regardless of the efficacy of the screening tool, simply asking about SDOH is not sufficient to remedy the problems that individuals are facing.
The key component necessary for change is actually connecting patients with community resources that can provide assistance in addressing these social determinants directly. Without the community resources, the screening tool would not be effective.
This means that it is the hospital’s job to know the community surrounding it. As Dr. Meyer outlined, the next step for the hospital is to “co-manage and make referrals downstream” rather than attempt to become the providers of these resources themselves.
To-Do 2: Distributing Resources Across the Care Continuum
While one may think Dr. Meyer would be in full support of money being given to hospital systems due to her position and current funding, it was the opposite. She believes, “the government should be giving less money to healthcare companies and more money to the social services agencies and community organizations” because too many community resources are underfunded and overwhelmed with their current workload.
Community resources are a crucial aspect of care as they can provide the more specified attention to each patient that large hospitals are not equipped to give.
Previous studies have shown an increase of referrals to community resources by larger healthcare institutions leads to an increase of patients at those third-party resources. Based on the nature of the new system, these community resources will only be under more financial strained as a result of New York-Presbyterian’s current pilot program. Therefore, increased funding for these organizations is more important than ever.
Dr. Meyer and Kastenbaum were enthusiastic about the pilot program, despite needing more time to collect data on the effectiveness of their tool. Still, their preliminary takeaways were acute:
· Tough tradeoffs are necessary to create a tool that is simple yet effective
· Gaining funding from a large institution takes time, patience, and determination.
· Lining up third-party partners are necessary to see the success of a program
· Financial support must be distributed equitably as to not over-burden any one aspect of the program
Dr. Meyer and Kastenbaum’s presentation kicked off an inspired discussion at the summit. Despite many audience members not working in a hospital setting, the points that were made about the importance of social determinants of health, the challenges faced during implementation, and the exciting consequences this initiative could have in improving healthcare delivery resonated with many.