Advancing Social Prescribing with Implementation Science

Laura Gottlieb; Erika K. Cottrell; Brian Park; Khaya D. Clark; Rachel Gold; Caroline Fichtenberg

doi:10.3122/jabfm.2018.03.170249

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Table 1.

Examples of Promising Social Prescribing Implementation Research

	Program Description	Research Opportunity	Findings	Next Steps
Screening Tools Research	The Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences (PRAPARE) is a national effort to help community health centers (CHCs) and other providers collect data needed to better understand and act on patients' social determinants of health. The PRAPARE assessment tool consists of a set of national core measures as well as a set of optional measures for community priorities. It was informed by research, the experience of existing social risk assessments, and stakeholder engagement. PRAPARE electronic health record templates have been developed in 4 EHR systems, including eClinicalWorks, Epic, GE Centricity, and NextGen.	As the pilot site for the Epic version of the PRAPARE tools, the OCHIN research team collaborated with the Kaiser Permanente NW Center for Health Research to leverage this innovative screening pilot in order to examine how to best use electronic health records (EHRs) to support point-of-care applications for social determinants of health (SDH) information. With support from the National Institutes of Diabetes and Digestive and Kidney Diseases, the research team engaged CHC stakeholders to refine the PRAPARE social needs assessment and develop a suite of EHR-based tools for collecting and presenting SDH information and facilitating referrals to community-resources to address identified needs.²⁷ The resulting tools were made available to 440 CHCs in 18 states who use the centrally hosted OCHIN Epic EHR. The team conducted qualitative interviews and site visits in 3 pilot clinics to understand barriers and facilitators to the uptake and use of the tools.	Pilot clinics screened over 1000 patients during the 2-y study period. As expected, most patients had at least one identified need. Per the recommendation of our pilot clinics, the team added a question to the screening tool asking whether the patient would like help with any of the identified needs, and if so, what kind of help they would like (eg, follow-up call from a community health worker or written information on community resources). This helped clinics prioritize patients needing follow-up. Clinics identified the need for standardized ways to code SDH data in the EHR and additional tools (eg, tablets) that would enable patients to answer the questions themselves. Another challenge was accessing up-to-date information on community resources where providers could refer patients with identified needs.	OCHIN and Kaiser Permanente NW Center for Health Research are collaborating on a 5-y National Institutes of Diabetes and Digestive and Kidney Diseases -funded research project to test a set of implementation strategies for helping CHCs routinely identify and take action on the SDH-related needs of patients with/at risk for Diabetes mellitus. The researchers will conduct a pragmatic, stepped-wedge, cluster-randomized trial in 30 CHCs to evaluate the impact of a set of scalable implementation strategies (the “SDH Action Plan”) known to support clinical practice changes on CHCs' adoption of SDH data collection and action.
Workforce Research	University of Pennsylvania researchers developed an inpatient community health worker (CHW) program called Individualized Management for Patient-Centered Targets Transitions.	Having defined an evidence-based CHW intervention in an inpatient hospital setting, researchers applied Goldstein's framework²⁸ for adapting evidence-based interventions in order to adjust the CHW intervention for implementation with a new population: outpatients with multiple chronic conditions. The goal was to retain the CHW intervention's core components of effectiveness and allow for efficiencies of scale. The team conducted in-person qualitative interviews and applied findings in a design-mapping process to refine the intervention protocol.	Revisions were made to the intervention's core components to address the main differences that arose between the original intervention and the needs of patients with chronic diseases in the new setting. These included changes based on outpatients' interests in focusing on one goal at a time, requests for chronic disease management support in addition to social supports, and outpatients' requests for more longitudinal supports.²⁹	As a result of the implementation research undertaken to adapt the intervention to a new setting, the research team was able to launch both single- and multi-center randomized controlled trials (RCTs) to test the effectiveness of the new intervention.^30,31 Combined, these studies led to the creation of the Penn Center for CHWs. The center is supported by Penn Medicine's operational dollars and now delivers the CHW intervention to more than 2000 patients annually.³²
Payment Model Research	In 2012, Hennepin Health, a county-based safety-net accountable care organization in Minneapolis, launched as a partnership between a level I trauma center, a federally-qualified health center, a county health department, and a nonprofit health maintenance organization serving the county's Medicaid beneficiaries.³³ A financial risk-sharing agreement across all 4 organizations has enabled activities that support social prescribing in Hennepin Health, including medical and social data sharing in the EHR, referrals to social services, and deployment of CHWs.	The capitated and financial risk-sharing payment model has enabled social prescribing services (eg, referrals to county social services and community support groups) and expanded the workforce focused on social prescribing (eg, care coordinators, CHWs and housing and social service navigators). Cost savings at the end of each year are reinvested into the program, focusing on workforce-focused interventions. Hennepin Health examined the impact of the program and these interventions on over 9000 adults enrolled from 2012 to 2014.³³	Analyses show that over 300 enrollees have been housed in 3 y,³⁴ and participants have experienced fewer Emergency Department (ED) visits, improved quality of chronic disease care, and an 87% satisfaction rating with health care services.³² The qualitative analyses document improved patient perceived quality of life, with enrollees highlighting improved social service support and care coordination among key contributors.³⁵	Research is ongoing to track triple aim outcomes and qualitative data to better understand valued components of the program and lessons for replication.

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Appendix.

Examples of Social and Economic Risk Screening Tools

Social and Economic Risk Screening Tool	Recommended Social and Behavioral Domains and Measures for Electronic Health Records⁹	PRAPARE: Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences¹³	Accountable Health Communities Screening Tool¹⁴
Total number of questions	24	21	10
Domain
Residential address	•	•
Race/ethnicity	•	•
Alcohol Use	•
Tobacco use and exposure	•
Depression	•
Education	•	•
Financial resource strain, sverall	•
Household income		•
Household size		•
Housing		•	•
Food		•	•
Clothing		•
Utilities (phone, gas, electric)		•	•
Medicine/health care		•
Child care		•
Transportation		•	•
Neighborhood safety		•^*
Interpersonal violence/safety	•	•^*	•
Physical activity	•
Social connections/isolation	•	•
Stress	•	•
Migrant/seasonal farmworker		•
Veteran status		•
Primary language		•
Incarceration history		•^*
Refugee status		•^*
Insurance status		•