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Driving Forces for Change: Cost and Quality Concerns

When a referral is made from these lists, the resource contact information and instructions are added to the after-visit summary. Preliminary data show variation in screening adoption and workflows.

Motivated by convenience, efficiency and cost, patients are attracted to ambulatory care

The SDH preference lists are now being pilot-tested; next steps are to assess uptake of the tools and identify barriers to their use, needed adaptations, and how to optimally integrate SDH information into patient care. When development processes occurred after the IOM report became available, many of its recommended domains were included. However, customization was the norm.

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Most interviewees wanted SDH tools that fit into existing workflows and avoided redundant data collection , so they usually excluded IOM-recommended domains on alcohol use, stress, depression, and physical activity which are often already captured from the screening tools.

Another common concern was how to administer SDH screening in ambulatory primary care workflows. As shown in Table 2 , the organizations we interviewed produced tools utilizing differing degrees of technology: all were accessible via paper, most in an EHR, and half in patient-facing portals.

This demonstrates the variability of primary health care settings' approaches to integrating SDH data tools into their health information technology structures. Various approaches have different pros and cons; developing and updating EHR-based tools require resources and infrastructure support, but SDH data collected on paper must be manually entered into the EHR, consuming staff time. Most interviewees used the combination of modalities that worked best for their setting.

This need for flexibility was universal. Although concerns were common, interviewees encountered little patient discomfort with SDH screening. KP was concerned about the impact of collecting potentially sensitive data via phone.

A New Approach to Ambulatory Services

Mosaic was concerned about the sensitivity of intimate partner violence and substance use items and omitted these. OCHIN debated which intimate partner violence item to include and finally chose a more general item, rather than the IOM-recommended 4-item measure.


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All interviewees were concerned about care teams being unable to address positive SDH screenings because of limited staff time, lack of local resources, etc. Although the WellRx team had concerns that SDH screening would be burdensome, its physicians reported that patients received more holistic care, lessening workloads, and improving care quality. Another concern was how best to communicate with local agencies, track outcomes of past referrals, and—if resource lists were created—how to keep them updated.

The processes used by these interviewees to develop SDH tools varied depending on organizational perspectives, needs, and goals. Their efforts highlight considerations that may help other organizations develop their own SDH screening plans. Thus, development of SDH tools must consider how data might be comparable across populations, yet customized to local needs. Local resource availability should also be considered.

Clinics hoping to refer patients to community resources to address SDH needs will require accurate lists of available resources, and maintenance of these lists likely requires designated staff time and standardized processes for integrating community resource information. Despite concerns about patient willingness to share SDH information, our interviewees' actual experience aligns with prior research showing low refusal rates Giuse et al.

As SDH screening becomes more widespread, it will be important to maintain awareness of how different patient populations respond. Diverse methods were used to integrate SDH screening into clinic workflows while minimizing burden to care teams. There is a need to collect SDH data expeditiously, without harming the patient's trust. Research is needed to determine which screening modalities best address this Garg et al.

Institutional support for integration of SDH into primary care and EHRs, in addition to recommended domains and items, could help standardize and focus SDH data collection. However, as indicated in Table 3 , IOM recommendations were followed loosely and all organizations interviewed added additional items to suit their patient populations.

This suggests an unresolved tension between tailoring and standardizing data collection in diverse settings. Our interviewees are not necessarily representative of all current SDH screening development processes. In addition, all interviewed organizations were based in the United States.


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The outlined processes are reflective of both researchers and patient populations within the United States. However, much can be learned from these organizations' pioneering efforts. We encourage others conducting similar activities to publish on their efforts. Second, we primarily interviewed individuals who developed and refined screening tools, rather than those who used the tools with one exception. We sought to provide insight into successes and barriers in tool development; tool implementation is beyond the scope of this article but deserves similar description.

Adoption of SDH data collection in primary care may be impacted by barriers similar to those that have slowed the uptake of other types of PRMs, as described earlier. This article summarizes how 6 diverse health care organizations sought to address similar challenges as they developed SDH screening tools to guide others hoping to design and implement such tools. More research is needed to assess how to implement these approaches in diverse care settings and how to use SDH data once collected.

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Your Name: optional. Your Email:. Colleague's Email:. Separate multiple e-mails with a ;. Send a copy to your email. Some error has occurred while processing your request. Please try after some time. Back to Top Article Outline. Table 1. Table 2. Table 3. Table 4. Adler N. Patients in context—EHR capture of social and behavioral determinants of health. The New England Journal of Medicine, 8 , — Berkowitz S.

Addressing basic resource needs to improve primary care quality: A community collaboration programme. Home health care software or home care software falls under the broad category of Health care Information Technology HIT.

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HIT is "the application of information processing involving both computer hardware and software that deals with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision making" [3] [4]. The state department of health issues requirement for that state. Other requirements in the U. California does not have licensure for non medical or custodial care services, and as such there are no entry requirements or minimum standards.

Full service agencies do preemployment background checks, including criminal , department of motor vehicle, and reference checks. Full service agencies also train, monitor and supervise the staff that provide care to clients in their home. There is a certification available for home care companies in California, administered by the California Association for Health Services at Home. Florida is a licensure state which requires different levels of licensing depending upon the services provided.

A New Approach to Ambulatory Services

Companion assistance is provided by a home maker companion agency whereas nursing services and assistance with ADLs can be provided by a home health agency or nurse registry. Since until , home care work was classified as a "companionship service" and exempted from federal overtime and minimum wage rules under the Fair Labor Standards Act. The Supreme Court considered arguments on the companionship exemption in a case brought by a home care worker represented by counsel provided by Service Employees International Union.

This case, Evelyn Coke v. Long Island Care at Home, Ltd. Evelyn Coke, a home care worker employed by a home care agency that was not paying her overtime, sued the agency in , alleging that the regulation construing the "companionship services" exemption to apply to agency employees and exempt them from the federal minimum wage and overtime law is inconsistent with the law.

In the court decision, the court stated the Fair Labor Standards Amendments of exempted from the minimum wage and maximum hours rules of the FSLA persons "employed in domestic service employment to provide companionship services for individuals The court found that the power of the Department of Labor DOL to administer a congressionally created program necessarily requires the making of rules to fill any 'gap' left, implicitly or explicitly, by Congress, and when that agency fills that gap reasonably, it is binding.

In this case, one of the gaps was whether to include workers paid by third parties in the exemption and the DOL had done that. Since the DOL followed public notice procedure, and since there was a gap left in the legislation, the DOLs regulation stood and home health care workers were not covered by either minimum wage or overtime pay requirements but see below. A rule issued from the DOL, entitled "Application of the Fair Labor Standards Act to Domestic Service," and meant to be effective from January 1, , was written to revise "the definition of 'companionship services' to clarify and narrow the duties that fall within the term; in addition third party employers, such as home care agencies, will not be able to claim either of the exemptions [from federal overtime or minimum wage rules.

Medicare often is the primary billing source, if this is the primary carrier between two types of insurance like between Medicare and Medicaid. Also, if a patient has Medicare and that patient has a "skilled need" requiring nursing visits, the patient's case is typically billed under Medicare. Private insurance includes VA Veterans Administration , some Railroad or Steelworkers health plans or other private insurance. The types of services available for home care have expanded throughout the history of the United States health care system do to continuous modernization of medical technology, particularly in the s.

Hospice care is a method of care that can be included in the home care realm, but is also available as in inpatient service. Hospice is a cluster of comprehensive services for the terminally ill with a medically determined life expectancy of 6 months or less. The available home care services are provided by mix of physicians, registered nurses, licensed vocational nurses, physical therapists, social workers, speech language pathologists, occupational therapists, dietitians, home care aides, homemaker and chore workers, companions and volunteers.


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