teaching social determinants of
TRANSCRIPT
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Teaching
in Family Medicine Residency
SocialDeterminants
of
Paul Ravenna, MDKatherine Wright, MPH, PhDElizabeth R. Ryan, EdDDeborah S. Clements, MD, FAAFP
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This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UH1HP29963, Academic Units for Primary Care Training and Enhancement, $3,691,515 total award amount.
This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.
Financial DisclosuresNational Collaborative for Education to Address the Social Determinants of Health
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Agenda• Overview of curriculum resources to teach SDOH
• Community Health Resource Navigator (CHRN) demonstration
• Northwestern Lake Forest Family Medicine Residency pilot curriculum development and evaluation
• Next steps for the National Collaborative for Education to Address the Social Determinants of Health
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Social Determinants of HealthHealthyPeople 2020
“…defined as conditions in the social, physical, and economic environment in which people are born, live, work, and age. They consist of policies, programs, and institutions and other aspects of the social structure, including the government and private sectors, as well as community factors.”
HealthyPeople 2020; retrieved from: https://www.healthypeople.gov/2010/hp2020/advisory/SocietalDeterminantsHealth.htm
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Social Determinants of HealthRoadmap
Family medicine physicians are uniquely positioned to address SDOH given their longitudinal relationships with patients that facilitate discussion around modifiable contributors to health
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Social Determinants of HealthSurvey Results; n=132 Family Medicine & Internal Medicine Residents
84% of residents stated they received previous training on SDOH in medical school
identifying SDH in their practice: 28%discussing those challenges with patients: 14%
However, the following proportion of residents rated themselves as highly experienced or expert at the following skill-based competencies:
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Social Determinants of HealthFamily Medicine Milestones
ACGME Family Medicine Milestonesretrieved from: https://www.acgme.org/Portals/0/PDFs/Milestones/FamilyMedicineMilestones.pdf
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Social Determinants of HealthFamily Medicine Milestones
ACGME Family Medicine Milestonesretrieved from: https://www.acgme.org/Portals/0/PDFs/Milestones/FamilyMedicineMilestones.pdf
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Social Determinants of HealthACGME common requirements
VI.A.1.b) Quality Improvement
Residents must receive training and experience inquality improvement processes, including anunderstanding of health care disparities.
IV.A.5.f) Systems-based Practice:
Residents must demonstrate an awareness of andresponsiveness to the larger context and system of health care, aswell as the ability to call effectively on other resources in thesystem to provide optimal health care.
ACGME Common Program Requirementsretrieved from: http://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRs_2017-07-01.pdf
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Curriculum Resourcesto teach social determinants of health
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Social Determinants of Health
• Many undergraduate medical schools have incorporated this topic into training, but often focus on change in attitudes and knowledge, and not skill development.
• SDH training in residency is sparse and highly variable in content, delivery and evaluation
• As a consequence, physician residents enter the workforce without being equipped with the skills necessary to address SDH
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Curriculum Landscape
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National Collaborative for Education to Address Social Determinants of Health
Review our collection or submit your own to contribute to our community of work.
12http://www.feinberg.northwestern.edu/sites/cpci/hrsa-grant/educational-resources/community-of-educators.html
Collection of Curriculum Resources
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Database of Curriculum Resourceshttp://www.feinberg.northwestern.edu/sites/cpci/hrsa-grant/educational-resources/community-of-educators.html
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Database of Curriculum Resourceshttp://www.feinberg.northwestern.edu/sites/cpci/hrsa-grant/educational-resources/community-of-educators.html
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GIS Resourcesto teach social determinants of health
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Community Health Resource Navigatorhttps://www.aafp.org/patient-care/social-determinants-of-health/chrn.html
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Aunt Berthawww.auntbertha.com
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UDS Mapperhttps://www.udsmapper.org/
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Community Health Resource Navigator (CHRN)Demonstration
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Community Health Resource Navigatorhttps://www.aafp.org/patient-care/social-determinants-of-health/chrn.html
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Community Health Resource Navigatorhttps://www.aafp.org/patient-care/social-determinants-of-health/chrn.html
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Community Health Resource Navigatorhttps://www.aafp.org/patient-care/social-determinants-of-health/chrn.html
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Community Health Resource Navigatorhttps://www.aafp.org/patient-care/social-determinants-of-health/chrn.html
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Community Health Resource Navigatorhttps://www.aafp.org/patient-care/social-determinants-of-health/chrn.html
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Community Health Resource Navigator
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Community Health Resource Navigator
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Community Health Resource Navigator
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Community Health Resource Navigator
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Community Health Resource Navigator
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Community Health Resource Navigator
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Community Health Resource Navigator
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Community Health Resource NavigatorReport Example
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NM Family Medicine ResidencyPilot Curriculum Development & Evaluation
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Our Residency Communities
We serve 3 Chicagoland communities close in proximity, but very different in terms of resources and health status
Northwestern McGaw Family Medicine Residency at Lake Forest
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Our Residency CommunityNorthwestern McGaw Family Medicine Residency at Lake Forest
Median Income
$87,967Grayslake, IL
$152,658Lake Forest, IL
$45,983Waukegan, IL
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Motivating Principles
Geography matters.
Zip code can be more predictive of health status than genetic code in some contexts
Pilot SDoH Curriculum Development
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NU Fam Med residency sites
Social & Economic Opportunity Index
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NU Fam Med residency sites
Educational Opportunity Index
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NU Fam Med residency sites
Overall Child Opportunity Index
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There are lots of moving parts.
As multiple systems operate simultaneously, we see complex interactions between social and contextual factors
Motivating PrinciplesPilot SDoH Curriculum Development
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Complex Interactions between IndicatorsH
ousi
ng
Men
tal
Hea
lth
Edu
cati
on
Publ
ic B
enef
its
Dom
esti
c V
iole
nce
Food
Se
curi
ty
$
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One size doesn’t fit all.
The interaction between individual genes and environment is unique
Motivating PrinciplesPilot SDoH Curriculum Development
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Personalized Medicine
No blueprint for each person’s unique disease susceptibility
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Personalized Medicine
No blueprint for each person’s unique disease susceptibility
Highlights the need for individualized health promotion efforts
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How can we enable students and residents to personalize care?
Geospatial analysis provides powerful information at the point of care
Motivating PrinciplesPilot SDoH Curriculum Development
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Erie HealthReach Waukegan
Poverty Index
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NM Grayslake Outpatient Center
Poverty Index
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Lake Forest Hospital
Poverty Index
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Curriculum Topic Areas
Housing Maternal Depression Education
Food Insecurity Domestic Violence Public Benefits
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Pilot SDoH Curriculum Development
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SDoH Skills GapPre-Curriculum Survey Results, n=21 Family Medicine Residents
1
2
3
4
5
Engaging Conversation Providing Resources
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(1=Novice to 5=Expert)
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Resident Mapping Exercise
Use the CHRN tool to identify resources for patient panels at both clinics
• Inclusion criteria:− Hypertension diagnosis− Adult patients
• 195 patient addresses mapped
• Completed an evaluation survey at the end of the session
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Pilot SDoH Curriculum Development
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Resident Mapping Exercise
Residents completed a brief evaluation indicating the utility of the CHRN tool for each patient
• Yes, the tool is useful at point of care: 113/195 patients total= 57.9%
• Broken down further:− Erie (FQHC): 60.8%− Grayslake Outpatient Center: 54.8%
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Pilot SDoH Curriculum Development
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Evaluation SurveyExample Items
• Which of the following, if any, do you wish you could write a prescription for? (check all that apply)
• Which of the following, if any, do you wish could be paid for through the health care system? (check all that apply)
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Social Determinants of HealthSurvey Results: Mental Health Assistance
WOULD WRITE A Rx FOR MENTAL HEALTH ASSISTANCE
WISH MENTAL HEALTH ASSISTANCE WAS PAID FOR BY THE HEALTHCARE SYSTEM
69%
62%
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Social Determinants of HealthSurvey Results: Housing Assistance
WANT TO WRITE A PRESCRIPTION FOR HOUSING
WISH HOUSING WAS PAID FOR BY THE HEALTHCARE SYSTEM
46%
23%
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Social Determinants of HealthSurvey Results: Adult Education
WOULD WRITE A Rx FOR ADULT EDUCATION ASSISTANCE
WISH ADULT EDUCATION WAS PAID FOR BY THE HEALTHCARE SYSTEM
23%
8%
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Social Determinants of HealthSurvey Results: Nutritional Food
WOULD WRITE A Rx FOR NUTRITIONAL FOOD
WISH NUTRITIONAL FOOD WAS PAID FOR BY THE SYSTEM
85%
85%
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Social Determinants of Health
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Survey Results, n=13 Family Medicine Residents
Food security is a social problem
Actual food insecurity is rare
I am worried that asking about food security will feel awkward
I am worried about what I can actually do to help patients
Food security is a medical issue
Food security is important enough that it's worth taking the time to screen
I am comfortable having a food security conversation with patients
I am confident I have the knowledge and tools to help patients with food security
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How does mapping patient addresses change your understanding of each patient's community?Survey Results, n=13 Family Medicine Residents
Helps me see feasibility in my plan for their healthcare
It gives me better insight into why some of their screening measures are out of control
Being able to see what resources are available can help to adjust what suggestions to give patients
Even when the map identifies resources, it doesn't help with all the stuff people actually need in order to use those resources
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Describe one limitation of mapping clinical dataSurvey Results, n=13 Family Medicine Residents
Making sure that the maps are frequently updated with correct information
Currently the only option is to locate resources that are around, would be nice to assess if pt's can actually access them based on certain parameters or offered services
Limited information about listed resources
Many pts without transportation--what resources are on bus-lines?
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Describe one benefit of mapping clinical dataSurvey Results, n=13 Family Medicine Residents
Would be useful for community planning. In theory I would be able to identify resources my patients don't already know about and could use.
Having point of care information to hand to patients regarding health and nutrition available to them
Easily available resources for patients; recognizing resource poor areas
Informing patients of nearby places to be active/get fresh produce
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Next Steps:• Next iteration of curriculum development
• Implementation at the point of care
• National Collaborative for Education to Address Social Determinants of Health
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Questions?
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Thank You@NUFSMFamMed
@NU_NCEAS