THE 2023 INNOVATOR AWARDS PROGRAM


of Health (SDOH) Institute and vice presi- dent of community relations and social investment, says ProMedica has been thinking holistically about health for more than 10 years. “Through our journey, we really understood two things: One is that things like housing, food access, and transportation really do impact what hap- pens at the individual health level, so that has to be part of your care delivery model.” The second realization, she says,


involves how ProMedica facilities serve as anchor institutions in the communities they serve. “Hospitals are often the largest employer in a community, and the assets and the resources that we have directly impact the broader health of our com- munity in a macro sense,” she explains. “We work at the individual patient level but also in terms of how we show up in a broader sense across communities and neighborhoods to drive health at more of the population health level.” Brian Miller, M.D., ProMedica’s chief


medical information officer and vice presi- dent for telehealth and value-based and primary care, says that when they began building an SDOH screening tool, there weren’t many examples to work from. “Our very first domain was around


food because we know food is medi- cine,” he says. “We built a screen that was integrated into our workflows, and then connected to orders for some of our food interventions that our teams could talk about. We built that from scratch in Epic. I sat in the room when our CEO at the time talked about our work and pitched the product to Judy Faulkner, who leads the Epic organization, and got her involved. In less than a year, our build was embed- ded into Epic’s foundational platform, and available to every customer they have from that point forward.”


Matching screening to clinical workflow Indeed, ProMedica even has an employee, Cheryl Crowder, whose title is director of SDOH clinical applications. She says it is often difficult for clinical and techni- cal people to work together to translate information about something like SDOH screening needs into the EHR. “Where we shine is putting the right people in the right place to get what we need.” To identify the non-clinical factors affecting health, she adds, ProMedica leaders have developed a series of validated questions that precisely pinpoint the issues with which people struggle. The tool is now


“Our goal was to bring in programming and organizations and wrap- around services to break down that traditional single-issue boundary within organizations. We’re connecting with other organizations in the area in this neighborhood-based approach. We’re building trust within the community, because we know that a lot of folks don’t trust healthcare systems particularly. Being able to meet with them about something that’s not a bill that they need to pay or service that they need to have has helped.” — Adrienne Bradley


part of all standard intake procedures at ProMedica, and all patients are screened across 10 core SDOH domains—housing insecurity, child care, transportation, education,


intimate partner violence,


purpose, employment, social isolation, financial strain and food insecurity. One challenge was finding the right spot


in the clinician workflow for the screening. “Part of our work was to get this screen-


ing done upfront so that we could either do it on an iPad in the waiting room or in our portal, so that most of our patients answer these questions a day or two ahead of their visit,” explains Miller. “It is fresh data at the point of the visit, and not complicating that workflow.” He adds that they automated as many


of the steps as possible, so that “we have the ability to just connect you downstream and not necessarily require any additional work from our clinicians.” ProMedica officials explain that screening responses trigger practice advisories, allowing physi- cians to integrate non-clinical needs such as food, housing and financial strain into plan-of-care discussions, adding identified issues to their diagnosis and activating referrals to which clinical integration team partners can respond. ProMedica has a Community Care


Hub, whose care navigation team mem- bers include social workers and commu- nity health workers. They provide the


intersection between clinical support and community connections. When regulations change about qualification requirements for a program, they’re up to speed on it right away. The response from community members has been “overwhelmingly positive for those clients who are served,” says Mary Peavy, lead community health worker. “They like that somebody is identifying that these other issues are hindering them from getting the care they need to receive. I can say that we definitely are making strides in helping clients meet their goals for housing, food, employment, and education. I am meeting with those clients monthly while they’re trying to attain those goals.”


Demonstrating health outcome improvements Working with a Washington, D.C.-based company called Socially Determined, ProMedica has developed analytics to show that proactive interventions can become a model for decreasing health- care costs and utilization while increasing healthier outcomes. The organization’s internal research found that individuals who used ProMedica’s food clinics, for example, saw an 18 percent reduction in ED usage, 5 percent lower readmission rates and a 6 percent decrease in per- member-per-year medical costs. Patients who benefited from financial coaching services experienced a 33 percent reduc- tion in ED visits, a 14 percent reduction in inpatient visits and a 6 percent increase in primary care physician visits. Healthcare cost savings per member range from $6,500 to $17,000. A post-assessment of 2,500 individuals who identified as hav- ing some type of risk in 2020 showed that more than half of them—around 56 percent—did not identify as having the same type of risk in 2021, ProMedica says. Adrienne Bradley, ProMedica’s direc-


tor of community impact, oversees these community- based interventions. “We have a financial wellness network, where we do free one-on-one financial coach- ing, and work with individuals to reduce their debt, increase their savings, and get better credit scores,” she explains. “We also do free tax preparation for anyone who makes $60,000 or less. Now we are consulting with another health system on helping them stand up their own financial wellness network.” Bradley says ProMedica has taken a


place-based approach to its community work. For instance, it has focused on the


MARCH/APRIL 2023 | hcinnovationgroup.com 5


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36