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before I get started to talk a little bit about community health needs assessments and as a guy who practiced for a long time in the community was actually drawn into a larger health system because I had that hard core group of patients who had strong social determinants and really had a hard time following the treatment plan and took a disproportionate amount of our bandwidth in the office with office phone calls utilization hospitalizations and I got to thinking wow if we don't get after this we're in a heap of trouble and you know in an outpatient setting at that time back in the 90s and early 2000s not a lot of care management social worker integrated behavioral health types of assets to throw these things so it's been an area of interest for me and certainly for health systems one of the ways that I think we can approach that is through something called the community health needs assessment so I'd like to talk a little about that today before I do that I just wanted to say how many here work actually for a large nonprofit or a nonprofit Hospital okay so a good chunk of you how many of you have ever heard the term community health needs assessment alright and how many of you have actually participated in crafting a community health needs assessment or it's implementation plan okay how many of you are in a large group that's and that's going to be going into MIPS okay and how many people are beginning a p-n we're gonna go for that model okay and then how many of you are in an ACO where you're actually in an at-risk contract where you're delivering care and I'm Chris for that that involves a care management okay so by the show of hands virtually everybody who's in this room should have some interest in that so what I'm hoping to do is I want to talk a little bit about social determinants and the importance and the impact of them and the role of place in health so we talked a lot about growing health as opposed to just treating disease I want to talk a little bit about the specifics of community health needs assessment and if you're pretty familiar with that we'll go through that quickly and then Fahmy oh I want to open up the discussion to see how we might integrate some of what's available through the community health needs assessment process the accountability for which actually lives with the hospital that has primary care physicians what's our role will may be influencing the agenda of those needs assessments to some degree on the health says on the hospital's dime if you will but through that how you might find synergies in terms of having the cheer some of the care management goals as well as some of the other efficiencies of making bigger investment social investing within your communities and strengthening that social safety net okay so we know from the County Health Rankings and other sources that social determinants and health behaviors actually drive a lot of health outcomes County Health Rankings estimates about a forty percent contribution from the social determinants and 30 percent from health behaviors like smoking drinking substance abuse and about a 10 percent contribution from the built environment you can trust that with maybe a 20% contribution of what actually healthcare does in driving health so as it turns out your zip code might be an important predictor for health outcome rather than how many medical conditions that you have and I think the other stat that really impressed me is relative to other developed nations we understand where laggards in terms of what we spend on the social services for our patients if you think of a big number of elderly one of the biggest problems facing our right now is not just the burden of the chronic illness but the social isolation because of the way the United States has evolved with a nuclear family structure and an erosion family and then social isolation isolation within communities it's a huge burden and actually when you work to fix that or help address that good things happen in terms of people's health now is family physicians you're very well aware that human needs influence health care and utilization and so it becomes sort of a it's a cycle of Maslow's hierarchy because let's face it if you don't know where your next meal is coming from you have stable housing you know you have been abused you're walking around in a heightened state of anxiety it's sucking up most of your bandwidth and so your ability you're in survival mode and your ability to really then attend your own health care needs is really dampened and imagine then that the feelings that you're experiencing then drives how you're thinking about and trying to make sense of what's happened to that gets disrupted it even happens with physicians that could have our thinking changes as we get more burned-out and so you look at the world in a completely different way and all that's bad we also know that if you have strong social determinants that obviously adds to the workload you're busy attending to survival by the same time you've got diabetes you're trying to manage as well as maybe chronic heart disease and your capacity to do this diminish there's a big mismatch in victor Montour described this a couple years ago and it's actually talked about workload and capacity and trying to even that out because when they're in balance you know health is not only restore but to be able to maintain and I think the other thing I like about this too is it actually starts to our daily function as an important predictor and we know functional statuses a strong predictor for mortality so last time Mike Mendoza was here from Rochester and he he's a guy who is now in public health and he talked a little bit about this continuum of public health and then the community setting the different populations that exist within communities and then the interface with primary care okay at that first point of contact with both community and with patients and then the rest of the medical system so in my setting in the Department of Community Health within a larger Health Network our role has been more or less to help bridge some of that space so a lot of what we have done is try to bring data-driven approach by using data that we gather not just in the EMR but actually from other community and other sources of public data so secondary data and then enhance with primary data done either through stakeholder interviews or focus groups it's the same process that's actually done in a community health needs assessment oh the purpose of that is actually engage members of the community or also our patients and then through that process try to establish priorities and then socialize that a lot of what I've done at Lehigh Valley Health Network is actually educating our board our philanthropists our other clinicians across other departments to see that they actually have shared skin in the game and under helping them understand both the power of place as well as trying to integrate what we're doing in some cases is if we can reduce the burden of the chaos in people's lives through care management resources as well as building up the available resources in the community that's maybe one less patient there's going to be a real challenge to in their space was essentially framing it as a way of here's a way to reduce your level of aggravation or for your nursing staff where your care coordinators who have to do that so the other thing that we have been somewhat successful in doing within a community health context is actually trying to establish innovation pilots so in that value-based framework I've used the term that we're lose less strategy our business folks like that because as a department we don't generate a lot of revenue but we use the opportunity work through grants or through collaborative efforts with primary care departments as well as that community interface for instance our cardiology division both does some community presentations but they've also now start of a very small pilot for what they hope will be a randomized control trial for using paramedics in the community we've used community health workers to engage young moms who've just had children and their families by doing home visitation in those spaces and the amount of data that we're getting back as we're starting to learn really more about what their lives are like is really invaluable so we use a mix of both quantitative and qualitative methods and then I think the biggest challenge when they had some informal conversations about is how do you measure success so what are the metrics by which to do that and I think this is a wide-open field where we actually need a lot more work it's very different than a clinical trial because the predictors of health from a social construct or even from a biocycle standpoint they're different and the end points so this whole aspect of patient reported outcomes I think is gonna be very very important as we move forward and I think putting some discipline into that science is gonna pay big dividends as you think about marrying that up as additional inputs in that sort of big data or machine learning environment think of with a risk stratification that you can do on the front end if you just add in a simple 10 question the social need screener there's someone at the time of enrollment into a plan and you have much better sense of what the lift is going to be in terms of keeping that person out of the hospital and keeping them healthy so the question I'm gonna have for you is how can in this value you achieve your population health goals and then also from the business proposition you know how can you integrate that the clinical care with trying to if you will keep the weeds down from folks who are so strong social determinants and how do you do that synergistically with the goals of a hospital that has had more of a service line orientation and is really trying to if you will continue to build their footprint or in the geography understanding that as they expand they take on other communities they have very different characteristics in society one community you see one community and so I think you'll need a menu of strategies what works in a medium-sized city like Allentown will not necessarily work the same in one of our rural campuses you know up in this coconut region and whether in eastern Pennsylvania so let's talk a little bit on chinoe um anybody wanted to try to define community health needs assessment or just review quickly maybe basically it's a self-study to three year cycle for looking at the number of domains that influence folks health and it's meant to be a collaborative thing so it's designed to engage the community as well as the stakeholders of a particular health system there's actually mandated through the Affordable Care Act as a way for a nonprofit hospitals to justify their nonprofit status by by virtue of what they're showing they are doing in terms of their community benefit the components really are is it's a data poll using secondary data enriched by primary data gathering and then that comes back to some type of a steering body and this is where I think you can have greater influence in terms of what's important from that then is a requirement to set up if you will an implementation plan with a very small selected list of priorities and then over the rest of that three-year cycle to measure the impact of whatever tactics are chosen in terms of where that works getting done and measuring that all right now that can be a process or an outcome or even an output type of a measurement and then the subsequent cycle you build on the previous work and continue to refine those priorities so each license campus needs to have that that's a little bit of a nightmare for those large systems that have like 20 campuses and again many folks have local experts more of those local experts looks like you as well as your care managers as well as some of the leaders in your faith-based organizations so you think the other thing about the community needs assessment is its emphasis or is on vulnerable populations as a nonprofit they have an obligation not to just chase the dollar but really focus on those that don't have so you are actually focusing it can become part of a Medicaid strategy those of you know Jeff Brenner from the Camden coalition recently was lured away by UnitedHealthcare a chance to talk to the president of United Healthcare community and state back in October oh is that a presentation done by Optima labs he's I did his part owner of often labs and he said well our strategy is pretty simple we hired Jeff because Jeff can go into a community and with his knowledge and background of building coalitions he basically can get out there and using the stakeholders in the community and his facilitation skills can actually build up and strengthen the social safety net in those communities so that they are willing to offer more or less at low lower cost the ability to help stabilize people's lives so they can participate better than their healthcare and then we go in and we're content to take a little lower profit margin in those markets instead of six percent our expectations only three percent but because he's done the field work he strengthened the social safety net he saves us tons of money that was pretty pretty brilliant in terms of you know a pretty good strategy so these are the domains and concentrate more in the top of the slide here the domains on the front end where we are gathering the data have to do with health outcome metrics like mortality and morbidity pretty core to what most health systems are looking at healthcare quality and access pretty core about health systems are looking at and then health behaviors and then demographics and social environment and as you look down that column there you'll see there are things there that really truly are sort of multi sector you know poverty levels educational attainment employment status homelessness a big one no housing is health and we're starting to see some grilles movement in that area although that's typically done through a coalition approach and then the physical environment so safe places for kids to run and play we have an OVC of epidemic like everyone else but when we did the primary data gathering we learned from parents and kids oh and my kids out there because of gang violence I don't want them to get caught in crossfire I don't them to go to the park because that's what the drug dealers methania and their files and you know other paraphernalia land on the ground but you could engage our local law enforcement folks have some interest in working as to our faith-based organizations of creating safe places for kids to be able to go after school where they can play and they can exercise and while it's small work it's kind of recreating hoping this kind of recreated maybe some of the communities that many of us grew up and can try to combat one of the root causes of something obesity something like that actually would count as as noble work you know with the new community needs assessment but look here in terms of as you think about whether you're in charge of quality whether you're in charge of strategy if you look at some of these domains and then if you were to take some of the metrics that you may choose cancer rates Hospital utilization provider rates chronic disease asthma related hospitalizations how many of them are core to the work that you're already doing as you had this wonderful opportunity to get a hold of whoever's in charge where if you are helping to direct some of the activities or the needs assessment you have a bully pulpit to say this makes sense from the triple aim and the quadruple gain perspective by using some system implementation things to the needs assessment you're gonna get some resource to have been from your health systems you may potentially then unburden or you may have extra resources that will help support your other primary care physicians practices managers who are doing this work so at our network we boiled down to fuel on the front end you do the data gathering on the back end then you need to use some type of a participation approach we this last time around that group was not as broad as I would like it to be I do think there's really good work happening I like a lot of wet wellSpan in York County in Pennsylvania has been doing they cover multiple counties and they actually have a by Counting coalition of business leaders other community-based organizations and faith-based organizations and actually some of folks who are those who use those services and they brought them together a group of 40 or 50 people and they take a look at the raw data from the needs-assessment and actually help with a prioritization process and then the hospitals within their network actually bring that home and they use a multidisciplinary group to sit down and invite their board of associates board member participants from the community or the practices a few of our practices have patient advisory groups and in a perfect world you could bring those folks together to further refine so we boiled this down to four priority areas they're purposely inclusive because this first time around the goal for our network was literally brought an awareness a lot of our clinicians really didn't have any idea what a community needs assessment was or why it was important we wanted to change that I think moving forward the goal would be try to bring a little greater specificity maybe do a little deeper dive in terms of working on fewer tactics but doing a better job with them so these in terms of prevention and wellness we chose to focus primarily on open BC and cancer screening and then we have done a lot of work on to your presentation was very helpful and validating I think a lot work that we're also trying to do in educating our clinicians developing tools for assessing patients and then also providing more rapid access we have warm handoffs now voting on an emergency department we started in the on risk at risk populations we have a lot of veterans in our community a lot of them are suffering from PTSD we have a lot of depression in our community and so everything that's mental health we've tried to do a little better job of can we identify it and then if we can identify it can we actually help to care coordinated so for instance in our network if you have a an abnormal mammogram you have a care manager who calls you and they actually navigate you right to meeting with the surgeon getting the biopsy working with interventional radiologists whatever it takes right if you screamed for moderate to severe depression we write a referral for you to go and get seen we found that out of 700 referrals for that purpose about 150 of them we're hitting a dead end in the referral system and died there Wow that's no way to really help people who are suffering so we actually negotiated and just recently got with funding from our PA pho a care navigator specifically who would help a person who can identify with depression to work with them within their health insurance plan and the other resources that we have and get them plugged in there's a warm handoff and get it done quickly even they may not be able to see a psychiatrist for two or three months particularly with the Medicaid rules in our state so these are little wins but their little system improvements that we've been able to do and say no I'm not going to change depression overnight but we have used that as quality driven you know modeled after some other programs to take something that for a lot of clinicians in our network when it comes to mental health yeah let them take care of it and that has parted into the space where you try to mainstream a little bit better right so in the third Erie Community Engagement a lot of this has been around opioids there's been some significant work done around homelessness we have a street medicine program that has been very successful generated a lot of goodwill and some really great philanthropy try to use that as a springboard to get to the policy issue of housing so we had one of the highest rent to income ratios in the United States for the city of Allentown as the center of our sound gets gentrified and the influx of young upwardly mobile people who have good jobs in the center of town it's been great for the center of the town but there's still a caller around there that has been problematic in terms of helping the people who always live there and what can they do to improve their street their streets their homes how we take you know we did through veterans have a win with rapid housing getting folks house and leveraging some of the resources within the VA system as a model of doing that but even the opportunity frame this as a human crisis as opposed to a policy problem has been helpful as you get before our board of associates and some of the educational presentations would be able to do progress remains slow because it's sort of like I have we remember recently say this is what we really ought to be into we're a tertiary Hospital we deliver health high quality healthcare services you know housing community that's not our business all right and so trying to get them to understand our CEO stepped up at that very meeting is said guess what these are all the people it all rolls downhill these are the people who stand up in our er who then clog up our Hospital and reduce throughput because we don't haven't placed on you go this is what I'm very grateful for that level of witness if you go to the work at hand so and then access health equity I think our most our attention has been paid on the rapidly evolving racial and ethnic mix that we have in our community and the growth interpreter services so I love the iPads and the video connection for live interpreter as opposed the old blue phones and we've tried to implement that as we've integrated three additional campuses into our networks in the last two and a half years we've had a rollout for that to go with our IT efforts and I'm pleased you know that's actually happening to where the feedback from both administrators and a handful clinicians is hey I really like this it really makes the encounter easier it reduces my burden of slowing me down in my day okay that's a win that's a protector against burnout so there's little ways that we can help in the culture that we're trying to support but at the same time you know get a checkmark up here so taking this from a check mark exercise we've just got to get it done to making it more meaningful as you're we're hoping to do this is just a brief overview we have at this point five campuses two or actually jointly licensed but in terms of some of the things that we did if you look at these closely a lot of these things are things that you're already doing or would not be hard to do in terms of the limit of outreach many of your patients who see you are leaders of nonprofits or faith-based organizations it's easy to engage them or invite them to come for some type of a meeting to talk a little bit about where you could apply the energy all of our outreach now done through or the folks who come looking for sponsorships who come to our marketing department they now use our names assessment as sort of their standard for whether or not they're gonna make a donation or lead to a sponsorship if they're part of the needs assessment the answer is yes and a lot of them who have been coming for years and say well we always get $5,000 you the answer is well does anything you're doing fit with our needs assessment of the answer's no both sorry we've had to change the way that we're doing it so another area where there's been some influence the more rural campuses have larger access issues particularly for specialty services so bringing high quality care closer to home has been one of the emphasis of emphasis for our physician group as we look at health centers and where to expand them on the outpatient side and then I think in portions of the slate belt in Pennsylvania there's high rates of cancer so a lot of these you know come from coal mining families there's a lot of smoking that goes on there and so something like lung cancer screening is very fledgling in that area and there's an opportunity now to try to bring that to scale in fact like grant has some ideas that he's been working on implementing to help do some of that so so in summary um I think there's a lot here and I think as clinicians and family medicine many of you are leaders within your health systems there are opportunities here if you will to hit multiple targets help targets at the micro level within your clinical microsystem you know sort of that miso level is sort of at that layer where internal institutional policy and direction is being said and at the macro level is that if we can get after the social determinants will better and build that social safety net I think there's an opportunity not to just reduce clause but I think we're going to see more patient engagement more motivated patients I think it's kind of helping to increase our joy of trying to help these folks at least knowing there's more energy all finished by just one example that um everybody as a community resource directory usually it's one paper or maybe it's built into epic we partner with our United Way they have this elegant system called United Way two-on-one and it's an online resource it also has a local 1-800 number that they can call for whatever they happen to need what's nice is they track every call and so we get data from them about the types of calls and the and the types of needs that they're addressing we committed small portions of a couple of our staff to help them update their database they fanned out and talked with our case managers many of whom have their little crib sheets right and we said no no no let's put it all on me here so you have one place one-stop shopping for internal phone for our community folks and for our patients because they have a patient facing was a huge win because our clinicians you know I've been pushing although I don't know that it's happening it is to get that as a link an embedded link within epic so that a clinician in the workflow if he if he's able to do it or she is able to do it great if not have whatever person is helping with some of the care management aspects but it just flows as part of the workflow and now you know there is now a place in a space where people can the law and then we've been working with the top ten or the community-based organizations working on one of the top ten needs and then as a feedback loop that helps from a policy standpoint but the data feedback portion so when we do our next site go the needs assessment we're gonna be looking and doing a deeper dive so for instance we're starting to do some data sharing particularly around mental health and depression always say mental health is hard they looked at the number of providers we actually got an agreement to establish a standardized query that'll be used by all the health systems and all of the mental health outlets to intergate either their problem list or whatever data where they actually keep their diagnosis list so that we have a better sense of what we say mental health what are the most prevalent mental health conditions in Lehigh Valley and that would be much better than what we're currently getting which is basically says you have a mental health problem in their community we know that depression anxiety eminently treatable and I think if we can understand what those targets are it's almost like saying you have cardiovascular disease was that hypertension as a heart failure physic tronic kidney disease it makes a big difference so so thanks we appreciate your attention and I love if you can help you with any of these questions above a grateful thanks Bob it's good