Social Determinants of Health and Behavioral Health: A Practical Guide

America leads the world in medical research and medical care, and for all we spend on health care, we should be the healthiest people on Earth. Yet on some of the most important indicators, like how long we live, we’re not even in the top 25, behind countries like Bosnia and Jordan. It’s time for America to lead again on health, and that means taking three steps. The first is to ensure that everyone can afford to see a doctor when they’re sick. The second is to build preventive care like screening for cancer and heart disease into every health care plan and make it available to people who otherwise won’t or can’t go in for it, in malls and other public places, where it’s easy to stop for a test. The third is to stop thinking of health as something we get at the doctor’s office but instead as something that starts in our families, in our schools and workplaces, in our playgrounds and parks, and in the air we breathe and the water we drink. The more you see the problem of health this way, the more opportunities you have to improve it. Scientists have found that the conditions in which we live and work have an enormous impact on our health, long before we ever see a doctor. It’s time we expand the way we think about health to include how to keep it, not just how to get it back.

(RWJF “A New Way to Talk About Social Determinants” 2015)

Objective

Our objective is to provide a framework and toolkit to allow caregivers in the state of Michigan to better understand and address the social determinants of health and behavioral health.

Overview

There is a growing body of research demonstrating the relationships between the conditions in which people grow, learn, and work and health outcomes. Determinants of health include social and economic factors, health behaviors, environmental factors, genetic makeup and health care services.  Although the importance given to each of these factors varies considerably by population and the analytic methodology used, social/economic factors are estimated to account for 30-40% of health outcomes and behavioral factors for an additional 30-40% of health outcomes.

The opportunity for primary care to impact behavioral health, including mental health and substance abuse, is significant. Fifty percent of all behavioral health disorders are treated in primary care. (Kessler et al., NEJM)   Up to 40% of patients in primary care have a behavioral health need, (Martin et al., Lancet 2007) and almost 50% of psychotropic medication appointments occur in non-psychiatric primary care providers. (Pincus et al., JAMA. 1998)

Spiral-Chart-6-updated-for-MEBai

MiPCT Toolkit: Addressing the Social Determinants of Health and Behavioral Health in Primary Care

During the past few years MiPCT POs /PHOs and practices have been engaged in the challenging work of transforming the way primary care is delivered in Michigan. They have made great strides in moving from a fragmented, acute health care system into a coordinated seamless health care system. The challenge for the next decade will be to cross the next frontier into community integrated health delivery system.   Michigan’s SIM model, the Blueprint for Health Innovation, launching this year, will pilot the creation of Community Health Innovation Regions to address the social determinants of health.  With the extension of the demonstration project, the key focus areas of addressing social determinants and integrating behavioral health were chosen for 2015- 2016.  MiPCT POs/PHOs are encouraged to utilize the framework and toolkit to address these areas.

Toolkit Objective

As there is little evidence to date to support the promotion of a specific model or process for addressing the social determinants of health and behavioral health, the toolkit is not designed to be prescriptive.  Rather, it brings together a variety of resources.  There are tips, ideas and tools to assist POs/PHOs and practices with assessing where they are at and making plans to take the next step. That next step may vary in complexity from the development of a single process to screen patients for social and behavioral health needs to the creation of a fully integrated system in partnership with SIM. This toolkit is a living document and not all categories have a tool; we encourage submission of tools on an on-going basis.

This toolkit is divided into five areas:

Section A: Key Websites

These websites have been chosen to give important context and background.

Section B: The PO Planning Framework

Planning for the work at the PO level contains key steps (on the left) a PO should complete in preparing for integrating behavioral health (middle column) or addressing social determinants (right column). The tools that support a PO in achieving these steps is contained in the grid.

For example, if you are looking at assessing your current state of integration related to behavioral health you have two resources:

(1)  OATI – 4, or

(2)  Integrated BH principles and tasks check list.

These are live links that will lead you to that resource.

Section C: Practice Planning Framework

Planning for work at the practice level works in the same way, with key steps and resources for each step.

Section D: The Implementation Framework 

Implementation at the practice level. identifies key steps in implementation at the practice level.   Each step has tools that help support the practice in achieving successful implementation.

The first four steps deal with addressing this issues on a population level – how the practice will create the processes and infrastructure to address social determinants of health and behavioral health. The last four steps are how they deal with these on a patient level. Each step has tools embedded in the step.

Section E: Health Literacy and Cultural Competency

Additional resources for health literacy and cultural competency are provided.

MiPCT Social Determinants of Health and Behavioral Health: A Practical Guide

Section A: Key Websites

The following websites are helpful in obtaining a broad background in social determinants of health and behavioral health:

Behavioral Health Integration

  1. Academy for Integrating Behavioral Health and Primary Care (AHRQ)
    • AHRQ created the Academy for Integrating Behavioral Health and Primary Care as a response to the recognized need for a national resource and coordinating center for those interested in behavioral health and primary care integration.
    • Additional tabs on research, education and workforce, policy and finance, lexicon, clinical and community, health IT, resources and collaboration
  1. Safety Net Medical Home Initiative Integration of Behavioral Health (Improving Primary Care)
  1. Substance Abuse and Mental Health Services Agency (SAMHSA)
    • SAMHSA-HRSA Center for Integrated Health Solutions  quick start guide with decision tree framework from administration to practice
    • Further tabs on models, workforce, financing , clinical practice, operations and applications, and health and wellness

Social Determinants of Health

  1. Social Determinants of Health Overview (CDC)
  2. A New Way to Talk About Social Determinants (RWJF)

Section B: PO Planning Framework pdf

  Behavioral Health Integration  Addressing Social Determinants
Financial analysis and business plan Sustainability Checklist (NCCBH)

 

Behavioral Health Funding for Michigan FQHCs (SAMHSA – HRSA)

Addressing Patient’s Social Needs: Business Case (Commonwealth Fund)

 

Data Set Directory of Social Determinants of Health (CDC)

Assessment of current state of integration OATI #4:  COMPASS-Primary Health and Behavioral Health (SAMHSA – HRSA)

 

Integrated BH Principles and Tasks Checklist (AIMS Center/UW)

Assessment of resources at practice, PO and community Key deliverable: Identification of  the relationships with psychiatric partners for developing care collaborative model  (No resource) Practical Playbook; Primary Care and Public Health Together (Duke/CDC)

 

Community Commons Interactive Maps: Poverty levels, education and more by census tract [Log in required] (Community Commons)

 

Current state assessment of community partnerships and joint planning of intervention OATI #1: Partnership Checklist (SAMHSA – HRSA)

 

Steps to Preventing Child Maltreatment (CDC)
Current state assessment for readiness for change OATI #3: Administrative Readiness Tool (SAMHSA – HRSA)

 

AIMS Center Organizational Readiness Worksheet (AIMS Center/UW)

GROW Planning Worksheet (Group Health)
BUILDING INTEGRATION ON A FRAMEWORK OF ADVANCED MEDICAL HOME CAPABILITY  PRESENT IN MiPCT PHYSICIAN ORGANIZATIONS AND PRACTICES

Section C: Practice Planning Framework pdf

  Behavioral  Health Integration Addressing Social Determinants
Financial analysis and business plan SBIRT Basics (SAMHSA – HRSA)

 

SBIRT Financing (SAMHSA – HRSA)

 

Behavioral Health Funding for Michigan FQHCs (SAMHSA – HRSA)

 

CDC Funding [offers resources on pre-award information, forms, and current Funding Opportunity Announcements] (CDC)

 

Assessment of current state of integration Integrated practice assessment tool (IPAT) (SAMHSA – HRSA)

 

CIHS framework (SAMHSA – HRSA)

 

Assessment of Chronic Illness Care [particularly sections 2, 7] (MacColl)
Assessment of resources at practice, PO and community Quick Start Guide to Integration (SAMHSA – HRSA)

 

Current state assessment of community partnerships and joint planning of intervention OATI #1: Partnership Checklist (SAMHSA – HRSA)

 

A New Way to Talk About SDH (RWJF)

 

SDOH Resources (CDC)

Current state assessment for readiness for change AIMS Center Organizational Readiness Worksheet (AIMS Center/UW)

 

MH Practice Readiness Inventory (AAP)

 

BUILDING INTEGRATION ON A FRAMEWORK OF ADVANCED MEDICAL HOME CAPABILITY  PRESENT IN MiPCT PHYSICIAN ORGANIZATIONS AND PRACTICES


Section D: The Implementation Framework

The steps to making the planning come to reality, with improvement in process and outcomes metrics, are outlined below.   Steps in brown describe the structure necessary for population health management of social and behavioral determinants of health at a practice level.  The steps in blue are the steps for patient care related to addressing social and behavioral factors.  Practices must use appropriate screening tools related to social and behavioral factors. The optimization of care is divided into three buckets:  addressing social factors, optimization of medication for behavioral issues, and partnerships for collaborative care related to mental health. Entering this information into a registry with appropriate follow up and panel management is the final step. Each step has tools and resources embedded into the diagram to enable practices and supporting POs to be successful.

New circle graphic

Social determinants of health  
    Tools to support action Poverty Behavioral factors (smoking, at- risk substance use)  Adverse childhood events Integration of behavioral health
Overview Documents Community Commons Interactive Maps (Community Commons) The Childhood Adversity Narratives CAN (Children’s Health Watch)

 

Behavioral Health Integration (Improving Primary Care)
1 Measurement of Process and Outcomes GROW Planning Worksheet (Group Health) Capturing Social and Behavioral Domains and Measures in EHRs: Phase 2 (IOM)

 

Measuring Vital Signs (JAMA)

 

Overview of Measures (Improving Primary Care)
2 Implementation Plan Strengthening Families- A 

Protective Factors Framework (CSSP)

Collaborative Care Implementation Guide (AIMS/UW)

 

Guidebook for professional practices for implementation (AHRQ)

 

Suicide prevention tool kit (SPRC)

 

3 Screening Tools for Identification of Social or Behavioral Issues Health Begins

Social Screening Tool V6

ACE and Resilience Questionnaires (Kaiser/CDC) Depression tool kit (Community Care of North Carolina)

 

SAMHSA Screening Tools

 

4a Optimization of Care: Treatment Intensification Commonly Prescribed Psychotropic Meds (AIMS/UW)

 

Primary Care Psychiatry –Pocket Guide V. 1.5  Feb 2014 (UCSF – Fresno)

 

4b Optimization of Care: Referral Partnerships for Advanced Services MiCCSI Community Resources Directory (MiCCSI)

 

5 Registry Utilization Clinical Workflow Guide (AIMS/UW)

 

Identifying a Population-Based Tracking System (AIMS/UW)

 

Section E: Health Literacy and Cultural Competency

Team based factors impacting integration Framework / toolkits Assessment of PO/ practice capabilities PO/practice care team process/ tools and training Patient Tools / educational materials
Health Literacy AHRQ Health Literacy Universal Precautions Toolkit (AHRQ)

 

The Health Literacy Environment of Hospitals & Health Centers: Making Your Healthcare Facility Literacy-Friendly (HSPH)

Ten Attributes of Health Literate Health Care Organizations (IOM)

 

The Health Literacy Environment Activity Packet: First Impressions and A Walking Interview (HSPH)

 

Measures to Assess a Health-literate Organization (IOM)

 

In Plain Words  (Children’s Healthcare of Atlanta)

 

Effective Communication Tools for Healthcare Professionals (HRSA)

 

National Network of Libraries of Medicine: Health literacy

Ask Me 3 (Partnership for Clear Health Communication)
Ethnicity /

Cultural Competency

Effective Communication Tools for Healthcare Professionals (HRSA)

 

Guide to Providing Effective Communication and Language Assistance Services? (HHS)

 

National Standards for Culturally and Linguistically Appropriate Services (HHS)

 

Feedback
Does this toolkit meet your needs? Do you have suggestions for additional resources? Please send us an email at mipctdemo@michigan.gov with the subject line “Toolkit Feedback”!