Tableau Dashboard

CONTENTS

• Background
• SDOH Screening and Referral Program Dashboard
• SDOH Program Reporting Overview
• Description of dashboard and included data modules
  • Screening Status
  • Positive Screens
  • Positive Screens: Food & Housing
  • Information Requested
  • Assistance Received
  • Referrals Made
  • Referrals Resolved
  • Additional Notes

Background

PHACO Program Aims to Address Modifiable Social, Economic, and environmental Factors in Primary care

• WHAT: Launched in March 2018, a 13-question screener was developed with input from SDOH subject matter exports, with the goal of addressing modifiable risk factors and improving quality of care for Medicaid patients presenting to Partners' primary care sites. The screener focuses on the following domains:
  • Employment
  • Education
  • Care of a family member
  • Food
  • Transportation
  • Paying for Utilities
  • Housing
  • Intimate Partner Violence
  • Paying for Medications
• WHERE: All Partners adult and pediatric primary care sites
• WHEN: Screener is assigned to all New Patient, Annual Physical, and Non-Urgent Follow-Up primary care visits
• WHO: Medicaid patients, as the program is primarily funded through Medicaid Delivery System Reform Incentive Payments (DSRIP)
• WHY: The SDOH screener helps to identify patients with health-related social needs and connect with appropriate community-based resources. We are hopeful that the SDOH screener will help our primary care practices to better address patients' unmet health needs and perform well on Medicaid ACO quality measures.

SDOH Screening and Referral Program Dashboard

Depending on your clinical/business need, the SDOH Dashboard can be a great resource for practices participating in the Medicaid ACO. Using this tool, you can see the volume of screenings, referrals, referral resolutions, and responses for patients who have been assigned or provided any responses to the questionnaire by department(s)/practice(s) to help drive strategic, clinical, and operational decision making.

SDOH Program Reporting Overview

• Data being captured in the Medicaid ACO SDOH Program Dashboard are refreshed weekly (typically Monday or Tuesday) directly from the PHS Enterprise Data Warehouse (EDW): See date/time stamp on dashboard.
• We understand that some users are using both this Tableau SDOH Dashboard and the PROMS Qlikview tool.
• While the PROMs Qlikview tool is also reporting screen completion information, our logic for generating the Screening Status numbers on the SDOH Screening and Referrals Dashboard is different; thus, reported information between the two tools is different.
• The tool you should use to obtain this information will depend on the question you’re hoping to answer.
• Details on the differences in logic between the two dashboards (as we understand them) are below

	SDOH Tableau Dashboard	PROMS Qlikview Dashboard
Data Level	Patient (patients are only counted once)	Encounter (patients can have multiple encounters and thus are counted multiple times)
Parameters	Only Completed Appointments	All appointments, regardless of status
	Only patients on Medicaid at the time of the appointment	For sites that are screening regardless of payor, information for these patients would be included

Description of dashboard and included data modules

Screening Status

• Each patient with a completed primary care visit and on MassHealth at the time of the encounter has one Screening Status (i.e. Assigned, Completed, Partially Completed).
  • Assigned: The SDOH questionnaire has been assigned to the patient for a scheduled appointment, but the questionnaire has not been started. No-shows and canceled appointments are excluded.
    • The SDOH questionnaire was assigned to the patient with a specified payer status (MassHealth, specified by PayorNM) and visit type (Annual, New Patient, and Non-Urgent Follow-Up, naming conventions and codes for visit types vary by practice, or Epic Department).
  • Partially Completed: The SDOH questionnaire is in-progress and responses are provided for some, but not all, of the questions in the SDOH questionnaire
  • Completed: All 13 (Adults) or 14 (Pediatrics) questions of the SDOH questionnaire have a response, which may include "I Choose Not To Answer".
  • Exclusions – Epic Statuses that the Medicaid ACO team is excluding from program reporting
    • Incomplete: A special status caused by a Cadence check-in programming point that saves the patient’s in-progress answers into the encounter.
  • If a patient was found to have multiple statuses, assignment was given in the following order of priority.
    • Completed
    • Partially Completed
    • Assigned
  • If a patient had multiple similar statuses after assigning priority per the previous bullet, the status from the most recent encounter was used.
  • When you export the data, use the following columns if you’d like to look at the information for a specific patient
    • Encounter_Date (date of the encounter from which the module’s data are derived)
    • RSO
    • Department
    • PayorNM
    • For sites screening without regard to payor status, filter this column to MASSHEALTH to look at Medicaid patients
    • PatientNM
    • BirthDTS
    • Status
  • A mapping of where these data are located in the PHS EDW can be found here.

Positive Screens

• Patients who screened positive in any of the 10 SDOH domains based on their most recent responses (if they provided responses to the questionnaire more than once)
  • Contains SDOH Questionnaire responses recorded through the iPad interface or through provider recorded Flowsheets
  • Because the Food and Housing domains have multiple questions, a patient is considered to have screened positive if they answered positively to at least 1 of the questions in the respective domain
  • If a patient provided responses to the SDOH questionnaire more than once, the most recent set of responses was used.
  • The Food and Housing domains are shown in orange and green, respectively, rather than blue. This differentiation is used to highlight the two domains with more than one question in the SDOH questionnaire, and of particular importance to the Medicaid ACO SDOH Program.
  • When you export the data, use the following columns if you’d like to look at the information for a specific patient
    • Encounter_Date (date of the encounter from which the module’s data are derived), the most recent date that the patient provided a response
    • RSO
    • Department
    • PatientNM
    • BirthDTS
    • QuestionNM
    • Filter to exclude the following:
    • Information Received Assistance
    • Information Requested More Information
    • SDH AMB Ref
    • Domain
    • AnswerTXT
    • PositiveFLG
      • 1 = Positive
      • 0 = Negative
    • Response_used
      • 1 = This was identified as part of the most recent set of responses for a patient at the question level
    • Domain_positive_response_used
      • 1 = This was identified as the response used on the dashboard to account for domains that had multiple questions

Positive Screens: Food & Housing

• The Food and Housing domains are the only ones which contain multiple questions (2 and 3, respectively). As such, we also have a module breaking down the responses by question for these two domains.

Information Requested

• Patients who requested information in any of the 10 domains (does not include IPV). A patient could have requested information for multiple domains.
  • When you export the data, use the following columns if you’d like to look at the information for a specific patient
    • Encounter_Date (date of the encounter from which the module’s data are derived), the most recent date that the patient provided a response
    • RSO
    • Department
    • PatientNM
    • BirthDTS
    • QuestionNM
      • Filter to More Information Requested questions
    • AnswerTXT
    • Domain

Assistance Received

• Patients who indicated that they received assistance in any of the 10 domains (does not include IPV) within the past 12 months. A patient could have received assistance in multiple domains.
  • This is based on the patient’s response to the screening questionnaire and does not necessarily correspond to Referrals Made
  • When you export the data, use the following columns if you’d like to look at the information for a specific patient
    • Encounter_Date (date of the encounter from which the module’s data are derived), the most recent date that the patient provided a response
    • RSO
    • Department
    • PatientNM
    • BirthDTS
    • QuestionNM
      • Filter to Received Assistance Questions
    • AnswerTXT
    • Domain

Referrals Made

• The most recent SDH Ambulatory Referrals that were made for a patient who was assigned an SDOH question
  • When a SDOH Referral Order is sent, the physician has the option to specify a reason for the referral and provide additional information in response to some questions. The specified reasons often include one of the nine domains or free-text that may be associated with one of the domains.
  • Referrals where a reason was specified and was able to be associated with one of the SDOH domains on the dashboard are counted under the identified domain
  • SDOH Referral orders without a reason (was left blank) or without a specified SDOH domain are included in the Other category
  • These referrals do not necessarily correspond to a patient’s response to the screening questionnaire and are placed at the provider’s discretion based on the conversation during the visit.
  • Because we are showing the most recent SDOH referrals for a patient, they may not have had a referral at their most recent encounter from where the responses and status information were obtained; thus, the Referrals Made Encounter_Date may be earlier than that of the Status or Response modules’ Encounter_Dates
  • When you export the data, use the following columns if you’d like to look at the information for a specific patient
    • Date (date when the referral order was placed)
    • RSO
    • DepartmentNM
    • PatientNM
    • BirthDTS
    • OrderQuestionResponseTXT
    • Domain
    • QuestionNM
    • Filter to QuestionNM = PHS AMB SOCIAL DET REFERRAL REASONS
      • Other QuestionNMs are questions associated with the SDOH referral order to which the provider provided responses/information but not necessarily a specific SDOH domain
    • Table
      • Filter to Referrals Made

Referrals Resolved

• The outcome of patient outreach attempts in response to the most recent SDOH referral(s) made
  • Currently only MGH and BWH have data on this
  • Because we are showing the most recent SDOH referral resolution for a patient, they may not have had a referral at their most recent encounter from where the responses and status information were obtained; thus, the Referral Resolution Encounter_Date may be earlier than that of the Status or Response modules’ Encounter_Dates
  • The following SDOH Smart Phrases used for documenting in Epic indicate the result of the SDOH Referral Order and are being reporting in the Referral Resolution chart:
    • SDHREACHED: The patient was provided resources and information to address SDOH need(s) identified in the referral order
    • SDHREFERRALOPEN: The SDOH Referral Order is open and being managed by the Referral Work queue manager, who is connecting with appropriate care team members to outreach to the patient
    • SDHREFUSED: The patient refused outreach from a care team member
    • SDHUNABLETOREACH: The patient was unable to be reached by the care team member
    • SDHICMPREFERRAL: The patient is in iCMP and handed off to iCMP
    • SDHPTOUTREACH: a Community Resource Staff (CRS, CHW, HA) attempted patient outreach and one of the following occurred:
      • Patient reached, and resources/information given
      • Patient was unable to be reached
      • Patient reached and refused
    • SDHFALSEPOSITIVE: Patient did NOT screen positive for anything or screened positive and selected “None” (don’t want more info) on Question 12, indicating an outreach is not necessary.
    • SDHREF: Patient is engaged in care with specific programs (iCMP, CP, Pedi iCMP) and in order to not duplicate efforts, a warm hand-off was provided to the care team lead of the program.
  • Referral Resolutions related to the most recent SDOH referral orders are presented on the dashboard
  • When you export the data, use the following columns if you’d like to look at the information for a specific patient
    • Date when the Smart Phrase was documented
    • RSO
    • DepartmentNM
    • PatientNM
    • BirthDTS
    • OrderQuestionResponseTXT
    • Domain
    • PayorNM
      • Although the patient was a MassHealth patient when they responded to the SDOH questionnaire, they may not still be on MassHealth when the outreach even occurred; thus, you may see payor names other than MassHealth in this column
    • Table
      • Filter to Referral Resolutions

Additional Notes

• Data on the dashboard are only for practices currently on Epic. We will be incorporating data from sites using REDCap into this dashboard soon.

• The RStudio code with annotations which generates the source data for the SDOH dashboard is available to share by request source data for the SDOH dashboard is available to share by request