PHACO-SDOH-Screening-and-Referral-Dashboard-Description-and-Defintions.md

+[[_TOC_]]
 #### 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.  
@@ -14,7 +15,8 @@
 
 
 #### 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).  
+##### **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 
@@ -36,8 +38,9 @@
         + BirthDTS 
         + Status 
     + A mapping of where these data are located in the PHS EDW can be found **[here](https://gitlab.partners.org/trang-hickman/phaco-sdoh/sdoh/screening-and-referral-program/tableau-dashboard/wikis/PHACO-SDOH-Screening-Status-Data-Map)**.
-        
-* **Positive Screens module:** 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) 
+
+##### **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) 
     + 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. 
@@ -62,10 +65,11 @@
         + 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. 
-
+##### **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. 
+##### **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 
@@ -77,7 +81,8 @@
         + 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. 
+##### **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 
@@ -90,7 +95,8 @@
         + AnswerTXT 
         + Domain 
 
-* **Referrals Made:** the most recent SDH Ambulatory Referrals that were made for a patient who was assigned an SDOH question 
+##### **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 
@@ -110,7 +116,8 @@
         + Table 
             + Filter to Referrals Made 
 
-* **Referrals Resolved:** The outcome of patient outreach attempts in response to the most recent SDOH referral(s) 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: 
@@ -139,6 +146,7 @@
         + 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 
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