EasyPI: Health Equity/Social Determinants of Health

Utilize all or some of these resources to get you ready for your project.

Social Determinants of Health

• Anti-Racism and Social Determinants of Health (American Academy of Family Physicians (AAFP))
• Beyond the Surface: A Proactive Guide Series on Screening for Social Determinants of Health (AAFP)
• Identify Social Determinants of Health to Improve Patient Outcomes (AAFP)
• Social Determinants of Health Resource Guide (National Committee for Quality Assurance (NCQA))

Health Equity

• The EveryONE Project Toolkit (AAFP)
• Health Equity Resources (Centers for Disease Control and Prevention (CDC))
• Health Equity (Institute for Health Improvement)
• The Evidence Base for Health Equity: What We Know Works (video)
• A Toolkit to Advance Racial Health Equity in Primary Care Improvement (California Improvement Network)
• Special Interest Group: Health Equity (WONCA)
• A More Practical Guide to Incorporating Health Equity Domains in Implementation Determinant Frameworks (National Library of Medicine)
• Avoiding Racist and Judgmental Clinical Documentation: Helping to Achieve Health Equity (American Family Physician)

Implicit Bias/Cultural Competency

• Project Implicit

Team-Based Care

• Indianapolis Provider’s Use of Wraparound Services Associated with Reduced Hospitalizations and Emergency Department Visits (Health Affairs)
• Health Equity in Preventive Services: The Role of Primary Care (AAFP)

Health Literacy

• Establishing the Efficacy of Interventions to Improve Health Literacy and Health Behaviors: A Systematic Review (BMC Public Health)
• Health Literacy: A Necessary Element for Achieving Health Equity (National Academy of Medicine)
• Promoting Healthcare Equity: Is Health Literacy a Missing Link? (Health Services Research)

Screening Patients

• Social Needs Screening Tool (AAFP)
• The Survey of Well-Being of Young Children (Tufts Medicine)
• Adverse Childhood Experiences Questionnaires (ACEs Aware)

Population Health

• Cooling the Hot Spots where Child Hospitalization Rates are High: A Neighborhood Approach to Population Health (Health Affairs)
• A Population Health Approach to Clinical Social Work with Complex Patients in Primary Care (Health and Social Work)

Discussion Race/Microaggressions

• Addressing Race in Practice (Institute for Healthcare Improvement)
• Talking about Racism, Racial Equity, and Racial Healing with Friends, Family, Colleagues, and Neighbors (National Day of Racial Healing Conversation Guide)
• Microaggressions Are A Big Deal: How to Talk Them Out and When to Walk Away (National Public Radio (NPR))

Community Partnerships

• A Community Partnership to Evaluate the Feasibility of Addressing Food Insecurity among Adult Patients in an Urban Healthcare System (Pilot and Feasibility Studies)
• Reductions in Hospitalizations among Children Referred to A Primary Care-Based Medical-Legal Partnership (National Library of Medicine)
• Rideshare-Based Medical Transportation for Medicaid Patients and Primary Care Show Rates: A Difference-in-Difference Analysis of a Pilot Program (National Library of Medicine)
• Return on Investment Calculator for Partnerships to Address the Social Determinants of Health (The Commonwealth Fund)

Government/Payer Partnerships

• Medicaid Managed Care Opportunities to Promote Health Equity in Primary Care  (The Commonwealth Fund)
• Supporting Effective Team-Based Primary Care through Medicaid Managed Care (Center for Health Care Strategies)
• Collaborating on Quality: The Opportunity For Payer-Provider Partnerships (RTI Health Advance)
• Social Determinants of Health Priorities of State Medicaid Programs (BMC Health Services Research)

Organizational Change

• Racial and Health Equity: Concrete STEPS for Health Systems (American Medical Association (AMA))
• Healthcare Organization Considerations in Support of Health Equity (New York Department of Health)

Z Codes

• Using Z Codes (Centers for Medicare and Medicaid Services (CMS))
• Utilization of Z Codes for SDOH among Medicare Fee-for-Service Beneficiaries (CMS)
• Using Z Codes to Improve Health Equity in Rural Indiana (American Hospital Association)
• SDOH and Medical Coding: What to Know (AMA)
• Using HCPCS Code G0136 for Social Determinants of Health Risk Assessment (AAFP)
• A Practical Approach to Screening for SDOH(FPM)

Disease Specific Information

• Cancer  (CDC)
• Cancer (American Cancer Society)
• Diabetes (CDC)
• Heart Disease (Heart Healthy Ohio)
• Heart Failure (American College of Cardiology)
• Hypertension (American Heart Association)
• Kidney Disease (HealthData.gov)
• Lung Disease (American Thoracic Society)
• Organ Transplant (National Library of Medicine)
• Osteoporosis (American Society for Bone and Mineral Research)
• Perinatal Care (Ohio Perinatal Quality Collaborative)

• Privilege Walk Activity
• The Poverty Simulation

• Health Equity Guiding Principles for Inclusive Communication (CDC)
• Guide to Evidence for Health-Related Social Needs Interventions: 2022 Update (The Commonwealth Fund)

• Hunger Vital Sign (Children’s Health Watch)
• Income, Transportation, Housing, Education, Legal Status, Literacy, and Personal Safety (IHELLP) (American Academy of Pediatrics)
• Core Set of SDOH Screening Questions (The Child & Adolescent Health Measurement Initiative)
• Reconsidering the Use of Race Correction in Clinical Algorithms (The New England Journal of Medicine)
• Use of Race in Clinical Diagnosis and Decision Making: Overview and Implications (Kaiser Family Foundation)

• Improve patient outcomes and help meet quality metrics
• Achieve team-based practice change
• Make practices more efficient
• Boost team morale
• Improve revenue.

These materials will guide you through identifying areas for improvement, understanding and using data, planning and making changes, and tracking performance over time.

• Quality Improvement Essentials Toolkit (Institute for Healthcare Improvement)
• Quality and Safety Topic Collection (Family Practice Management)
• Quality Measures (AAFP)

Quality Measures & Intervention Selection

Process Mapping

Workflow & process mapping creates a visual map of the steps your practice is currently using for a specific patient care or administrative task.

Benefits of process mapping include allowing the entire team to visualize and appreciate what role/contribution they and their colleagues play in the care of patients; gives an overview of the current processes that allows the team to plan for change; identifies unintended variations in care, inefficient procedures, and opportunities to involve other team members in care; improves communication between team members; gives team members increased ownership in patient care; and can increase employee job satisfaction.

View an outline of the mapping process and the following instructional video on the process:

Data Collection

• Data Collection Information & Tips

Now that you’ve collected data, implemented change, and have your outcomes, it’s time to submit your project for credit! Family physicians will use the ABFM’s Self-Directed Performance Improvement (PI) Project pathway to do so.

This activity provides a mechanism for satisfying your PI requirement for continuing certification by sharing with the ABFM how you have assessed and improved the way your practice addresses SDOH; health equity (broadly defined); and/or systemic ways in which you assure that patient access, experience, and care are equitable.

• You may report a project conducted alone or within a single practice group, an ACO, or other larger group practices
• You can use this pathway whether you see patients in a continuity setting or if you are providing non-continuity episodic care (e.g., hospitalist, telemedicine, locums, urgent care, emergency department, etc.).

Log into your MyABFM Portfolio to access this PI activity. To help you through the process of applying for credit, below you will find links to a blank application to review to make sure you have all of the information you will need; a completed sample application for an “Improving Screening for Social Determinants of Health” project with helpful notes; and a video guide that walks you through each step.

Once you’ve submitted your application and it has been approved (may take up to 10 days for approval), you will fulfill an ABFM certification requirement and you will have earned 20 ABFM points and 20 American Academy of Family Physicians Prescribed CME credits. If you have any questions regarding your PI activity requirement for the ABFM or if you have any issues with your application, please contact Ann Williamson at the ABFM. You can also visit the OAFP’s ABFM Certification webpage for more information on all things ABFM!