Use the Social Determinants of Health platform to:
If a patient answers any of the SDH survey items affirmatively, the patient record will be flagged, and FQHC staff notified. Staff then has the option to refer the patient through the platform's intranet to either internal staff counselors for follow-on intervention, or to third party community resource providers.
Third party resource providers include:
The platform contains a feedback application to enable the internal counselor or third party resource provider to provide feedback thru the patient record as to the status of referral, as well as the patient's progress going forward. This feedback mechanism facilitates referral accountability and prevents patients from “falling through the cracks”.
Here is the list of the SDH platform's applications/features:
NOTE: Proactive health coaching is one of the elements included in PCMH recognition, and its use may count toward valuable PCMH recognition points, as well as fulfill certain meaningful use requirements (Call for details)
ChangeAgent is our proprietary interactive goal setting tool that uses Motivational Interviewing to help patients identify motivations, strengths, and barriers for achieving behavior change. All goals can be shared with the Health Coach for follow-on discussion (Call for details)
The Task Tracker tool allows patients to specify the steps needed to achieve the behavior change goals they set using the ChangeAgent tool. All Task Tracker steps can be shared with the Health Coach for follow-on discussion (Call for details)
Vision Board allows patients to upload photographs and images that help them visualize the steps needed to achieve the behavior change goals they set using the ChangeAgent and Task Tracker tools. All Vision Board content can be shared with the Health Coach for follow-on discussion (Call for details)
Our proprietary CBT Re-framing Tool employs Cognitive Behavioral Therapy principles to enable patients to take their unhelpful thoughts and feelings and re-frame them into neutral or positive ones. Re-framing results can be shared with the health coach for follow on discussion. This is an essential tool for teaching patients the basics of cognitive re-framing (Call for details)
The Life Satisfaction Survey is a 10 item survey that measures life satisfaction and general wellbeing across 10 life-dimensions. Responses to the survey questions can alert staff to the need for follow-up or intervention, which may help to mitigate unnecessary office and ER visits or hospital readmissions (Call for details)
The Lifestyle Behaviors Survey enables the patient to identify critical behaviors that directly impact health and wellbeing, and to further identify which behaviors the patient wishes to change or improve. Responses to the survey questions can alert staff to the need for follow-up or intervention, which may help to mitigate unnecessary office and ER visits or hospital readmissions. (Call for details)
The Medical Care Inventory enables the patient and coach to identify areas where the patient needs to improve medical care self-management (Call for details)
The Resilience Checkup allows both the patient and health coach to assess the patient’s level of resilience, and to identify areas where resilience-building may be needed (Call for details)
MindSpa is an audio relaxation sanctuary offering hypnotherapy, guided imagery, ambient sound, and self-soothing exercises to calm the mind and revitalize the spirit (Call for details)