ACTION PLAN FOR A SOCIAL NEEDS PROGRAM

This document will guide early stage design and development of a social needs program, and will also help evaluate or expand a current
program. This document highlights key information to consider as you make your design decisions. Once you are ready to act, more detail will
be required, and some information will evolve; however, this tool will help you move through future steps much more efficiently.

The Action Plan is broken up into sections that correspond with the content covered in the weekly virtual sessions of the Workshop 201:
Designing an Effective Social Needs Intervention. However, your team will likely need to iterate on this plan over time. We strongly suggest
working as a team to fill out each section. You will likely need to have conversations with individuals outside of your team and collect additional
data to make certain planning decisions. You will have an opportunity to submit your Action Plan for feedback from one of our Health Leads
experts at the mid-point and at the end of the workshop.

Note on terminology: We understand that as health care is evolving, terminology evolves as well. In this workshop, we are referring to the
individuals served by these efforts as “patients.” However, we recognize that organizations may also refer to these individuals as “clients,”
“customers,” “leaders”, etc.

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TABLE OF CONTENTS:

VISION AND PURPOSE COMPLETE AS PRE-WORK

STAKEHOLDER PRIORITIES COMPLETE DURING WEEK 1
DEFINING YOUR TARGET POPULATION
BUILDING PROGRAM AIMS AND GOALS
DEFINING SCOPE OF SERVICE: SOCIAL NEEDS CATEGORIES AND RESOURCE COMPLETE DURING WEEK 2
CONNECTIONS
SCREENING FOR SOCIAL NEEDS COMPLETE DURING WEEK 3

SOCIAL NEEDS TEAM COMPLETE DURING WEEK 4

MAINTAIN A COMMUNITY RESOURCE INVENTORY COMPLETE DURING WEEK 5

MEASURES AND DATA COLLECTION
REVIEW OF AIMS AND GOALS
REVIEW OF ACTION PLAN
NEXT STEPS

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VISION AND PURPOSE – PRE-WORK
As you embark on your journey to address patients’ social needs as a standard part of care delivery, a clearly articulated vision will help your
team stay focused on designing, piloting, implementing and sustaining a system that will successfully address the needs of your patients and
community. It will also help you to effectively communicate to others why you are doing this work and how it will be valuable to your
organization, your patients, and your community.

As a team, discuss and write down your answers to the questions below. Think broadly! Your ultimate vision may not be accomplished in the
near term, and that’s okay! Throughout this workshop we will support you in identifying the steps you need to take towards meeting your
vision.

What are the motivations for addressing patients’ social needs Better help people’s health and well being
at your organization and in your community? Help community people who don’t know or are afraid to ask for help
due to legal status
Help people who do not ask for help due to the severity of depression
What data/evidence is informing your call to action? Time studies, chart reviews, ER history

What changes would you like to see as a result of your efforts Patients not being afraid to ask for help
to address patients’ social needs? Better health outcomes

How will this work be different from or improve upon what you This will be more organized and process oriented.
are doing now to address patients’ social needs?

What will success look like for your organization? For your Better resource guide and work flow chart
patients? For your community? (note: consider how you will Patients being more comfortable asking for help
measure success and use measurable terms where possible) Ability to ensure successful referrals

As you begin this work, what are you most excited about? Most Excited about helping others manage their own health
concerned about? Concerned about workflow

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STAKEHOLDER PRIORITIES – WEEK 1
Consider the stakeholders from whom you will need support or input for your program to succeed. You may need to adjust the goals listed
above after thinking this through. Get specific about which design decisions different stakeholders should be involved in and how.

Stakeholder Name(s) and Role(s) (if What type of support is needed? How do you plan to engage this
applicable) Collaboration? Feedback? individual or group? (how often,
Decision-making/Approval? when, etc.)
Executive Sponsor(s) Suzanne

Clinical Champion(s) Pat

Patients Feedback, awareness of needs Focus groups, surveys,

Staff who address patients’ Veronica R On planning team

social needs (Social workers,
community health workers,
patient navigators, etc.)

Clinic staff who can support Kathy, Jenna, Wendy, Patty On planning team
your work (MA, nurse, etc.)

Community stakeholders Garden Quarter, Head start, Input on content, feedback on Focus groups, key informant
(social service providers, local United Way, Sample County tools, and financial support when interviews and discussions
public health department, etc.) Community Foundation appropriate

Others

What are your lingering questions or next steps on engaging stakeholders

Are these draft decisions? What additional input do you need? From Whom? What questions do you still have?

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DEFINING YOUR TARGET POPULATION –WEEK 1
Use this section to clarify the community of patients that will be the focus of your initial improvement work to address social needs. This section
will guide your choice of which social needs to address and how to address them, as well as what resources you will need to support these goals.
The community of patients described below may not include all the patients you hope to target long term- but it is where you plan to start.
What patient population(s) do you want to All patients , with a focus on Hispanics (?) who may not know what services are available.
target with this initiative? What are their Pilot program will roll out on a few days/week, depending on availability of volunteers.
defining characteristics? Changes will be made after evaluating flow and process.

In which clinic or other location does this

population receive care? CL as well as outreach sites and mobile health sites as well as Sample Hospital with
Celebremos.
What is the size of the initial patient
population? 2000 unique patients

How many of these patients do you intend

to serve in one year? What volume goals 500 in the first year - still under discussion
are required by your grant (if at all)?

What is your rationale for initially focusing Hispanics face a variety of barriers to receiving high quality health care. Some are a result
your work on this population? of their low socioeconomic status, others are due to the specific features of the population.
This may help manage personal responsibility for their health and make them better
advocates for their neighbors and families.

What are your lingering questions or next steps on defining your initial population?

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BUILDING PROGRAM AIMS AND GOALS – WEEK 1
Clear aims and goals will focus your work and guide your design and implementation decisions. A clear aim statement will be measurable and
specify how much improvement by when.

Example aim statements from Health Leads’ partners can be found in the Aim Statement Guide. At this stage, it may not be possible to assign
hard numbers and dates to your aim statement. Make your best estimation for now, but do be clear about WHAT you want to accomplish (aka
your main outcome) and for WHOM (what population of patients). Use your Vision and Purpose work to inform your aim statement.

Create an aim statement: Decrease wait time for patients (eliminate NPs from doing the SDOH assessment)
What are you trying to Screen all patients for SDOH
accomplish? Reduce ER visits among the clients

Choose measures (process and Time Studies, EMR reviews, ER historical data
outcome): How will you know
that you are accomplishing what
you intend to?

List your goal statements: Within six months, 25% of patients will be screened.
What will you need to achieve in Within six months, 50% of screened patients will have been successfully navigated to additional services.
order to reach your aim? Within three months, a formalized volunteer training program will have been developed and piloted.
Within three months, a documentation process will have been developed and implemented.
Within 2 months, all staff will be in serviced on the program, goals and change process.

How will your work to address This program will blend into the Patient Navigator role, and will include the VISTA volunteer who will be
social needs support other onboard in the summer. Additionally, it may be a way to utilize volunteers in a more robust way.
programs/initiatives at your
organization?

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DEFINING SCOPE OF SERVICE: SOCIAL NEEDS CATEGORIES AND RESOURCE
CONNECTIONS – WEEK 2
The social need domains that you choose to focus on are a fundamental building block for your intervention. When choosing consider:
• What is the value of each category or resource for both patients and staff (financial value, practical value, emotional value, and
organizational value)?
• Are resources available in your community to address these needs, and what common barriers exist?
• Does the workforce you choose have the time and skills for the social need domains you will be able to address? If not, will training be
made available?
• For which social needs categories do staff at your organization already facilitate patients access?
• Based on your data and community engagement efforts, what are the most common, highest priority needs for the target population?

Use the Scope of Service Decisions and Targets tool to identify the social needs categories that you will aim to connect
patients to in the next year.

Instructions:
1) Review the need categories, sub-needs within each category, and descriptions listed in the tool as a team. Indicate which
social needs you will include in your initial scope of service by choosing either “Yes” or “No” in column A for each social need
listed.
2) For each need category included in your scope of service, please indicate:
a. The type of support patients will receive from your staff to access these resources
3) On tab 2 of the spreadsheet, input contact information to known resources available in your community. This will help you
build your resource directory if you do not currently have one available.

What are your lingering questions or next steps on the Scope of your Referral and Navigation Services- either on the Social Need Domains you’ve
chosen, the resource types you’ve focused on, or the specifics of the support that you will provide?

Are these draft decisions? What additional input do you need? From Whom? What questions do you still have?

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SCREENING FOR SOCIAL NEEDS– WEEK 3
A sustainable screening process will ultimately be essential to connecting patients with the resources they need and want to be healthy. Your
starting point for screening will depend on your program’s capacity. The questions below will help define a starting point, and going forward,
you will build on this and need to develop detailed workflows.
When it comes time to choose a specific screening tool, consider consulting Health Leads’ Screening Toolkit.

How are you currently collecting information We have signs in the clinic rooms offering additional help, often times nurses or interpreters
from patients on their social needs? will query the patient, but not a systematic screening.
If you aren’t currently screening patients, what We will not screen for services we cannot provide. We currently have an intern working on a
tool, or questions will you use? resource directory that is much more specific and user friendly than existing ones.

If you are screening patients for social needs,

do you want to add or modify any questions? If
so, how?

Where will screening fit in the workflow of your We would like to develop a process map. (attached)
operations? Who will be affected?

Given the initial screening population you have We believe that up to half of those screened would need services, as we serve a very needy
defined, how many patients per year are likely population to begin with.
to require services?
What is the process for taking action when a We are looking at a triage approach, where easier needs can be handled by a volunteer,
patient screens positive? Outline a set of with increasing complexity moving up to staff positions. See attached flow sheet.
potential steps with the staff/roles involved.

Are you intending to screen for emergent Some – we already screen for domestic violence and mental health. We may not screen for
needs? If so, will your team address these emergency housing because we have little in our county.
needs with patients? What other teams/staff
might you need to involve with these cases?

What are your lingering questions or next steps with screening patients for social needs?

we are still in the process of gathering more information on all services available in the county.

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SOCIAL NEEDS TEAM– WEEK 4
In this section, start to identify key roles while considering capacity and sustainability for staff. Use the table below to start designing your
staffing plan. For “initial capacity” please indicate how much time (e.g. FTE, hours, etc.) your staff or volunteers will have at the start of your
program to devote to these activities.

Function Staff/Roles and Initial Capacity New or Existing Workforce Additional Training and
Supervision Required
Screening Volunteers Yes

Intake for positive screens VISTA (2 years) Volunteers (including VISTA ), Yes
depending on severity

Navigation to resources Patient Navigator, depending on Volunteers (including VISTA ), Yes

severity depending on severity

Managing the community VISTA (2 years) Volunteers Yes

resource inventory

Building/maintaining partnerships Executive Director, Clinical VISTA, Patient Navigator No

with community providers Manager, Patient Navigator,
Wellness Coordinator

Measurement and data collection Executive Director, Clinical Volunteers Yes – looking at measurement
Manager, Patient Navigator, tools currently
Wellness Coordinator
Gathering patient feedback Patient Navigator, Wellness NO
Coordinator, Mobile Health Team,
Front Office
Project management Executive Director, No

What are your lingering questions or next steps with your staff planning?
Draft decisions

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MAINTAIN A COMMUNITY RESOURCE INVENTORY– WEEK 5
In the first two weeks, you considered which social needs you would address and for which patients. Now it’s time to think through how you will
find and maintain the right set of resources. The following questions below will guide your resource directory development.

Where does resource information already exist? Currently utilize a binder (Patient Navigator, and one on RN side) as well as People In need
Resource Guide. Working with public health intern on updating, and putting patient
friendly information in there that can be shared.

Where will information on community resources

be stored and maintained going forward? A database stored on the Access Drive, but also some type of decision tree that can help
guide people to the best resources. VISTA can be the prime ‘updater’ of information,
although trained community volunteers can also do this on a regular basis.
Who will find new resource information to start? Currently in progress with public health intern.
What internal teams have resource information
that you could tap?

Who will the community resource inventory be All clinic staff and volunteers. Currently talking with United Way to look at how this could
made available to? be shared.

What do you know about the community based It would be good to have an actual point person for contact. For organizations that have
organizations you currently work with? What do them, an intake coordinator may be perfect. Working with the Mental Health Board to
you wish you knew? buy into this program and encourage/fund part of a position at several currently funded
agencies.
How will you maintain accurate contact VISTA will be primarily responsible for this work, whether on own or be delegating. Info
information for the resources in your community? will be updated by phone calls, information from Intake Coordinator’s meetings, Network
Council, United Way meetings, etc.
What organizations are highest priority for Sample (substance abuse), Housing Authority, various Example, townships
establishing or deepening your relationship with
to best meet the needs of your community?

What are your lingering questions or next steps with maintaining a community resource inventory?
Want to be sure to delineate what services can be accessed without citizenship. Also need to know where bilingual services are available.

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Are these draft decisions? What additional input do you need? From Whom? What questions do you still have?

MEASURES AND DATA COLLECTION - WEEK 5

A solid measurement strategy should reflect what you are seeking to accomplish and the key processes involved. It will provide data that you
can use to understand your progress, identify opportunities for improvement, and allow you to share your successes and challenges with
leadership, funders, and other stakeholders. Since measuring and evaluating your program is a specific set of activities that you need to budget
for and allocate staff capacity to complete, we recommend planning your approach from the beginning.

Use the table below to start building your measurement strategy. We recommend reviewing your stakeholder map, aims, goals, and measures
from Week 1. You may also want to review any processes you have defined and think about where opportunities for data collection exist.

Measure Type How will the data be collected? Does a baseline exist? How often will the data be
(when, where, by whom) reviewed?
List the Outcome measures you VISTA will collect data on daily No Weekly initially, then monthly
plan to track (see response from screenings. Will consult with
week 1): Patient Navigator about referrals.
Per your aim and goals: Volunteers will follow up with
Immediate, intermediate and patients to determine success of
longer-term health impacts: referrals. Information will be
Mental health status tracked in EMR. And shared with
ED and Board
Healthcare utilization/cost
impacts: ER visits reduced

List the Process measures you VISTA will collect data on daily No Weekly initially, then monthly
plan to track (see response from screenings. Will consult with
week 1): Patient Navigator about referrals.
Measure: Patients Volunteers will follow up with
screened/served: Metrics: patients to determine success of
• # screening tools handed referrals. Information will be
out tracked in EMR. And shared with
• % completed ED and Board
• % screen positive
• % positive who resource

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 community resource
referrals
Measure: Patient use of referral
Metrics:
• (down the road?) - % patients
successfully connected to
community resource.
• % of patients who report
resolving a social need.

Your program data can also be a tool to help you identify disparities in services or resource connections across patient populations (e.g.
race/ethnicity, geography, gender, age, etc.). Reviewing data across different patient populations can help you identify opportunities to improve
your program and more effectively engage certain patients.

What type of disparities in care, We think transportation will be a big issue, as well as access to services if a patient is undocumented.
service delivery, or health Financial issues will always rise to the top, but we hope to help increase availability of dollars by helping
outcomes require the greatest patients qualify for programs they are eligible for.
attention?

We will track positive screenings and compare month over month. We will also track unsuccessful
How will you identify these referrals by category to help identify gaps.
disparities in your data?

REVIEW OF AIMS AND GOALS – WEEK 5

Look back at your Program Aims and goals from Week 1. Considering what you have learned during this workshop and the decisions you
recorded in this Action Plan, do you need to revise these? If so, please write your revised aim statement and goal statements below (if
necessary).

Program Aim Statement:

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Goal statement(s):

REVIEW ACTION PLAN – WEEK 5

Look back at your Action Plan and make sure all the pieces fit together. Some key questions to consider during your review:

• Does the Workforce skillset match with the scope of • Does your patient population match with your scope of
services you chose? service?
• Does the volume goal for year one align with the overall • Will your defined metrics help track to your goals?
aim?

NEXT STEPS – WEEK 5

Each week you have been formulating key steps in your Action Plan. Review these next steps as a team and prioritize what your team will work
on over the next six months.

What steps does your team need Recruit VISTA, engage potential funding sources (United Way, Mental Health Board, Sample County
to take in the next 6 months? Community Foundation) pilot screening tool, recruit initial volunteers, develop volunteer training program,
finalize documentation procedures, train staff on program, THINK OF A NAME!

What does your team need to Must review initial progress, make changes where needed, ensure resources are kept up to date, look at
complete in the next year? expansion with other community agencies

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