From Screening to Action: Augusta Health's Journey to Better Health Equity

The newly required Social Drivers of Health (SDOH) measures have left a lot of health organizations challenged to find the best way to screen and support their patients’ Health-Related Social Needs (HRSNs). If you’re feeling overwhelmed, know that you’re not alone!

Recently, one of our clients was one of two national awardees honored by CMS with a Health Equity Award in 2024. This community hospital in Virginia not only successfully implemented the required measures but created a cultural shift in their patient care to further emphasize their commitment to reducing disparities in health care access, quality, and outcomes.

Augusta Health is a 255-bed community hospital located in Virginia’s Shenandoah Valley. They serve Augusta County, Staunton, and Waynesboro, as well as the surrounding areas. They use Medisolv to track and submit their eCQMs and implemented the Equitable Care Module in the beginning of 2023 to meet CMS’s new health equity reporting requirements.

Health Equity Measures – Reporting Requirements

The three health equity measures required in the IQR program are:

1. HCHE –Hospital’s Commitment to Health Equity
   1. Hospitals must attest to certain statements that demonstrate their organization’s commitment to identifying and reducing disparities in health access, quality, and outcomes.

2. SDOH 01 – Social Drivers of Health
   1. This measure captures how many inpatients were screened for all five Health-Related Social Needs (HRSNs)

3. SDOH 02 – Screen Positive Rate for Social Drivers of Health
   1. This measure captures patients who were screened positively for each of the five HRSNs.

Questions about these requirements? Check out our other blogs about these measures for more resources.

• An Intro to CMS’s SDOH Measures
• What is Social Determinants of Health (SDOH) Data?
• A Guide to CMS’s New Health Equity Measure
• 2024 Hospital IQR Requirements

Augusta Health’s Health Equity Journey

The health community has long recognized that social risk factors can negatively impact a patient’s health, including poor outcomes, increased readmissions, and a longer length of hospital stay. Many health conditions and diseases can show improvement with simple behavioral changes such as a diet with fresh fruits and vegetables, managing stress, medication adherence, and getting enough sleep.

But what if a patient doesn’t have access to healthy food or running water? What if they are experiencing homelessness and/or have unreliable transportation?

If a healthcare provider doesn’t have the full picture of a patient’s situation, they may not be able to provide the exact care they need. Limited or no running water might mean they can’t take care of that wound well after surgery. Limited or no transportation options means they will be challenged to attend follow-up appointments with their PCP.

Augusta Health recognized the critical role HRSNs play in patient outcomes and started collecting this data well before the mandate from CMS. First, they identified key stakeholders. They created a work group, which included representation from Quality, community outreach, case management, clinicians, IT, and leadership.

Additionally, Augusta Health joined a collaborative with other regional health care providers. They met on a monthly basis and were able to learn effective strategies from one another.

Opportunities to Improve

Medisolv was another valuable resource for Augusta Health. In early 2023, Augusta implemented the Equitable Care Module to track the SDOH-01 and SDOH-02 measures as eCQMs.

During their implementation with Medisolv, Augusta Health realized that while they had good foundations, there was room for improvement and cohesion. Megan Howell, Quality Data Management Coordinator at Augusta, shares some insights. “We realized that some of our team members…especially in case management, were asking the social drivers of health questions but these were being asked informally and they weren’t consistent.” These inconsistencies resulted in missing data and documentation.

Howell and her team worked to develop a health equity strategic plan for the hospital that included measures and performance goals. The plan laid the framework for the hospital, and they checked it against the CMS requirements to ensure they were meeting all the IQR requirements. The Medisolv Equitable Care Module helped to track each step of their HCHE measure for easy attestation and submission, while the SDOH measures specified as eCQMs allowed them to have near real-time insights into screening results. These results showed them what percentage of their population was screened and who screened positive for any of the five HRSNs – transportation difficulties, utilities assistance, food insecurity, housing instability, and/or interpersonal safety.

Simplifying the Screening Process

With the strategic plan in place, the team standardized their screening questions. Augusta Health had a goal to make the screening process as simple as possible.

They examined the questions from their position as healthcare providers, but also ensured that patients from a wide range of circumstances would be able to understand the questions and answer them appropriately.

When creating the questionnaire, they knew to phrase them so there would be consistency in the responses – “yes” for positive answers and “no” for negative ones.

Some patients might not understand what utilities are, so they added an example to clarify utilities might mean gas, water, or electricity.

They rolled out the screening to case management first and provided education for all case managers and social workers. This ensured that the case workers were comfortable with the questions and knew their documentation responsibilities.

In 2024, Augusta Health expanded their screening process to include the emergency department, and then to their pre-admission testing clinic for patients preparing for surgery.

In the future, they’d like to broaden the scope of the question(s) about transportation, since a patient’s circumstances in getting to work may differ from their ability to get to medical appointments. Adding these details can help to create a clearer, fuller picture of a patient’s social and economic needs.

Community Resources

As a part of this work, Augusta curated a comprehensive community resource list that they believe will be the most beneficial and impactful for patients. This resource list enables them to have possible solutions when a patient answers a screening question with a positive response.

Howell feels passionately about providing these resources and thinks that it is vital that the list is updated frequently and that there is a workflow on how the information is provided to all of the healthcare team members so they can make referrals to inpatients and outpatients.

After their first quarter of screening patients using the questions and the Equitable Care Module, they found that they had screened 66% of their inpatients; 7% of those had positive screens. They were able to identify that transportation was the highest area of need (3%) with food insecurity close behind (2%).

Positive Results from the New Screening Measures

By harnessing the power of these analytics (both with Medisolv and their own research), the team was able to drive actionable change within their communities.

Addressing Transportation Challenges

In the fall of 2022, Augusta Health implemented a mobile clinic named Augusta Health Neighborhood Clinics.

The mobile clinic team identifies strategic areas and populations where primary care services are needed the most. They began with three locations and only four clinic days a month, but now have 14 locations and serve 15 clinic days a month. Within the program’s first full year, the clinics provided over 1,700 primary care visits for 825 patients.

They are using their health equity data to ensure the mobile clinic is reaching neighborhoods with rural geographic barriers and local cities with high poverty rates and adverse social and health barriers.

Focus on Food

In 2018, Augusta Health had a vision for a farm-to-institution project that would bridge the gap between quality healthcare and access to nutritious, locally grown food. They wanted to incorporate community outreach programs focused on food security for disease prevention and community wellness.

Six years after the original seeds were planted, the farm now grows 150,000 pounds of produce.

The Augusta Health Food Pantry was established in 2021 and focuses on equitable access to nutritious foods for patients who have screened positive for food insecurity. And every week, nurses deliver 40 bags of farm-fresh produce to home health and hospice patients.

Through these programs, over 15,000 pounds of produce has been distributed to members and 2,000 bags have been delivered to patients.

Looking Ahead

Augusta Health’s vision is to be a national model for community-based healthcare systems. In response to the growing health equity concerns acknowledged by the healthcare industry, for the first time in decades, the Augusta Health Board of Directors embarked on an effort to recraft the organization’s mission statement. They wanted the new statement to better reflect the growing importance of health equity and inclusivity, along with improving health in the community.

They hosted listening sessions with diverse team members, gathered input from community partners and health systems leaders, and went through several revisions. In June of 2023, they released their new mission statement, which is “to strengthen the health and well-being of all people in their communities.”

With their new mission in mind, they continue to iterate on their processes to maintain strong community relationships so that they have resources to provide to patients who screen positive.

Augusta Health has made the most of the Medisolv Equitable Care Module and other tech to tackle disparities in their patient outcomes. They've used all the tools available to them to dig into health equity data, spotting key issues like transportation and food insecurity. Furthermore, Augusta Health has institutionalized the SDOH screening process, which not only ticks the boxes for CMS's health equity mandates but integrates seamlessly with their EHR and calculates near real-time results with these measures as eCQMs tracked in Medisolv.

We believe all these efforts show how committed they are to cutting down disparities and boosting healthcare access and quality for everyone they serve. We are so proud of them and congratulate them on their well-deserved CMS Health Equity Award. Right on Augusta.