Best Practices from the Field: Using Social Determinants of Health Resource and Referral Data to Increase Equitable Access and Connection Rates to Essential Resources

Prior to COVID-19, health care investments in SDOH programs to support connecting patients to community resources were on the rise, supported by a proliferation of technology solutions like Aunt Bertha, Unite Us, NowPow and others. These resource databases serve as critical tools for tracking the local services landscape and connecting people to the essential resources they need to be healthy (Cartier et al. 2019). However, when adopting these technology solutions to support SDOH programs, it is important to recognize that more resource information does not always result in people being connected to resources. There are best practices for managing resource information, and using and interpreting the data to effectively and equitably connect people to resources. Here, we aim to provide examples to demonstrate the ways in which data usage and interpretation can impact equitable access to essential resources and improve connection rates.

Buprenorphine for Pain: A Transition Guide from Full Agonist Opioid Prescriptions

Buprenorphine for Pain: A Transition Guide from Full Agonist Opioid Prescriptions is a tool intended to aid clinicians in switching patients off of full opioid agonists to buprenorphine, a partial mixed opioid agonist for pain management.

The information presented in this document should not be considered medical advice and is not a substitute for individualized patient or client care and treatment decisions.

Buprenorphine Resource Guide

The Buprenorphine Resource Guide is a resource that contains the various FDA-approved formulations of buprenorphine for Opioid Use Disorder and pain management. This resource guide also includes a brief history of buprenorphine and explains its analgesic effects.

Cardiac Rehabilitation Implementation Guide to Enhance Patient Referrals & Engagement

Despite the many benefits of Cardiac Rehabilitation, enrollment remains quite low – nationally, only 10% to 34% of eligible patients enroll. This resource provides guidance and tools to support awareness of the value of Cardiac Rehabilitation with patients, reduce barriers to participation, and implement evidence-based interventions, such as automatic referral with care coordination, to increase enrollment and patient engagement.

Cardiac Rehabilitation Programs – New England, New York, New Jersey, Ohio & Mid Atlantic Regions

Hospitals may treat patients who are eligible for outpatient cardiac rehabilitation (CR) that do not live or work nearby. Developing and maintaining a list of active CR programs with the facility’s address, contact information, and other relevant details can help CR care coordinators find a program that may be more convenient for the patient.

Regional listing for the following IPRO QIN-QIO areas are available:

Mid Atlantic (DC, DE & MD)

https://drive.google.com/open?id=1djV0rkR7Aamy72e4jOZ8Di5RApwtbj3o

New England (CT, MA, ME, NH, RI & VT)

https://drive.google.com/file/d/1ylOrOg67_5bzZVHq8J4Cs5qKziqEFJM9/view?usp=share_link

New York, New Jersey & Ohio

https://drive.google.com/file/d/13e8YETnQmlDO4c8WBuCNMubDYtwfkgra/view?usp=share_link

CDC Clinical Practice Guideline for Prescribing Opioids for Pain – Updated November 2022

This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1–49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1–3 months), and chronic (duration of >3 months) pain.

The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care.

The guideline addresses the following four areas:

1) determining whether or not to initiate opioids for pain,

2) selecting opioids and determining opioid dosages,

3) deciding duration of initial opioid prescription and conducting follow-up, and

4) assessing risk and addressing potential harms of opioid use.

CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation.

CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers.

CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient’s circumstances.