Chronic Care Management – Incorporating Social Drivers of Health Project

Last Updated: Oct 18, 2023

The Pennsylvania Medical Society’s (PAMED) “Chronic Care Management – Addressing Social Drivers of Health” is a CME-accredited initiative designed to support the incorporation of social drivers of health (SDOH) screenings and tools into chronic disease management. 

The Nature of the Project

• PAMED is piloting a Performance Improvement activity; up to 20 AMA PRA Category 1 Credit(s)™ will be awarded to physician participants who are PAMED members.
• Up to 20 practices in underserved communities will be selected for the project.
• Selected practice sites will choose one chronic condition — either asthma, cardiovascular disease, COPD, or diabetes — and identify 1-2 quality improvement metrics to target throughout the year, along with corresponding social drivers of health that could impede positive patient outcomes.
• The practice site will conduct periodic chart audits throughout the year which will be used to track progress and change tactics if needed.
• Participating locations will upload Excel spreadsheets (or other report which captures appropriate data) to PAMED’s online application portal. PAMED project staff/contracted consultants will review and give feedback to providers. 
• Working in collaboration with the practice site, PAMED will create and provide a comprehensive list of SDOH resources, based on geographic region, for the health care team to reference, and focused handouts for patients to reference during and after the visit.
• Applicable patients seen by a participating provider will be given a brief survey at the end of each visit related to discussions with the provider about SDOH resources. Surveys will be returned by mail (envelope provided by PAMED). This is a voluntary survey which will be directed to PAMED for compilation. Patients can complete the survey anonymously. If they wish to provide their name and contact information and acknowledge on the survey that they are sharing some personal healthcare data, a social worker or social worker in training will be available at no cost to contact the patient to further explore SDOH resources.

What’s in it for the practice?

• Administrative stipend paid to practices selected.
• CME opportunity for PAMED members (20+ credits for physicians).
• PAMED provides tracking tools and supporting materials/resources for patient engagement.

Rules for applying: 

• Must be a member of PAMED. 
• Must be a physician-focused project. For every 5 participating physicians, one CRNP or PA may be included.  
• Each project will target only ONE chronic condition in the practice.

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Questions? Contact CMEAdmin@pamedsoc.org.