SDOH Clinical Care
0.1.0 - STU 1

This page is part of the SDOH Clinical Care for Multiple Domains (v0.1.0: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 2.0.0. For a full list of available versions, see the Directory of published versions

Patient Story 1 Personas

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Patient Persona

Persona Name Rebecca Smith
Role Patient
Age 32
Ethnicity African American
Primary Language English
Highest Education Level High School
Employment Status Employed
Clinical Health Concern Asthma
Social Risk Factors housing instability, history of food insecurity, transportation barriers
Location San Francisco
About Persona Rebecca is an admin assistant at a local community college in town earning $30,000/year. She recently separated from the father of her 3 children (ages 18mo (Lily), 3 (James) and 6 (Anna)). Her children’s father has not sent child support and living on her one salary while supporting the needs of three children is difficult. Initially, after the separation, she had to stay with friends, then she found a place briefly, but they got evicted when the landlord sold the building. She has recently found a small apartment in the city, but the rent is high. Much of her salary goes to childcare, diapers, and rent, leaving little left over. Either utilities or rent are late month to month. She gets caught with shutoff letters from the utility company, but she needs electricity for her nebulizer and critical needs of her young children, resulting in healthy and abundant food being sacrificed to pay the bills. It has all happened so fast she has little awareness of the resources that might make it all better. Rebecca’s asthma is poorly controlled, and she has missed several days of work after running out of medication. Although she measures her peak flows and found them consistently in the yellow zone, and even red at times, she has not been able to control the asthma by adjusting her medication because it is expensive. To compensate, she tries to space out doses to make them last longer. She feels if she just could settle some of the stresses of living, things would be okay. She does not own a car and relies on public transportation. Between home and daycare and work, she spends two hours on the bus daily.
Typical Routine & Interactions Rebecca’s typical day is to rise at 6am to get the kids up and fed. She needs to drop them off at daycare at 7:30am in order to get the many buses to work and be there by 9am. She picks the children up again at 6:30 pm and then it is home, dinner, baths and bedtime. This repeats daily.
Challenges & Goals With rent, childcare, utilities and basic necessities of 3 young children, her salary is simply not stretching far enough. She saves money by buying low-cost foods such as macaroni and cheese and cereals and spacing out her asthma controller medication to every other day instead of daily. She cannot afford fresh fruits and veggies. She is so tired at the end of the day she does not have much left to give. She is uncertain whether she will receive child support payments anytime soon. Rebecca’s goals are to control her asthma condition, find more affordable medication options, feed herself and her family well, and to settle into stable, affordable, and environmentally safe housing.
What Persona wants from health care system Treatment plan that addresses both her asthma condition and life situation. Contact information for social worker or case manager. List of affordable and accessible food options. Referral to case management to access available Federal or State benefits.


Primary Care Physician Persona

Persona Name Dr. Carla Sanchez
Role Primary Care Physician to Rebecca Smith and Family
Age 40
Ethnicity Hispanic
Primary Language English
Qualifications (Practitioner) MD
Employment Status Employed
Organization (Practitioner) Sanchez Family Practice
Location San Francisco
About Persona Carla is a caring, competent, and innovative doctor. She is married with two young children. She really enjoys being part of a community and having long term relationships with her patients. She has been in private practice for 12 years and works alongside another Family Practitioner, an Advanced Nurse Practitioner, a Care Coordinator, two Clinical Staff Members, and two Front Office Staff Members. Carla’s practice recently became an NCQA Level 3 Patient Centered Medical Home (PCMH).
Typical Routine & Interactions Carla’s day begins with hospital rounds seeing an average of two to four patients and continues in her office seeing about nineteen patients. She often sees patients with social risk factors that she cannot readily address as a clinician. The practice sees fifty patients per day and makes another fifty phone calls a day for transitions of care and population management. Carla feels her EHR does a good job with prescription writing and medication reconciliation but is not useful with helping her document non-clinical findings.
Challenges & Goals Carla is becoming overworked and on the verge of burnout. Carla is aware of other practices starting to incorporate social risk screening tools into the clinical workflow. She would like to use her EHR to conduct initial screening for her patients and to document social risk observations during a clinical counter. She is frustrated with the lack of guidance on what codes she can use to document screening, diagnosis, goal setting, and interventions activities and thereby facilitate payment. She also struggles on how to better coordinate referrals to community-based organizations. Most referrals are unidirectional, and she does not know whether the patient was seen by the referred to provider or what the outcome of the intervention was. Her practice recently adopted a new screening tool to use for all annual wellness visits.
What Persona wants from health care system Carla wants to provide team-based whole person care, and she wants to be able to work with her clinical staff and their EHR system to document both clinical and social risk information for her patients. This will improve her and her team’s ability to identify the right interventions to meet their patients whole person needs. She wants herself and her team to use the EHR system to access relevant patient information existing in clinical and non-clinical settings, including the following: past social risk screenings, problem list, medications and refill pattern, and diet history. She wants herself and her team to use the EHR system to support electronic closed-loop referrals to community-based organizations which can assist with navigation for specific services and programs and, in turn, optimize the care coordinators time, provide broader mitigation of the needs, enhance the overall results, and lead to higher patient and provider satisfaction. Carla would also like to more efficiently aggregate social risk data on her patients to improve her practices quality improvement initiatives.


Care Coordinator Persona

Persona Name Reeza Shah
Role Care Coordinator
Age 30
Ethnicity Asian
Primary Language English
Qualifications (Practitioner) LCSW
Employment Status Employed
Organization (Practitioner) Sanchez Family Practice
Location San Francisco
About Persona Ms. Shah is a compassionate licensed social worker working at the Sanchez Family Practice. She recently joined Carla’s practice to support the PCMH care coordination activities. She enjoys working with patients and family members in managing their health and connections to the community.
Typical Routine & Interactions Ms. Shahs day begins at the clinic reviewing emails and confirming her schedule for the day. Having access to patient data in the EHR is helpful. However, social risk data relevant to some patients is not always available or is recorded as free text in a notes section of the EHR, making it difficult to locate consistently. Not all patients have been screened for social risk factors. Reeza enters her encounter notes in between patient visits, while at lunch, or after seeing all patients for the day. On busy days, she sometimes has to finish charting after working hours.
Challenges & Goals The ability to administer social risk screening questions from the EHR has been helpful from a workflow perspective; however, it is a challenge to integrate and act on the data as part of the diagnosis, planning, and treatment activities. Ms. Shah wants to be able to document social risks in the EHR in a coded way so that it can be readily incorporated in the patient record, inform the care plan, and be used to identify the appropriate interventions. Ms. Shah is unsure how regularly Dr. Sanchez and her partner read her notes in the EHR or whether they are implementing her recommendations into a shared care plan for the high-risk patients.
What Persona wants from health care system Ms. Shah wants the ability to communicate with Dr. Sanchez and the other clinicians more directly. She would like the referring clinician to complete a standard referral template including reason for referral. For every referral, she wants to know whether they have had a social risk screening completed and what interventions have been identified by the PCP.


Clinical Staff Member Persona

Persona Name Samir Patel
Role Clinical Staff Member
Age 27
Ethnicity Asian
Primary Language English
Qualifications (Practitioner) RN, MA
Employment Status Employed
Organization (Practitioner) Sanchez Family Practice
Location San Francisco
About Persona Mr. Patel is a passionate and dedicated clinical staff member. Mr. Patel recently began administering social risk screening questions to all annual wellness visit patients. This is a new workflow and he often feels uncomfortable asking patients some of the questions.
Typical Routine & Interactions Mr. Patel spends most of his time triaging all the practice patients. When a patient checks in for a visit, he is responsible for finding and escorting the patient to the exam room. He is the main staff member responsible for administering the social risk screening questionnaire for all annual visits and entering the patient responses in the EHR. He recently completed an Empathic Inquiry training class to help with his administration of the social risk screening questions. He knows some questions are challenging for some patients to answer.
Challenges & Goals Being able to administer the screening questions while remaining sensitive and empathetic to a patient’s need, preferences, strengths, and weaknesses. Creating trust with patients so they feel comfortable answering the questions.
What Persona wants from health care system Mr. Patel is not fully comfortable asking all the questions in the screening tool. He would like to find other modes of administering the questionnaire before or after the visit.

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