WA Portal Blog

Social Determinants of Health

December, 2019 -- Today, while working at the Family Birth Center, I reviewed some of the Social Determinants of Health that I had learned during my Public Health education in Houston, Texas. I talked about them with the residents in service. 

This was prompted by my meeting with a Hispanic family who mentioned during our conversation that they were undocumented in the United States (long-term immigrants). They had not been able to learn English since they have had to work 2-3 jobs to be able to make ends meet. They have four children, born in the United States, who are US citizens and communicate in two languages (English and Spanish) as do the great majority of first-generation individuals in the United States. The children are insured by Medicaid and can access care using their insurance. However, the parents are not very savvy on accessing and obtaining regular care due to difficulties navigating the system. This family exemplifies the importance of becoming a Patient Centered Medical Home. All staff members were aware of the difficulties the family had faced during the care of their children. We explained to them in their native language the resources available to them. We reached out to the social worker who provided them with information about the way to continue their health care after discharge from the hospital. 

The WA Portal has great resources for providers, staff, administrators, and other people interested in learning more about Social Determinants of Health and ways to mitigate their effect on health care. There are also resources on transformation of practices that take into consideration the Social Determinants of Health of our patients and families. Take a look at this great podcast from the Institute for Healthcare Improvement

This podcast explains the best way for Moving Upstream, addressing the quadruple aim through screening for Social Determinants of Health and the subsequent intervention to mitigate their effect on health. 

Please let me know what you think. Is this appropriate for your center? How can we help you to improve this aspect of your Practice Transformation?


Adriana Linares, MD
Adriana C. Linares, MD, DrPH
Blog Editor
Family Medicine with OB
PeaceHealth, Vancouver, WA

From the editor -- I am a Colombian family physician who has worked in Washington state for the past five years. I moderate this blog as part of the transformation efforts of our team.

We will explore the four aims, or pillars, of health care, and welcome your feedback, comments, criticisms, and especially solutions to some of the topics we discuss. Please let us know what you think.    - Adriana Linares


Critical Crossroads: Pediatric Mental Health Care in the Emergency Department. A Care Pathway Resource Toolkit

November, 2019 -- In my role as a faculty member at a Family Medicine Residency Program, I treat adults, children, pregnant women, and elderly patients. My hospital has had an increase in the number of children with mental health issues. When treating these children, we face many barriers, including the lack of: resources, providers who treat children, follow-up after discharge, and lack of facilities that will accept children for inpatient care. 

The Federal government, as a response to the psychiatric-care crisis, published a toolkit for treatment of children seeking care for a mental health crisis in emergency rooms. Our collaborators reviewed the toolkit and they recommended it as a very important resource for the creation of a process to treat children in an emergency department (ED). You can find the toolkit in our portal.

Furthermore, the toolkit describes best practice for follow-up after discharge and recommends methods for accessing resources in communities. This toolkit plays an important role in helping organizations in the state of Washington streamline their care and service for children. 

What do you think?  Will this toolkit work for you?



October, 2019 -- Do we still need them? I have been out in different locations for the last 3 weeks participating in different learning opportunities. I am surprised by the number of presentations targeting opiate epidemic and use of Medicated-Assisted Treatment (MAT).

Twenty-five years ago, when I was in graduate school (Public Health – University of Texas Health Science Center) we learned about the fifth vital sign: pain. The implication was that we needed to change our approach to managing pain and none of our patients should feel any pain. We used a scale from 0 to 10 and we had drug treatments for each of these numbers.

Today, after the realization of the association between prescription opiates and overdoses, we have gone to the other side: none of our patients should be receiving any opiates.

Where is the balance?  How do we decide the next steps?

In Washington State, we must review the PDMP (Prescription Drug Monitoring Program) website every time we are prescribing any Schedule II medicine.

We have obtained and curated several resources related to the opiate epidemic and MAT. The Collaborative Care for Chronic Pain is one of them. This project, as part of the Dr. Robert Bree Collaborative, was a study around the state of Washington that made several recommendations to improve the care of patients with chronic pain.I would like to get your comments related to what is next with the use of opiates. Do you think the approaches to the use of opiates are appropriate? Do you think they are too strict?  Please let me know. We can start a great conversation.


Create a My Portal Team

August, 2019 -- There's a great feature on the WA Portal that allows you to create and work with a team. It lets you communicate via the portal, share resources, review strategies, and send comments about resources to all the members of the group. Here's how!

  • All members register for a My Portal account here
  • Answer all demographic questions and, if work is not associated with an Accountable Community of Health, click "I don't know" for that required field. 
  • Subscribe to Exchange Notifications - Check this box to be notified of new exchange postings within the team(s) you belong to. Subscribing to notifications is essential for Learning Community participation. 

Then, we have a great video tutorial with step-by-step instructions on how to create a My Portal account. You'll find help here for creating a team, inviting people to the team, sharing resources, and more.Please give it a try and send comments so we can continue to improve the process.


Subscription Model

          by Adriana C. Linares, MD, DrPH

July, 2019 -- All of us know that a major expense of medical care in the United States is the cost of prescription medicines. Why is it that we pay such high prices for medicines in this country?
One theory is that insurance companies and the Centers for Medicare & Medicaid (CMS) are not able to negotiate directly with manufacturers to buy medicines. Well, good news: “Washington State is one of the states that has been approved for a modified 'subscription model' for payment through Medicaid (Apple Health).”

The Washington State News (June 13, 2019) reported that the Centers for Medicare & Medicaid Services (CMS) approved Washington State’s proposal to negotiate directly with the manufacturer for drugs purchased through state Medicaid.

What do you think? Please send comments so we can start a dialogue about this.


Maternity Care as Part of the Patient Centered Medical Home

          by Adriana C. Linares, MD, DrPH

June, 2019 -- Recently I read two articles published in the NEJM, New England Journal of Medicine, about Maternal Mortality and Postpartum care.  The first article reviewed the latest statistics and provided the new recommendations by ACOG to prevent maternal mortality. The second article talked about the importance of social determinants of health to improve postpartum care in the United States.

I found a great resource in the WA Portal Resource Library for clinicians, psychologists and social workers called Before, Between & Beyond Pregnancy: Resource Guide for Clinicians.  This tool provides resources to improve the care of women of reproductive age before they get pregnant, during pregnancy, and after pregnancy. In addition, when looking at this resource I found a link to the Reproductive Health Maternal & Child with great links to other aspects of maternity care.

I invite all of you to check out these resources. They are invaluable for improving the care we provide when working in the context of the Patient Centered Medical Home.


  1. Mann, S, Hollier, LM, McKay, K, Brown H. Perspective, November 1, 2018. What we can do about Maternal Mortality-And How to Do it Quickly. N Engl J Med (379;18: 1690-1691.
  2. Murray Horwitz, ME, Molina RL, Snowden JM Postpartum Care in the United States – New Policies for a New Paradigm N Engl J Med 379:18; 1691.

Please send your comments. I will be glad to review and answer them.Take care!!


The Triple Aim: An interview with Dr. Donald M.Berwick

          by Adriana C. Linares, MD, DrPH

March 5, 2019 -- Hello. This afternoon while precepting at my clinic I received an e-mail from the IHI (Institute for Healthcare Improvement). They were advertising a blog by Dr. Donald M. Berwick related to the Triple Aim.

I would like to encourage all of you who are interested in this topic to read this great interview. What I liked most was the end of the blog where they talked about what surprised doctor Berwick about the Triple Aim concept. He mentioned that social determinants of health need to be taken into consideration when trying to reach the Triple Aim in different organizations. He ends with the following quote:

“There are some good programs. Some countries have programs and approaches that we need to copy, but we are taking baby steps so far on the health of populations and giant progress is available if we want to go for it.”


New name, continuing mission

Our new name

February 14, 2019 -- The Practice Transformation Support Hub Resource Portal (WA Portal) started life as part of the federal State Innovation Model (SIM) initiative. A collaborative effort led by the Washington State Department of Health’s Systems Transformation team and the University of Washington’s School of Medicine Primary Care Innovations Lab, WA Portal will continue as the SIM initiative sunsets. As we move into this next phase of WA Portal, we’ll do so with a new name:

Healthier Washington Collaboration Portal
Resources to support Washington State’s health and wellness community

We’re changing the formal name, but we’re continuing the same mission of providing a collaborative environment—or virtual workbench—to help our partners in the state’s health and wellness system share and connect with the resources needed to meet their innovation and transformation goals.

Why Healthier Washington?

Since Governor Inslee launched the Healthier Washington initiative in 2014, it’s been synonymous with work done as part of the SIM funding. But its triple aim of better health, better care and lower costs for Washington residents doesn’t end with SIM.

As the governor stated in 2014, “Our goal is to help Washington’s seven million residents lead healthier lives and access the best quality health care at the best price…”

That work continues under the Healthier Washington umbrella. Healthier Washington is an ongoing, multi-partner, multi-faceted effort to help improve the health of people in our state, and our state’s health and wellness system.

WA Portal’s new formal name reflects that broader meaning.

We’re still WA Portal

We may have changed our name to better describe our ongoing mission, but we’ll always be WA Portal.

We created WA Portal with and for Washington’s health and wellness community. And, as our new name suggests, we look forward to our continued collaboration.

Thanks to all of our partners! Your ongoing support makes WA Portal possible.

- The WA Portal team


The Children’s Behavioral Health Integration and Value Transformation Toolkit

      by Blake Edwards, MSMFT, LMFT, CMHS, Behavioral Health Director-Columbia Valley Community Health; Statewide Lead Behavioral Health Champion-Pediatric Transforming Clinical Practices Initiative, Washington Chapter of the American Academy of Pediatrics; Governing Board Member-North Central Accountable Community of Health

January 2019 -- To the extent we as health care providers resign ourselves to treatment in a vacuum, we neglect person-centered care by perpetuating a system in which treatment revolves around silos rather than around the needs of a whole person. Collaboration is essential to effective health care, not elective.

We each naturally and necessarily engage in our work with people from differing areas of expertise. That being said, psychotherapists, psychologists, psychiatric prescribers, social service specialists, as well as primary care physicians—and, I should add, other health care specialists and education and community-based partners—best serve their clients and patients when they integrate efforts to provide care. Within the treatment fray, conscientious providers aim to treat the whole person, not just the part they are naturally apt to see at first assessment. A collaborative approach enhances communication of evaluative and ongoing therapeutic feedback, increases clinicians’ adherence to the treatment plan, and helps reduce risk, frequency of crises, and unnecessary emergency room visits and inpatient stays.

In the coming years, behavioral health agencies will be paid based on measurable health outcomes and demonstrable evidence of value, rather than strictly through fee-for-service or no-risk capitated payment arrangements. Value-based payment is shaping up along a continuum, with statewide efforts enabling providers to move along that continuum. This involves risk sharing and incentives to reward providers for achieving quality. So, how can behavioral health agencies make a positive impact on the quality and effectiveness of physical health care, on achievement of standardized population health measures, on improving client/patient experience, and on reducing unnecessary costs of care?

I developed the Children's Behavioral Health Integration & Value Transformation Toolkit to support children's behavioral health agencies in Washington State in taking practical steps toward integrated care and value transformation. It is not intended as a blueprint but, truly, as a "toolkit" from which to tailor vision and practical steps in a direction that may be right for a particular behavioral health agency. Those behavioral health practices enrolled in Pediatric TCPi will receive training, technical assistance, and coaching through the grant initiative, but the toolkit itself is being offered widely as a free resource.

We see more effective treatment outcomes when we share not only our perspective but also responsibility as we partner to provide optimal care. It is important for behavioral health providers to be well connected to and collaboratively engaged with multidisciplinary care teams to ensure that the most effective and integrated treatment that can occur does occur.

Blake Edwards


First step to obtain NCQA Recognition - Creation of a Team

December 2018, Adriana Linares -- We have all heard about the special recognition that some medical practices are applying for.

What is the importance of that recognition?

Health care in America is evolving. A lot of payers are switching from the fee-for-service model to a model that reimburses based on quality and metrics. Practices that want to be successful need to complete all the requirements to compete in this new environment.

What are benefits to medical practices?

The benefits are several. One of the most important is that practices provide better care to patients with less resources and with clear workflows that help each person in the team work at their highest level of competence. The PCMH model encourages the fulfillment of the Four Aims for Quality Medical Care: Patient satisfaction, Medical care, Low cost and Staff satisfaction.

I have a story to tell

In 2014 my clinic in Vancouver, WA decided to apply for NCQA recognition as part of the transformation to be a Patient Centered Medical Home. What was the first step for this clinic?

Team Creation

The stakeholders and the staff determined participants in creation of the different requirements to apply for NCQA recognition. After that, they created a list and started the learning process. A lot of research, internet searches, contact with different people who had gone through the transformation, etc.

How did they keep the information organized? How did all the people access the information?

The clinic created a work space in their shared drive to collect all the information obtained by different members of the team. The shared drive repository has been a life-saver for the clinic. The subsequent applications have gone smoothly since all the information related to NCQA and PCMH is located in one place.

Reviewing the WA Transformation Portal, I found something very similar: My Portal Teams. This feature allows practices to share problems, challenges, resources within the practice and with other practices that are going through the process. They have list-servers, repositories of data, virtual meetings. My Team is a great tool that all the participants can access at any time (at their convenience) where they can post comments, share resources, ask questions, write ideas to be shared with all the team members.

I invite all of you to review this resource. Please let me know what you think.

Teams User Guide



November 2018 -- By now, I think all of us involved in health care have heard this word. Burnout was defined by Christina Maslach and her colleagues at the University of San Francisco as “an erosion of the soul caused by a deterioration of one’s values, dignity, spirit and will.”

When talking about the best way to optimize health system performance we think about the three aims: enhance patient experience, improve population health, and reduce cost. However, an article by Thomas Bodenheimer and Christine Sinsky describes a fourth aim: improve the work life of health care providers including clinicians and staff.

I attended the AAFP FMX in New Orleans this year. This meeting of several thousands of family medicine doctors had a specific path related to physician well-being. The AAFP also organized the first-ever meeting related to wellness this year: Family Physician Health and Well-being Conference.  The next meeting is in Phoenix, AZ, June 5 to June 8, 2019. Something is going on.

What is going on?

Why are all the stakeholders, organizations, boards, residency programs and medical, nursing school and other entities concerned about this? How can we improve the way we deal with Burnout of staff and clinicians when working within the Patient-Centered Medical Home?

We have several resources available. Healthier Washington: The Practice Transformation Support Hub provides access to articles related to wellness, resilience, burnout and prevention of suicide. One resource that I found useful and pertinent is about the Washington State Medical Association's Physician Wellness website. This site provides information about ways to promote wellness programs at the local and national level.

1.    Bodenheimer T, Sinsky C. From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider. Annals of Family Medicine, November/December 2014 vol 12 no 6 573-576.

Please comment on this. I hope the information is useful for you.



The 4th Aim of Practice Transformation

We are going to write about the four aims, or pillars, of health care. We decided to start with the fourth aim.

To be able to excel on our work, we as health care workers need to be satisfied.

I attended the American Academy of Family Physicians FMX (Experience) meeting in San Antonio, and came back motivated and ready to continue my efforts for excellence in health care. You know what helped me? The American Academy of Family Physicians presented a new portal: Physician Health First. It provides great resources, strategies and evaluations to enhance physician wellbeing. The Academy has heard its members and is working on trying to alleviate some of the problems associated with health care in the United States that burden the practice of medicine in our country.
I invite all of you to review the resources available on the WA Portal related to well being. We have included also resources related to staff wellness and providers in different areas of medicine.


Clinical Data Repository (CDR) Application for Behavioral Health Providers

October 2018 -- Behavioral health providers contracted with Medicaid now have free access to OneHealthPort, Washington state’s Provider Data Service and Health Information Exchange (HIE) system, for a more comprehensive view of a client’s engagement in care.

As an HIE system, OneHealthPort houses the Clinical Data Repository (CDR) which allows users to view client/patient data for “the purposes of managing treatment, payment or business operations” (OneHealthPort, 2018). The CDR contains data for all Medicaid beneficiaries. The CDR allows for shared care planning as it contains claims, EHR data and utilization history for medical, dental and pharmacy lines of service.

Behavioral health providers can access the CDR at no cost to look up client utilization history and to view uploaded clinical summary documents. As an additional service, providers on the CDR may connect their EHR platforms so clinical information can be stored, accessed, and aggregated in one location. For example, a behavioral health provider can access the CDR to identify a client’s engagement in the healthcare delivery system to enhance coordination with other providers involved in client care.

Simply, the CDR is a population health tool to improve and coordinate whole-person care. Why not become a CDR user?

To learn more about the CDR and how it can benefit your practice contact Deb Hemler, Vice President of Development with OneHealthPort.

By:  Pierce County ACH's Strategic Improvement Team

OneHealthPort. (2018, October). Use of CDR. Retrieved from OneHealthPort: http://www.onehealthport.com/cdr/use-cdr


Collaborative Care Model for Behavioral Health Integration

Joseph Cerimele MD, MPH Co-Investigator and Curation Lead  cerimele@uw.edu
Joseph Cerimele MD, MPH
UW Medicine Department of Psychiatry

My clinical work includes working as a consulting psychiatrist in two ways in primary care clinics – one as a direct consultant using telehealth technology to see patients, and the other as an indirect consultant in a population based model of care called collaborative care. The Portal includes resources on both models of care. The Telepsychiatry Toolkit from the American Psychiatric Association provides background information on telepsychiatry, along with clinical training, reimbursement, and technical considerations. Telepsychiatry is one way to distribute specialist physician visits to areas with fewer specialists such as psychiatrists. Reimbursement for telehealth is expanding under MACRA, and 49 states cover telepsychiatry under Medicaid. Collaborative care is team based care involving the primary care clinician, a care manager, and a psychiatric consultant. Resources from the AIMS Center at the University of Washington are included in the Portal and are standard tools for clinics to use in deciding whether or how to implement collaborative care. One recent example is the Financial Modeling Workbook that can help organizations understand associated costs and revenues. Is your site working on new strategies for telehealth or on implementing a population based model of care such as collaborative care? Check out the Portal for resources.


Social determinants of health are central to health care

​   Ian Bennett, MD, PhD Professor, UW Department of Family Medicine Co-Director ibennett@uw.edu  ​
Ian Bennett, MD, PhD
UW Medicine, Departments of Family Medicine and Psychiatry & Behavioral Sciences

Early this week I had an encounter with a relatively new patient to me, which made me pause. She was desperately upset, saying she had been told by an ED physician that she “has lung cancer.” The physician had been evaluating her for possible pneumonia. I reviewed the discharge materials she had been given and found there was no mention of any sign of abnormalities in the range of imaging that was done. It turned out that this 50-year-old Washington native had dropped out of school early and was illiterate, which contributed to her misunderstanding the comments of the ED doc (probably related to them doing some smoking cessation counseling). Unsurprisingly, she and her family faced additional obstacles to health care involving lack of employment, housing, and insurance.

While sociologists, educators, and economists have pointed to the role of social factors in health and well being for decades it has only been in recent years there has been increasing awareness of the crucial role that social determinants of health (e.g., education and income), have on health throughout the lifecourse. As described in a recent article about screening for social determinants in primary care pediatrics, health care delivery sites can make a big difference in connecting patients to community services. These linkages improve the effectiveness of the health care delivery as well and lead to better health outcomes. The accountable communities of health (ACHs), throughout the state of Washington have made connection of community resources to the health care delivery systems a priority. WA Portal

Find out more about the opportunities to link community services to the work of care delivery sites by searching “social determinants” on the WA Portal resource library.