It is encouraging to see many healthcare systems and payers focusing on the impact of social determinants of health (SDoH) and looking for ways to partner with community-based organizations to address and improve these issues locally. Although this is a necessary step, I believe that providing access or referrals to community organizations is not the full answer. While healthcare systems can provide referrals and connect patients to resources such as food banks or employment resources, it may not be enough to create individual engagement and empowerment to use those resources. We more fully need to appreciate the role played by the environment in which we grow up and the choices available to us in shaping how we respond to SDoH factors as individuals.

As part of an innovation center where we align data science with SDoH to help systematically disadvantaged individuals, I’ve been witness to projects and research that point to the theory of individual resiliency as part of the equation. The American Psychological Association defines individual-level resilience as the process of adapting well in the face of adversity, trauma, tragedy or threats.[1] A review of the research on

resilience by the WHO found that an individual’s ability to successfully cope in the face of significant adversity develops and changes over time, and that interventions to strengthen resilience are more effective when supported by environments that promote and protect population health and well-being. Further, supportive environments are essential for people to increase control over the determinants of their health.[2]

Also, in addition to traditional resilience methods, the emergence of methods to assess an individual’s capacity for self-care are adding significant insights into personal determinants of health. In particular, the needs of the growing population of complex patients with multiple chronic conditions calls for a different approach to care. Clinical teams need to acknowledge, respect and support the work that patients do and the capacity they mobilize to enact this work, and to adapt and self-manage. Further, clinical teams need to ensure that social and community workers and public health policy advocates are part of the proposed solution. Researchers at the Mayo Knowledge and Evaluation Research (KER) Unit and the Minimally Disruptive Medicine (MDM) program led by Dr. Kasey Boehmer are developing qualitative methods and measures of capacity and individual’s ability for self-care.

Take post-traumatic stress disorder (PTSD), as an example. It has been estimated that around 50-60 percent of people in the US will experience severe trauma at some time in their lives. Around one in 10 goes on to develop PTSD, which is permanent in a third of cases. But some people who have lived through major traumatic events display an astonishing capacity to recover.[3] A complex set of factors can be attributed increasing an individual’s resiliency to trauma including their personality, their individual biology, childhood experiences and parental responses, their economic and social environment as shaped by public policy, and support from family and friends.

I could apply this to patient engagement as well. In any given population we may be able to determine which factors cause one individual to not only take a referral to a food bank but continue to receive services to improve their food insecurity versus another individual from the same neighborhood and population who did not. Perhaps the first individual connected with a case manager at the food bank who did regular check ins. Maybe they had family or friends who drove them to the food bank weekly or attended nutrition classes at the center that provided them with regular group support.

What might social determinants of health look like in 2025 if we could capture, analyze and use these “resiliency” factors or personal determinants of health? In 2025, SDoH will evolve to:

• • SDoH will evolve and morph intoPDoH – Personal Determinants of Health
  • Policy makers at local, state and federal levels will recognize the role that these factors play toward health and well-being of people and will enact policies to provide support for prevention versus late stage clinical intervention
  • PDoH will be broadly integrated into Cognitive Health Records and built into AI-based risk predictive models
  • Bridging isolation (mental and physical) will be a key focus: Transportation-driven access challenges will be addressed through co-location of services and broadly through digital technology, tele-consults (at non-traditional location such as food pantries) and drone deliveries (everyone loves drones)
  • PDoH will evolve to integrate pharmacogenetic/genetic based data and measures of self-care capacity
  • From my perspective, we will be better at understanding “who are our patients” beyond clinical diagnoses through both AI driven deep neural network analyses of PDoH data and qualitative studies leveraging discrete choice methodologies and other consumer choice and segmentation research methods

SPOTLIGHT ON PATIENT CARE:

In a collaboration between Parkland Health & Hospital System and North Texas food pantries, the partners wanted to test their ability through connected data share and cross-organizational care coordination using a social-to-health Dallas Information Exchange Portal (IEP) to impact the health care experience of food-insecure individuals with diabetes and/or hypertension.

Individuals who were enrolled in the program had a significantly higher outpatient appointment attendance and a near significant decrease in no-show/same day cancellation of appointments versus a control group. In addition, satisfaction surveys showed that 93% of respondents either agree or strongly agree that the program has made them more likely to go to their doctor’s visit. These results seem to strengthen the idea that those individuals with adequate social supports, and connectedness between the health system and community providers increases individual engagement in health and well-being.

About Vikas Chowdhry

Vikas Chowdhry, MS, MBA, is PCCI’s Chief Analytics and Information Officer with more than 15 years of healthcare experience. He works closely with data science and clinical teams at PCCI to develop machine learning driven technologies and products that can empower clinical and social services providers and individuals to create communities that are healthier and more productive. Vikas would like to thank the teams at Parkland and PCCI who helped him understand the nuances and impact ofSDoH on the people served by Parkland. Vikas would also like to thank NatashaGoburdhun from NDGB Advisors who contributed to this post.

[1]https://www.apa.org/helpcenter/road-resilience; accessed on July 19, 2019

[2] Strengthening resilience: a priority shared by Health 2020 and the Sustainable Development Goals; World Health Organization, Regional Office for Europe; http://www.euro.who.int/__data/assets/pdf_file/0005/351284/resilience-report-20171004-h1635.pdf, accessed July 18, 2019

[3]https://www.theguardian.com/science/blog/2014/dec/19/unbroken-resilience-louis-zamperini-post-traumatic-stress-disorder; accessed on July 18, 2019

 

By Natasha Goburdhun, MS, MPH, PCCI’s Vice President, Connected Communities of Care

For safety-net healthcare systems, helping patients with social needs such as transportation, food or housing, just makes sense from a mission perspective. But when it comes to creating a business case, it gets more complicated.

A Kaufman Hall survey of CFOs cited cost reduction, managing changing payment models and improving performance management as the top three challenges for health systems. So, while research may show impacts on costs and utilization from interventions that address social determinants of Health (SDoH), some organizations may not be willing to take the risk of investing in strategies that are outside their scope of service and may not show immediate financial returns. But I would argue that the impact of social determinants of health are everywhere in current health system operations and costs.

“High-utilizers”, individuals who suffer from a multitude of chronic diseases and often complex social/economic challenges, require intensive primary care, and frequently have issues with access, often gain the attention of financial and operational leadership, particularly if the organization has value-based contracts or large uninsured populations. In my experience, to truly manage this population requires addressing the upstream issues that are preventing them from leading and maintaining a healthy life.

But with limited resources and time, health systems need to develop a clear strategy by understanding exactly which individuals to treat, and what intervention will best address their healthcare and social needs.

From my experience working with the full channel of care, I believe the critical success factor in developing this strategy is leveraging data science and technology to conduct a comprehensive data analysis of the target population.

1. 1. Analyze claims, clinical, social and economic data from your community at the individual and block level, to determine what social determinants are most impacting your high-utilizer population, such as lack of transportation, food insecurity etc. Finding key contributing factors and root-cause issues for your target population is critical.
   2. Test interventions that other health systems have found lead to improved cost savings and health outcomes. Start with issues with available solutions like transportation, referrals to food banks, and housing services.
   3. Engage external partners to help you execute the intervention, particularly social services and community-based organizations (CBO) that have expertise in addressing social needs, through a collaboration with a comprehensive governance model.
   4. Measure outcomes and adjust strategies as needed.

Scale your initial interventions to other populations, and/or move to more complex social needs.

SPOTLIGHT ON PATIENT CARE:
While some health systems may not be ready to dive into a SDoH strategy, but many realize that the cost of social determinants could already be impacting their daily operations:

1. High No-Show Rates in Clinics

Average no show rates in primary care clinics are 19% with specialty clinics rates running higher, with an average cost between $125 to $350 [1].  That can add up over the course of a year to significant revenue loss for health systems. Lack of transportation or access to affordable daycare play a big role in no show rates among other SDoH. An estimated 3.6 million people missed medical treatment due to transportation issues [2].

While many health systems and health plans have implemented programs with rideshare companies to solve this problem with some success [3]. Targeting the precise patient population that will benefit from rideshare services is critical. In addition to integrating and aligning transportation services for high-need patients, health systems should also explore other emerging technology and non-traditional option to bring services to where residents already are, instead of attempting to find ways to bring them to traditional healthcare access sites. For example, use of telemedicine and digital health as well as deployment of health services in non-traditional settings such as food pantries and or other CBO settings.

2. Unnecessary Emergency Department Utilization for Vulnerable Populations

 Dallas has the fifth highest city jail population, and emerging research suggests that underlying social, behavioral and health issues, particularly substance use disorders and mental illness, contribute to incarceration and recidivism, and that treatment, combined with seamless care continuity for individuals when they return to communities, can help prevent both [4]. Parkland Health and hospital system is designated care provider for this vulnerable population in Dallas. While inmates receive healthcare through Parkland Jail Health program, upon release many former inmates end up without support and in the Parkland emergency department (ED) to seek treatment, driving up unnecessary utilization and costs.

To prevent unnecessary ED visits or a return to jail, Parkland and PCCI are developing an intelligent discharge tool and predictive risk score, combining clinical, social (housing, transportation, job training access) and behavioral factors for inmates, to help connect those being released to community resources. We are also digitally the jail health, clinical providers and community providers on one secure technology platform to better generate real-time cross-sector referrals, track utilization and follow-up, and document services. As a result, transition plans for inmates will comprehensively incorporate medical, employment and financial support like resources.

3. Manage Transitions of Care

Hospitals across the country often struggle with providing homeless patients transitional care to post-acute care facility. If an appropriate place cannot be found, many of these patients stay in the hospital longer than necessary, increasing unnecessary inpatient utilization. And there are no signs of this issue abating anytime soon. In California, hospitals discharged homeless patients nearly 100,000 times in 2017, a 28% increase over 2015.

Two different programs in California have sought to mitigate these issues for hospitals and to assist patients with their social needs. In Los Angeles, the National Health Foundation opened a 62-bed facility for discharged hospital patients who needed less intensive medical oversight than a nursing home. At the facilities, patients have access to case managers for assistance with transportation, food and permanent housing. Area hospitals will often reserve beds at the facility for homeless patients, and L.A. Care Health Plan also leases beds there for their members.

In San Jose, Santa Clara Valley Medical Center created a one-year partnership with Skyline Health Center, a local nursing home. Skyline allocates fifteen beds to the hospital for homeless patients or patients who have no one to care for them at home. During the first ten months, 55 patients were sent to Skyline, and 42 were discharged, the majority to long-term housing programs or family members and friends. Of those discharged, only six were readmitted, a low number for this population [5].

About Natasha Goburdhun

As Vice President, Connected Communities of Care, Goburdhun uses PCCI’s advanced analytics to provide detailed insights on community health and social needs and assists community organizations, payers and providers in developing strategies and impact/equity measures that address the needs of vulnerable populations. She has over 20 years of strategic planning and operations experience in health plan, provider and community-based organization sectors.

 

 

[1] https://www.solutionreach.com/blog/which-wins-the-national-average-no-show-rate-or-yours

[2] https://patientengagementhit.com/news/overcoming-transportation-barriers-to-drive-patient-care-access

[3] https://patientengagementhit.com/news/do-rideshare-tools-reduce-transport-barriers-patient-no-shows

[4] Healthcare Plays Vital Role in Reducing Recidivism; EthicsDaily.com; November 2, 2017; https://ethicsdaily.com/report-healthcare-plays-vital-role-in-reducing-recidivism-cms-24443/; accessed July 14, 2019.

[5] https://khn.org/news/finding-homeless-patients-a-place-to-heal/

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By Leslie Wainwright, PhD, Chief Funding and Innovation Officer

Addressing the social determinants of health (SDoH) in communities is a hot topic of conversation in healthcare. The industry has bought into the theory that 20 percent of an individual’s health is determined by clinical care and the rest by social, economic, genetic and behavioral factors. But perhaps more importantly health systems need to recognize that they can’t solve this issue on their own.

From my perspective at PCCI, I’ve seen an increase in value-based contracting models in recent years, and health systems and physicians are looking beyond the four walls of their institutions to build relationships with outpatient, behavioral health, post-acute care, and now non-medical providers. The number and types of collaboratives between health systems and non-traditional providers has been growing over the past several years with a recent report gathering information on over 200 different partnerships between hospital and community-based organizations across the country.

But while health systems may be embracing community provider relationships, I believe that sustainable success in addressing social determinants of health requires a fundamental shift in the way health systems view their role in improving the health of their communities.

Over the past ten to fifteen years there has been an evolution in how health systems have approached improving health outcomes. Initially health systems focused on providing high-tech solutions for care delivery such as robotic surgery, and advanced imaging techniques. Then to meet the need for increased access and demand for outpatient services, health systems seeded service areas with ambulatory surgery centers, urgent care, retail clinics, and physician offices.

In each of these evolutions the strategies centered on a solution created by the health system alone. And one could argue that the main beneficiaries of these investments were often the health systems themselves – increased market share, improved reimbursements. But such a self-centered approach will not work when addressing social determinants where the root causes lie outside the four walls of the health system.

Effectively creating a System of Community will require a collaborative mentality from health systems. While they may have power and influence to gather partners to the table, execution of successful interventions lies with social services and community-based organizations that are the experts in understanding and helping individuals address social needs.  Even if not leading, health systems should still be active participants in this work. Indeed, there are areas where their contributions to the organization of partners is critical:

• Community Health Needs Assessment

CHNAs, which all health systems are required to complete, can be a starting point for developing strategies to address social determinants of health by quantitatively and qualitatively identifying the needs of the local community. To supplement the CHNA, additional SDoH data should be incorporated to help identify needs at the block level which can help pinpoint exactly where an intervention will likely make the most impact.  These enhanced data should map and evaluate SDoH needs at the block, not zip code level, and should be supplemented with qualitative surveys to understand capacity for self-care, isolation, and learned helplessness across individuals and community.

• Governance Structure

At the core of any collaborative with community partners should be a formal governance structure that defines the policies and documentation that will enable partners to execute and measure success of their strategic interventions. A formal governance structure can also ensure that all partners have a voice at the table and may help to mitigate any fears that community organizations have that the health system is in control of the initiative.

• Legal Structure and Data Sharing

Now more than ever, technology, and indeed cloud technology, can connect disparate partners across multiple settings to exchange, share and report on data about the same community members. But there are significant legal and compliance requirements involved in sharing data across entities. Health systems have the expertise to ensure that policies around data sharing are in accordance with Medicare and HIPAA regulations. Health system experts in data privacy and security can provide advice and support to community-based providers in developing policies and procedures required to share data securely.

Improving patient engagement is at the top of the list of priorities for most health systems. The only way that a health system can achieve this is by creating strategies that start and end with the needs of the community. To find success in addressing social determinants of health, health systems will need to cede control and the notion that they need to create, lead and execute the strategy alone.

SPOTLIGHT ON PATIENT CARE: DALLAS CONNECTED COMMUNITIES OF CARE

The Connected Communities of Care (CCC) platform was first implemented in Dallas in 2014 and serves as a comprehensive foundation for partnership by leveraging a web-based information exchange/case management software platform providing seamless connection and coordination between healthcare providers and a wide array of community-based social service organizations.

Since its inception, more than one million services have been documented and more than 215,000 unique individuals who have been impacted by a network of six health care systems and over 100 community-based organizations. The novel approach to addressing SDoH and organizing cross sector information sharing through sophisticated connections has garnered national recognition and has made a lasting impact in Dallas.

Not only has this collaboration connected existing organizations in a new system of community health, it has also changed the way health systems define competitors vs. collaborators. Local health systems that may have viewed each other as competitors for services, have recognized that prioritizing the needs of the community through collaboration makes a stronger impact than any isolated intervention.

 

About Leslie Wainwright

Leslie Wainwright, PhD., is the Chief Funding and Innovation Officer at Parkland Center for Clinical Innovation (PCCI). She is passionate about entrepreneurship and innovation, and has experience that spans academic research, pharma/biotechnology and healthcare delivery.

Dr. Wainwright would like to thank Natasha Goburdhun from NDGB Advisors who contributed to this post.

 

By Steve Miff, PhD, President & CEO of PCCI

The term “social determinants of health” is far more than a trendy new buzzword in health care. Serving the physical, mental and social needs of the community is not just the right thing to do but can mean substantial improvement in care and reduction in unnecessary healthcare costs.

Several studies have shown that addressing social needs, such as food or housing insecurity, can have a significant impact on a person’s healthcare outcomes and costs. Individuals experiencing housing insecurity or homelessness have higher rates of chronic diseases such as high blood pressure, heart disease, diabetes, asthma, chronic bronchitis, and HIV.  This in turn leads to higher utilization of healthcare services such as emergency room visits, inpatient hospitalization and longer lengths of stay compared to those individuals with secure housing. Similar results are seen in those experiencing food insecurity.

Hospitals often state that part of their mission is to provide high quality care and improve the community’s health, or community benefit. A recent study of hospital mission statements in three states (Ohio, Florida and Texas) found that while quality was cited most often (65%), the second most frequently used term was community benefit (24%).[1]  If community benefit or community health is part of your health system’s mission statement, how much are you really doing to address the whole health of a community vs. just addressing their “sickness” needs?

At PCCI, our combination of data scientists and expert clinicians believe that health systems have an obligation to address social determinants of health to ultimately remove the disparities and inequality that we see in our community’s health. Yet this is tricky because success requires outreach skills, community relationships and data insights that extend beyond the traditional promise of health-related services. That said, there are three key elements that can assist health systems in making an investment in social determinants of health a reality. In order to move from theory to action, my suggestion is that health systems do the following:

1. Leverage the board’s community presence to align on areas of greatest need

As part of health system leadership, board members ensure alignment between mission and a defined SDoH strategy at all levels of the organization. As community representatives themselves, board members can also create the momentum and connections that health systems need to bring community and business partners together to create a governance structure for launching a connected community of care.  Such governance structure will guide the strategy, legal and policy needs, and the investment and execution of a connected and aligned SDoH strategy.

2. Invest in long-term partnerships to ensure sustainability

Recognize that as health systems, you alone cannot solve for social determinants. To truly meet the social, behavioral and emotional needs of some of the most vulnerable individuals in your community, you need to identify community partners with expertise in these areas. With the assistance of board members, assemble a partnership collaborative, with a formal governance structure, to build community-based strategies around SDoH needs. Support the sustainability of this collaborative with technology and data science techniques to identify specific root causes of social need in target populations, share data, and measure impact of interventions.  Identify an independent partner to evaluate the effectively of the SDoH initiatives and measure the cost, savings and impact across the community and for the health system.

3. Develop your own financial models that demonstrate the impact of SDoH

Between 2000 and 2017, hospitals and health systems across the country spent $620 billion in uncompensated care. We propose that health systems create an internal “at-risk” ACO-like model for their uninsured population and invested just five to ten percent of their annual uncompensated care dollars in developing community engagement programs to address social determinants of health.  These systems would see a three to four-fold return by addressing upstream, root causes in the community and increasing preventive, social and emotional support services to individuals in the community.

SPOTLIGHT ON PATIENT CARE

Texas Health Resources (THR), a 29-hospital faith-based non-profit health system based in Arlington, Texas has supported their mission “To improve the health of the people in the communities we serve” by creating a ten-year strategic plan to move from a hospital- to a patient-centric to a population health-focused organization. The THR board of directors has been an integral part of overseeing every step of the strategy to ensure that there is measurable and sustainable improvement in their community’s health.

Data and information gathered from regular Community Health Needs Assessments, has led to the creation of more than 200 non-profit partners across the region, including formal agreements with the American Cancer Society, American Diabetes Association and the March of Dimes, to increase health and well-being through programs focused on behavioral health, chronic disease management, child automobile safety, healthy eating, and provision of low-cost mammograms.

Board committees regularly monitor progress toward strategic goals and receive input from local community health councils and entity boards. But this commitment to community health is not just at the leadership level, employees of THR can spend between 8-12 hours of paid time annually to volunteer at local or THR sponsored community organizations to support community health efforts.

Most recently, THR announced a new initiative called Texas Health Community Impact which employed a data-driven, outcome-focused approach to identify areas of need in their communities. Mental health was indicated as a priority through the community health assessment. Zip code level data analysis and qualitative research helped them identify specific areas where seniors and youth lacked access to food and were also isolated, which led to depression and physical problems. As a result of this work, THR will distribute $5.2 million in grants to twelve agencies that will focus on interventions for these issues.

These grants only represent a portion of the financial investment that THR has made to its communities. In 2017 they provided $362.5 million in charity care, $31 million to community benefit programs and in volunteer hours, and $456.6 million in unreimbursed Medicare services.[2]

[1] Cronin, CE, Bolon, DS. Comparing Hospital Mission Statement Content in a Changing Healthcare Field. Hosp Top. 2018 Jan-Mar;96(1):28-34.

[2] https://www.texashealth.org/news/system-awards-5.2-million-in-community-impact-grants

 

About Steve Miff

Steve Miff, PhD., is the President and CEO of Parkland Center for Clinical Innovation (PCCI). He is a seasoned executive with more than 20 years of experience in healthcare analytics and consulting. He has served in various leadership positions in technology/consulting start-ups and on multiple boards. Dr. Miff is a recognized national thought leader with over 100 peered-reviewed and independent thought leadership publications.

Dr. Miff would like to thank Natasha Goburdhun from NDGB Advisors who contributed to this post.