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.