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 Non Medical Drivers of Health (NMDOH), 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 Non Medical Drivers 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 NMDOH 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 NMDOH. 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 Non Medical Drivers of Health (NMDOH) 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 Non Medical Drivers 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.1SDOH2″ alt=”” width=”917″ height=”555″ />

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 Non Medical Drivers of Health by quantitatively and qualitatively identifying the needs of the local community. To supplement the CHNA, additional NMDOH 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 NMDOH 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 Non Medical Drivers 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 NMDOH 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.