We’ve known for some time that social determinants – everything from poor nutrition to unstable housing to domestic violence – create barriers to health. Even if we target everything correctly in terms of medical diagnoses and care plans, social determinants can inhibit a patient’s ability to pursue and reach treatment and prevention goals.
The Affordable Care Act has focused the spotlight on population health and the importance of addressing the patient as a whole. Yet as a nation, we have fallen short in accounting for the true impact of social determinants in the overall health of our nation. Even the obvious need for integrated behavioral health remains largely unmet. While we ask patients to assume accountability for their own health, we have not adopted community accountability where obstacles clearly exist.
A 2013 report regarding potentially preventable hospitalizations found: “If the rate of preventable hospitalizations among residents of low-income neighborhoods could be reduced to the level among residents of high-income neighborhoods, there would be 500,000 fewer hospitalizations per year.”1
To diminish the effects of social determinants, we must work not only to identify the gaps that exist between clinical care and community services, but also work to collectively identify the right community resources to address closing these gaps.
Conifer Health has worked with the MediCal population for many years and has found a holistic approach to be most successful. This entails daily member evaluations for a variety of condition codes, regardless of service location. Once members have been classified, reports are analyzed based on these codes to create an overall view inclusive of behavioral health, utilization patterns, homelessness, substance abuse and more. It takes much more than addressing medical conditions to drive effective management. Analysis is of little value without the vital step of collaboration in developing action plans specific to each member.
The National Healthcare Quality and Disparities Report focuses on disparities in healthcare delivery related to racial factors and socioeconomic factors in priority populations. It finds a 55-percent miss rate in the low-income population in achieving quality measures compared to benchmarks, as opposed to a 30-percent miss rate in the high-income population.2 Researchers estimate that more than 95 percent of the trillion dollars spent annually on healthcare in the U.S. funds direct medical services, even though 60 percent of preventable deaths are rooted in modifiable behaviors and exposures that occur in the community.
Researchers estimate that more than 95 percent of the trillion dollars spent annually on healthcare in the U.S. funds direct medical services, even though 60 percent of preventable deaths are rooted in modifiable behaviors and exposures that occur in the community.3
System Reconfiguration and Stabilization
Care delivery focused on the whole person and overall population health necessitates both community collaboration and accountability. The impact of social determinants should also prompt innovation around promoting positive behaviors within our communities. The need is apparent to reconfigure the system to create communities of care where all are resolute in the collaborative effort to improve overall health within their sphere of influence.
The coordination of care is traditionally performed by nurses, care managers and social workers. Over the last few years, the use of community health workers and health coaches has shown promise. One untapped, free resource is the organization of existing patient relationships in the delivery of care. This goes beyond the education of spouses and family members. These are influential relationships that are already rooted, and each social interaction is an opportunity to promote healthy behaviors. Where is the best place to consistently make an impact? In day-to-day life.
Care coordinators are embedded in clinical practices, payer organizations and other healthcare organizations, yet meeting people where they live or work can aid in keeping a finger on the pulse of the population’s social needs. Care coordination is fueled by more than risk stratification and data. Care coordination can be a global look at the community of patients and the community as a whole. Rather than simply reacting to episodes of care, care coordinators and community assets can work to solidify the path of population health.
Care coordination is far from free. Although statistical analysis on cost savings can be partially offset by these costs, the savings from avoidable hospitalizations and improved quality outcomes is far greater. One study found that patients who received enhanced decision support had total costs of care that were 5 percent lower than those who did not receive enhanced support; additionally, they had 12 percent fewer hospitalizations.4
CMS Addressing Social Needs
The Centers for Medicare & Medicaid Services created its Accountable Health Communities Model (AHCM) based on emerging evidence that addressing health-related social needs through enhanced clinical-community linkages can improve health outcomes and reduce costs.5
CMS states: “Unmet health-related social needs, such as food insecurity and inadequate or unstable housing, may increase the risk of developing chronic conditions, reduce an individual’s ability to manage these conditions, increase health care costs, and lead to avoidable health care utilization.”
I encourage you to read about the AHCM, which will roll out over a five-year period, and will test a three-track model that includes awareness of available community services, navigation services to assist high-risk beneficiaries with accessing services, and alignment to ensure that community services are available and responsive to beneficiaries’ needs.
The AHCM is essentially a demonstration of federally funded care coordination. Like many other CMS Innovation Center pilot programs, the AHCM seeks to identify and address social needs such as housing instability and quality, food insecurity, utility needs, interpersonal violence and transportation.
At the end of the five years, CMS hopes to understand how solving these problems affects total cost of care, emergency department visits, inpatient hospital admissions, and quality of care for its high-risk Medicare and Medicaid beneficiaries.
Closing the Gap
But more work can be done in the meantime – especially with school-age children. For instance, in communities where hypertension and diabetes are prevalent, awareness can start at an early age. Care coordinators can identify opportunities within a community and coordinate efforts with community partners, health workers, health coaches, schools, churches, teachers and other influential existing relationships, to develop nutrition and exercise programs that involve students and their guardians. Engaging the youth of a community can change the trajectory of the health of an entire community for generations.
The current fragmentation of care coordination – in hospitals, post-acute settings and elsewhere – implores the hub of primary care to be closely connected to other services that stretch deep into the community. For instance, here in Rochester, New York, the Urban League and other social organizations have become partners in promoting health to ensure patients can access housing, transportation and other needs. Tapping into existing services and relationships not only supports the ROI of care coordination efforts, it also increases the collaboration and accountability of each organization to the citizens in the community.
Innovating the way we engage patients within our communities by leveraging existing relationships, care coordination, reciprocal mentorship and collaboration, can facilitate mitigating the impact of social determinants on the overall health of a community.
Read other articles in this care coordination series:
- Centers for Disease Control and Prevention. Potentially Preventable Hospitalizations – United States, 2001-2009: Results. November 2013.
- Agency for Healthcare Research and Quality. National Healthcare Quality and Disparities Reports. Accessed in February 2017.
- The New England Journal of Medicine. Accountable Health Communities – Addressing Social Needs through Medicare and Medicaid: p. 1. January 2016.
- Health Affairs. Health Policy Brief: Patient Engagement. February 2013.
- Centers for Medicare & Medicaid Services. Accountable Health Communities Model. Accessed in February 2017.