Ad­dress­ing so­cial de­ter­mi­nants of health

Modern Healthcare - - INNOVATIONS - By Rachel Z. Arndt

Most of what de­ter­mines how healthy you are isn’t med­i­cal—it’s so­cial and be­hav­ioral. Re­searchers at the Univer­sity of Cal­i­for­nia at San Fran­cisco have found that be­hav­ior ac­counted for roughly 40% of all deaths in the U.S. Mak­ing pa­tients health­ier through pre-emp­tive in­ter­ven­tions rather than re­ly­ing solely on med­i­cal treat­ment can sig­nif­i­cantly de­crease health risks.

That idea drives Health­ify, a soft­ware suite that gives providers and oth­ers re­sources to con­nect pa­tients with com­mu­nity or­ga­ni­za­tions that can help ad­dress such is­sues as food in­se­cu­rity and af­ford­able hous­ing.

Af­ter work­ing in Bal­ti­more health clin­ics and see­ing how health­care failed to ad­dress the so­cial de­ter­mi­nants of health, four re­cent grad­u­ates of Johns Hopkins Univer­sity founded the com­pany; they’ve since moved to New York. “What we saw on the ground was that the big­gest needs fam­i­lies had were not clin­i­cal needs,” said Manik Bhat, co-founder and CEO. “They were so­cial needs.”

These so­cial needs started com­ing to the fore­front of medicine af­ter the pas­sage of the Af­ford­able Care Act, which put a greater em­pha­sis on pa­tient out­comes and pop­u­la­tion health. But at­ten­tion hasn’t nec­es­sar­ily meant suc­cess, and or­ga­ni­za­tions have strug­gled to fig­ure out how best to im­prove health through un­con­ven­tional means. Health­ify is out to help in that strug­gle.

“This is one of the best ways to re­duce costs over time for the most at-risk pop­u­la­tions,” Bhat said.

But fig­ur­ing out which prob­lem to tackle first isn’t easy. Very of­ten, pa­tients deal­ing with un­healthy di­ets live in so-called food deserts and likely face lim­ited trans­porta­tion op­tions. It’s also dif­fi­cult fig­ur­ing out which pa­tients have which needs. What’s more, once a con­nec­tion is made with a so­cial ser­vices or­ga­ni­za­tion, it’s tough to know if the pa­tient fol­lows through and if there was any sub­stan­tive re­sult­ing change.

Health­ify at­tempts to an­swer all of those ques­tions. The plat­form in­cludes search, for find­ing providers and com­mu­nity or­ga­ni­za­tions; track­ing, for keep­ing track of re­fer­rals and pa­tients’ needs; and co­or­di­na­tion, for get­ting mul­ti­ple part­ners in­volved. The com­pany cur­rently has 25 en­ter­prise clients, a mix of providers, gov- ern­ment or­ga­ni­za­tions and health plans, many of which are Med­i­caid man­aged-care plans. “We’re grow­ing very rapidly,” Bhat said, draw­ing on the $2.5 mil­lion in seed fund­ing the com­pany raised in 2016.

When a pa­tient comes into a care set­ting, a care man­ager can screen the pa­tient us­ing the Health­ify plat­form, fig­ur­ing out what the pa­tient’s so­cial needs are, and then help con­nect them to the proper ser­vice, us­ing the search tool, and make a re­fer­ral. The Health­ify plat­form, which in­te­grates into elec­tronic health records, then takes over, send­ing the pa­tient text-mes­sage re­minders about the re­fer­ral and let­ting the care man­ager know if the pa­tient showed up. “These bidi­rec­tional re­fer­rals let you co­or­di­nate with mul­ti­ple dif­fer­ent part­ners,” Bhat said.

Ac­cessHealth Spar­tan­burg, a South Carolina not-for-profit that helps con­nect low-in­come, unin­sured peo­ple to physi­cians, uses Health­ify in its screen­ing process. The soft­ware is in­te­grated into its case-man­age­ment soft­ware, and it links pa­tients to or­ga­ni­za­tions that might help with so­cial de­ter­mi­nants. “If you don’t have trans­porta­tion to get to your doctor’s ap­point­ment, it’s not that much of a help to get a doctor’s ap­point­ment,” said Carey Roth­schild, di­rec­tor of Ac­cessHealth Spar­tan­burg. Dur­ing the screen­ing, Health­ify not only iden­ti­fies that need but also iden­ti­fies re­sources to ad­dress it and then texts that in­for­ma­tion to pa­tients. “This has made the process eas­ier and our com­mu­ni­ca­tion and work­flow more stream­lined,” Roth­schild said.

All of this elec­tronic search­ing, track­ing, and co­or­di­na­tion yields plen­ti­ful data. “The data we col­lect is pretty pow­er­ful,” Bhat said. “We’re kind of the sole peo­ple who un­der­stand what the ser­vices are in a com­mu­nity, how that com­pares with what the need is, where the gaps are, what re­fer­rals are made, what re­fer­rals are suc­cess­ful, and what the changes in out­comes and spend are when those re­fer­rals are made.”

Health­care or­ga­ni­za­tions rel­ish this data, Bhat said, be­cause it gives them a com­pet­i­tive edge and helps them re­duce spend­ing and emer­gency depart­ment uti­liza­tion. And, of course, it makes pa­tients health­ier. “Our even­tual goal,” Bhat said, “is build­ing a world in which these so­cial needs aren’t hin­der­ing their health.”

“What we saw on the ground was that the big­gest needs fam­i­lies had were not clin­i­cal needs. They were so­cial needs.” MANIK BHAT

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