Complete care
Hospitals tackling social determinants are setting the course for the industry
DEALING WITH COLD WINTERS was not Chimera Campbell’s biggest challenge after moving from Florida to Chicago in 2012. The 39-year-old couldn’t manage her asthma, and that led to frequent emergency visits to Mount Sinai Hospital, a part of Sinai Health System. “I was in the ER constantly with chest tightness, pain and having problems breathing,” Campbell said, estimating she visited the ER six times a year.
Then, Campbell received a phone call from a staffer for the safety-net system asking whether a community health worker could visit her home and identify and get rid of any environmental factors that could be aggravating her asthma.
Campbell agreed and the worker, Kim Artis, discovered that household dust and secondhand smoke were the culprits. “Patients don’t come into the clinic saying their house is dusty or their husband is a smoker,” Artis said. “So that is the missing link we provide once we go to the home.”
Since working with Artis for the past two years, Campbell has not visited the ED for her asthma. Artis “helps me with my health, my mind, the body and my spirit,” Campbell said.
Systems adopting such unconventional approaches to managing chronic disease are becoming less unusual as the concept of addressing social determinants of health sweeps the industry. Income, education, employment, food security, housing stability and violence are all targeted factors to help improve patient health.
But addressing issues that can’t be managed within the walls of hospitals and clinics has proven costly and so far has shown scattered results.
“At this point a lot of providers aren’t sure how to fully engage and what actions do they actually do to make themselves ROI-positive,” said Anita Cattrell, chief innovation officer at Evolent Health, a managed services company that helps systems transition to value-based care.
The role of social determinants
Individual behaviors are the largest contributors to premature death, accounting for 40%, according to a 2007 New England Journal of Medicine story, while healthcare made up just 10%.
The concept of social determinants of health was first introduced to U.S. policy in the 1960s when President Lyndon B. Johnson declared a War of Poverty that brought about Medicaid, Medicare, food stamps, Job Corps and Head Start.
“There was a recognition in this country that problems of violence, abuse and lack of access to good nutrition, housing and transportation were harmful to people living in certain areas,” said Rita Numerof, a St. Louis-based healthcare consultant.
But it wasn’t until 20 years later that hospitals began hiring social workers to connect patients with community support services.
And then came a policy that pushed hospitals to concentrate on volume. In 1983, the CMS implemented the diagnosis-related group, or DRG, as its method for reimbursing providers. “One of the problems was that there was no connection between payment and outcomes,” Numerof said.
Today, fee-for-service remains healthcare’s Achilles’ heel, slowing the move to value-based care and preventing it from achieving the Triple Aim.
“The reality is that today, most hospitals are still getting most of their revenue from fee-for-service medicine,” said Anne Weiss, managing director at the Robert Wood Johnson Foundation. “So, I don’t think that we can sit back and be complacent and say the transition from volume to value is going to address everyone’s social needs. But I do think it’s one reason why the topic has gotten more attention.”
The U.S. also has increasingly faced scrutiny for spending more on healthcare than other countries while delivering less than ideal outcomes.
A 2017 Commonwealth Fund report found that compared with 11 other nations including the United Kingdom, Australia and the Netherlands, the U.S. fell last in terms of efficiency, access, equity and health outcomes.
The U.S. also spends less on social services than other developed nations. The Organisation for Economic Co-operation and Development shows that the U.S. spends the largest share of its gross domestic product on healthcare, at 17%, while ranking 23rd out of 34 nations in terms of social service spending.
“What we’re really recognizing is that ZIP code is more important than your genetic code,” said Dr. David Friend, chief transformation officer and managing director of the Center for Healthcare Excellence & Innovation at global financial advisory services firm BDO.
The right approach
Stacy Ignoffo is program manager of Sinai’s Urban Health Institute. That organization for the past 11 years has sent community health workers to patients’ homes for a oneon-one approach. In 2011, the program began including asthma patients. In its first year, the program reduced ED visits from asthma by 73% and decreased hospitalizations by 75% for a cost savings of $8 for every $3 spent.
It’s an admirable effort on a small scale, but the ultimate goal of social programs is to reform healthcare into well
“Kim helps me with my health, my mind, the body, and my spirit.” Chimera Campbell, left, with community health worker Kim Artis
care that changes both the health and economic outlooks of an entire community for generations to come. That’s not a small or easy task.
Understanding that they can’t do it alone, providers have looked to community and municipal partners to make a more lasting impact that may require less direct investment.
Kaiser Permanente, for example, has engaged government agencies to create policies aimed at improving public health.
“We’re absolutely thinking about the upstream interventions that we need to do with our community partners to see what really is impacting the fabric of our communities—things that impact poverty and race inequities,” said Dr. Bechara Choucair, Kaiser’s senior vice president and chief community health officer.
The Oakland, Calif.-based integrated system also has invested $200 million to fight homelessness and housing instability through its Thriving Communities Fund. (See related commentary, p. 27.)
Choucair said the work Kaiser has done with cities has led to the creation of policies that address healthy eating, active living and early childhood education. Kaiser also is the only healthcare provider member of the Billion Dollar Roundtable, a consortium of large companies that each spend a minimum of $1 billion every year supporting minority- and women-owned firms.
Other systems, such as ProMedica, based in northwest Ohio, have focused on solving food insecurity by working to revitalize local communities. The system in 2015 co-founded the Root Cause Coalition, a not-for-profit collaborative of health systems, insurers and advocacy organizations dedicated to addressing the causes of health inequity.
Such lobbying efforts on the part of health systems have led to higher taxes on sugar-sweetened beverages and cigarettes, cities working to promote walking and bicycling, and interventions to reduce violence.
In still another unique example, the Cleveland Clinic recently handed over its laundry business to the Evergreen Cooperative, which builds community wealth by allowing employees to share business ownership in historically impoverished areas. The move created 100 local jobs.
“We see this as an important step we can take to support the health and well-being of our neighbors,” said Ralph Turner, executive director of patient support services at the Cleveland Clinic.
The city of Cleveland exemplifies how wealth can impact health. The median household income in the inner-city neighborhood of Hough is $18,500, while eight miles east in the more affluent suburb of Lyndhurst, the median is $63,000. Hough is 98% African-American and the average male life expectancy is 64 years. In Lyndhurst, which is 86% white, men can expect to live up to 88 years.
Leveraging purchasing power
The Democracy Collaborative is a community development organization that helped start the Evergreen project and has in recent years set its sights on the healthcare industry as a willing and capable sector of the economy to tap for investment opportunities. The group even published a paper, titled Can Hospitals Heal America’s Communities?
David Zuckerman, director for healthcare engagement at the collaborative, said initiatives like Evergreen show how providers can more effectively address social needs by leveraging their enormous purchasing power to help combat poverty.
“It’s a tremendous way of illustrating that you can as a
For the past 11 years, Stacy Ignoffo, program manager of Sinai Health System’s Urban Health Institute, has sent community health workers to patients’ homes for a one-onone approach. In the first year of a program for asthma patients, it reduced ED visits by 73% and decreased hospitalizations by 75% for a cost savings of $8 for every $3 spent.
health system, in an era of tight margins, get the quality and price that you need while also having this tremendous social impact in the neighborhoods in a way that will really be a game-changer,” Zuckerman said.
Evolent’s Cattrell said the healthcare industry needs to see investments in social determinants as not just a financial benefit but as a public good shared by all.
“Right now, ROI is almost all monetary,” Cattrell said. “When you think about providing some of those larger initiatives like supportive housing or legal assistance, they have much a broader effect beyond just healthcare costs— there’s not a good framework yet to really think about it more holistically.”
Unlike other developed countries with more robust social safety nets, healthcare providers in the U.S. are stepping in to find the right supports to address patients’ social needs, and in some cases, they must provide those supports themselves. Yet the majority of providers and payers have made small investments. For not-for-profit hospitals, much of that investment has been tied to community benefit requirements to maintain their tax-exempt status.
The hospital’s role
A 2017 survey by the Deloitte Center for Health Solutions of 300 hospitals and health systems found the vast majority, 88%, were committed to addressing social determinants and were screening patients for social needs. The survey also found 72% of hospitals had not made any investments. Nearly 40% of hospitals surveyed said they were not measuring the outcomes of their initiatives. Most systems have limited their activities to target a small subset of their patient populations, such as high utilizers, or those who are at risk of becoming frequent ED visitors.
Many initiatives going on today serve as “pilot projects.”
“The reality is that this is a field that needs to continue to be built and a field that needs to continue to grow,” Choucair said.
In addition to its policy work, Kaiser has invested in ways to benchmark and improve its social programs. Last year, Kaiser launched the Social Needs Network for Evaluation and Translation, known as Sonnet, which evaluates the success of the system’s social interventions. Kaiser also partnered with the Robert Wood Johnson Foundation to create the Social Intervention Research and Evaluations Network, or SIREN, with the goal of building consensus on common measures and methods to address social determinants of health.
Such tools have been used over the past two years to address how well Kaiser identifies and then addresses food insecurity among members. Sonnet surveyed Kaiser Medicare Advantage plan members in Colorado and found many members were food-insecure, yet the majority of that age group had not been screened. The research also found a lot of those members may have been slipping through the cracks because those patients did not have a higher rate of utilization than members who were not food-insecure, which indicated a need for broader screening.
Those findings helped Kaiser employ the screening tool Your Current Life Situation, a survey drafted by SIREN researchers that is deployed in Kaiser’s primary-care and emergency department settings. Within the health system’s Northwest region, survey responses are included in patients’ electronic health records, which are then used by a patient navigator to help them find community resources to meet their social needs.
Independent research points to an economic rationale for addressing social needs. For example, homelessness is tied to greater use of emergency care. A recent examination of the economic impact of medical respite programs, which provide temporary medical care for homeless persons who don’t need to be admitted to a hospital, found the programs reduced ED visits by 45% and readmissions by 35% for a savings of $1.81 for every dollar spent.
“We see more economic return in providing our services than maybe some folks who don’t have the same mission that we have,” said Ruth Krystopolski, senior vice president of population health for Charlotte, N.C.-based Atrium Health. The system spent $306 million in 2017 on uninsured care as a safety-net provider, a figure that Krystopolski said pushes the system to find ways to reduce costs.
In 2015, Atrium began collecting demographic data from various sources including local universities and public health departments with a goal of identifying, cataloging and documenting patient social determinant information to then connect them with community supports.
Atrium’s recent pilot project involves screening food in- security among senior patients at highest risk for readmissions. The system then provides emergency food services and helps them complete SNAP applications. So far, Atrium has reduced readmissions 60% in this group.
But not everyone sees the value of these efforts. Consultancy Leavitt Partners in May published a survey of 600 physicians that found the majority believed fixing inequality in income, transportation, food access and housing did benefit patients’ health, but they didn’t think it was their responsibility to fix those issues. “I don’t think systems have adopted this en masse, but I think there has been an uptick, and that it has been driven by an increasing sense of the economics,” said David Smith, co-founder of Health Care Council of Chicago, a collaborative of Chicago healthcare businesses to address health disparities.
The road ahead
Sinai’s Ignoffo has not found sustainable funding to meet the upfront costs involved in running the community health worker program. It’s currently funded through public and private grants.
The lack of payment from private or public payers for those services is a challenge. “There’s a little bit of money out there for providers, but it’s not significant and there’s also not a lot of infrastructure,” said Dr. Gail Cunningham,
Sinai has not found sustainable funding to meet the upfront costs involved in running its community health worker program. It’s currently funded through public and private grants.
senior vice president and chief medical officer at the University of Maryland St. Joseph Medical Center.
The University of Maryland uses community health workers to address social ills so discharged patients won’t return to the hospital. The program has reduced readmissions by 65% among at-risk patents living at home.
But Maryland’s payer system is unique in that hospitals in the state every year receive a fixed amount to care for patients. That motivates them to reduce unnecessary utilization.
“In other markets where every case you see you bring in more money, it may not make as much sense unless there are other pressures, rewards or penalties within in the state to drive change behavior,” Cunningham said.
Cattrell said as hospitals and health systems take on more risks and develop their own insurance plans, the incentive to provide care in the most cost-effective and potent manner will only continue to underscore the importance of social determinants.
“The idea and the transformation of late is how do we integrate social determinants in a way that is not something that is just being done to the patient off to the side but is truly part of their care plan,” Cattrell said. “I think the perception of what a social need is and how it relates to the broader person is where the real transformation is happening.” ●