Targeting the social determinants through intervention, education

Studies have long tied social, environmental and economic factors to poor health and reduced access to care. Hackensack Meridian Health CEO Robert Garrett discusses how the New Jersey-based system made addressing the social determinants of health a top priority, and how he and his team are getting it done.

Can you talk about the genesis of your comprehensive SDOH program?

We understand that the path to better outcomes, more equity in healthcare and more value in care delivery depends greatly on developing and executing a robust strategy to screen patients for social needs. We believe this is the best way to address a fundamental failure in American healthcare: your ZIP code too often determines the state of your health.

Focusing on SDOH is one of the network’s seven strategic priorities and involved hiring new leaders, including Nicole Harris-Hollingsworth, an expert in community and population health. We also hired 25 community health workers—nonclinical staff with contextual expertise and extensive ties to the community—who are an integral part of the program’s success.

A key for all health organizations is to assess the needs unique to your community. Our network determined five priorities: food, housing, transportation, caregiver support and mental health/ substance abuse treatment.

What were some of the program's early initiatives, and how has it evolved?

We understood that clinicians needed the screening process to be as easy as possible, so we built it right into our electronic health record system. In October 2018, the network started screening Medicare and Medicaid patients in a targeted region in New Jersey. When the federal pilot ended, the network had screened more than 100,000 patients and made 6,000 referrals to community services based on need.

The initial results were so compelling that we prioritized expansion throughout the network, which has 17 hospitals and more than 500 patient care locations. The network also learned that to succeed, there needed to be team members beyond physicians who could conduct the assessment.

Essentially, there are two approaches to reaching at-risk patients: at a point of contact in the network, and through member data provided by Horizon Blue Cross Blue Shield and other insurers through our Healthy Connections program.

Community health workers play a vital role; it’s like having a healthcare personal assistant. Additionally, the community health workers can log important information directly into the EHR regarding a patient’s social needs. That data is used to drive community referrals, which the community health worker vets and relays to the patient using a platform called Unite Us.

Education around SDOH plays a critical role in your work. Can you discuss the role of the medical school?

At the heart of the Hackensack Meridian School of Medicine is the innovative Human Dimension program to teach future physicians about the importance of SDOH. This is how we can transform care delivery—at the beginning, in how we train physicians.

While many schools offer courses or classes, this approach is foundational to our curriculum. Students go out in pairs to underserved patients throughout the entirety of their medical education. They do this while they are also mastering the hard sciences required of any M.D. candidate in the nation. By viewing healthcare through a broader lens that includes nonmedical issues, we add a human dimension to the training of future physicians.

Future physicians must understand that there’s so much more to patients than what’s in a medical chart. This is how we improve outcomes, make people healthier and create more equity in American healthcare.

What's the impact from the system's efforts so far?

With more than 1 million referrals made to community resources and more than 330,000 patients assisted, we consider this tremendous progress. The network is now screening up to 5,000 patients a day. But there is more to be done.

This past June, our team had a “crack the vault’’ party to start assessing what we’ve learned so far. It will take at least a year to compile and review baseline data. The results will help us further shape the program and assess effectiveness.

“Future physicians must understand that there’s so much more to patients than what’s in a medical chart.”