Research proves what our common sense already knows: the biggest factors that affect our health are our daily choices and experiences. Health care systems that are able to seamlessly integrate these “social factors” into their care delivery and reimbursement strategies will be significantly more effective in managing health, improving experience, and creating value for their customers.
We know this first-hand after leading the development, implementation and assessment of an internal protocol to assess social determinants of health – like adequate food, safe housing, and dependable relationships - as a standard of care at primary, specialty and community-based care delivery sites. Outcomes from the first three years of work showed measurable improvement in patient health outcomes, family experience and provider satisfaction, while lowering total annual spending on healthcare.
Focusing on these “social determinants of health” (SDOH) has exploded within health care. Here we address common questions from health systems interested in SDOH:
What screening tool should our health care system use?
Many health systems approach SDOH with an interest in screening patients for needs and as a result, turn their attention to a discussion of selecting a screening tool to accomplish this. To date, there is not one gold standard SDOH screening tool. Andermann’s recent review of screening for social determinants of health in clinical care found while many screening tools for social determinants of health exist, there is not yet a sufficient evidence base around “multi-dimension screening” (i.e., asking about multiple determinants in one screening tool vs. single dimension screening which asks about one determinant, e.g., housing) with which to develop national screening recommendations around. Morone reviewed thirteen tools tailored to pediatric populations and similarly found a lack of comprehensive, multidimensional tools for the pediatric population. The Accountable Health Communities 10-item tool shows promise, although to date has not been validated in pediatric populations. Multiple additional tools exist.
Incorporating SDOH screening into electronic health records has also increased over time both by health care institutions home grown screening tools, and also EHR company platforms (e.g., EPIC Healthy Planet). Boston Medical Center’s THRIVE model discusses their process with roll-out within EHR in this interview detailing how technology is used to facilitate the patient visits from both the provider and patient perspective, but also how the incorporation of SDOH within the EHR allows for population-level data analysis as well as the ability to model predictive analytics in the future. Embedding SDOH tools within EHRs does have many positive attributes, however, the necessary change management associated with on-boarding staff and providers within health care systems should not be overlooked.
How do health systems work with community agencies to address SDOH?
Health systems often are not set up to address SDOH needs internally, and thus require referrals to appropriate community agencies and supports. Over time, it has become apparent that successful models in this space include tangible partnerships between health care systems and broader community agencies within education, public health and policy. Kathleen Tebb and colleagues discuss several models focused on the adolescent health population in their recent paper in Health Equity including Housing Prescriptions within Boston Medical Center.
Lindau and colleagues released a number of papers in this month’s American Journal of Public Health on the effects of community prescriptions for SDOH related referrals including how the technology works but also new thinking in how this type of intervention led to the sharing of community resources between people and how this model can lead to improved data on the connectedness of communities.
Pediatricians have a long history of advocating for investment in early childhood. HRSA’s Maternal and Child Health Bureau funded The Early Childhood Comprehensive Systems Collaborative Improvement and Innovation Network to build coordinated care systems. One of the five drivers of the model is a focus on social determinants of health.
Outside of the health system, social support agencies, those that receive referrals from health systems, remain underfunded. There has been some work to bring funders together to support funding partnerships for social determinants of health work.
What are the data implications of community partnerships addressing SDOH?
The importance of bi-directional data flow is important to consider in these community partnerships. Health care systems have large amounts of patient data from the perspective of medical model and clinical care while community agencies often have data that is more relevant to SDOH. The importance of models which seek to marry clinical and community data will be necessary to discuss including the pertinent infrastructure changes that will be required to move forward. Within the landscape of pediatrics, it is important to consider how family information will be both captured and used within systems that currently collect data on individual patients. For example, if a caregiver of three children gets screened for SDOH upon bringing one child to clinic, how does the health care system ensure that multiple screenings and referrals do not occur when other children may be brought in in the near future?
With the necessity of multi-sector partnerships combining both health care systems and community partners, several models of city dashboards have launched as a step toward shared outcomes and data. These dashboards work to set targets for a city, presumably developed in sessions with multiple stakeholders and there is shared accountability in working to improve the outcomes of choice. The City Health Dashboard is one national example of this, providing data on the 500 largest cities in the United States. This tool is further described in the April 2019 issue of American Journal of Public Health. Other examples of large dashboards include the County Health Rankings and the Spartanburg Community Indicators Project.
What are we learning about payment models addressing SDOH?
Implementation of SDOH screening and referral within health care systems continues to rely heavily on grant and foundation funding as research on promising payment models such as the Center for Medicare and Medicaid Services (CMS) Accountable Health Communities, statewide accountable care organizations, and other value-based payment models emerge. Specific to pediatrics, CMS recently created the Integrated Care for Kids (InCK) Model, a seven-year grant to improve child health and reduce Medicaid expenditures by providing coordinated care across physical, mental and behavioral health, child welfare, public health, schools, social health and other “core child service” entities. The InCK grant requires the development of an alternative payment model to support this more holistic approach to child health.
How can health systems contribute to larger community impact?
As Castrucci and Auerbach note, health systems involvement with policies that address the conditions that contribute to health is paramount to addressing SDOH on a population level. While a focus on connecting individual patients is necessary, it is only one part of the work needing to be done to have a lasting community impact.
Photo Source: Castrucci & Auerbach
Genesis Health Consulting has a long history of work in working with pediatric health systems in around SDOH. Please email us at firstname.lastname@example.org to learn more about our work in this area.