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The healthcare community is gradually accepting that social determinants of health (SDOH) can improve quality of care. Finding a way to apply the data can be difficult, but several hospitals and health systems are showing how it can be done.
SDOH involves socioeconomic and societal issues, such as lack of transportation to follow-up visits and poor nutrition, that can play a role in the delivery of healthcare, affecting outcomes and quality of care. The relevance of SDOH has been getting attention for several years, and some organizations are seeing success with applying the data in ways that directly affect patients.
However, not everyone is on board, says Adaeze Enekwechi, PhD, former associate director for health programs in the White House Office of Management and Budget under the Obama administration. She also previously served as a policy authority with the Congressional Budget Office and the Medicare Payment Advisory Commission. Enekwechi is now a vice president at McDermott+ Consulting in Washington, DC.
“I wouldn’t say it’s a foregone conclusion that everyone has accepted the importance of social factors and how they can adversely affect health. More people are aware of it, but there are many nonbelievers despite the research and data,” she says. “Among those who understand the importance of social determinants, the systems that have been collecting data on things like race, ethnicity, and language access are finding ways to use that data in a meaningful way. But not every hospital has that.”
Enekwechi says SDOH often boils down to simply knowing where your patients come from. She uses the example of a hospital in Chicago, where some patients might come from the affluent Hyde Park neighborhood, and others might come from the inner city, where resources are quite different.
“That kind of data on patients, broken down by ZIP codes or other factors, can help you address an issue like no-shows. You might find that many of these patients are reliant on public transportation and that for them to come from less than 10 miles away, they have to make a two-hour commitment to public transportation,” she explains. “That causes them to miss work. If you’re expecting them to leave their hourly job, lose that income because their lunch hour won’t accommodate the visit and the travel time, you’re expecting far more of that patient and it is not realistic.”
Matching no-shows to SDOH as simple as ZIP codes can identify patients who need intervention beyond the standard processes that might apply to all no-show patients, she says.
“Calling them and leaving messages or sending postcards is not going to solve the problem,” she says. “They have to work, they have to deal with transportation issues that you and I might not have, and no matter how much they want to do the right thing for their health, those circumstances can’t come together in a way that gets them to their 11:00 a.m. appointment.”
There are ways to apply SDOH without an expensive purchase of data and analysis, Enekwechi says. Even a simple focus group can reveal information about the limitations some patients face, she says. Partial solutions might include a Saturday clinic for those who have a hard time making weekday appointments, she notes.
“That’s the kind of peeling-back-the-onion approach to using social determinants to understand your patients better. It’s not always a large program with lots of data analysis, but it can be. If you haven’t done this before, you need a place to start.”
Hospitals often have a wealth of data available to them, but merging that information in a way that improves quality can be challenging, she says. Layering another volume of demographic data on top of that only complicates matters, she says.
“I’m starting to see that health systems want to understand their patient populations in a holistic manner, and they’re starting to see social determinants of health as a key tool in achieving that. But so far, we’re seeing more in pockets, and I’m hoping to see growth in the near future,” she says.
Even the smallest hospital can use SDOH to address patient issues and improve quality, Enekwechi says. Payers can drive the use of SDOH because they have a vested interest in making sure patients have the best outcomes and because they may have existing resources and data analysis capacity to help hospitals apply the information in a meaningful way. Hospitals interested in making more use of SDOH might first approach payers for assistance, she suggests.
In recent years, the use of SDOH to improve care has focused mostly on reducing hospital readmissions, notes Bita Kash, PhD, MBA, FACHE, director of the Center for Outcomes Research at Houston Methodist hospital. Methodist has worked recently to collaborate with community not-for-profit partners to improve post-discharge self-care support for patients at highest risk of readmissions, she notes.
Some of the issues have involved food security, for instance, so Methodist worked with the local Meals on Wheels program, which has specially trained staff and volunteers who go into the home to deliver food but also make note of the recipient’s health and any existing needs. Another community partnership uses the medical home concept to ensure discharged patients are seen by a physician after leaving the hospital.
“The research team at the Center for Outcomes Research realized that, not just at Methodist but nationally, this is the way to address some of the most challenging aspects of care. Research is showing that hospitals with the highest proportion of Medicaid patients are engaging in many, many partnerships,” Kash says. “Methodist is investing a lot of money into supporting community providers and energy into developing partnerships and key relationships in the community.”
The center has researched the most useful ways to apply SDOH in reducing readmissions and found that the high impact strategies involve community collaborations, she says.
A good resource for hospitals seeking to use SDOH is the Area Deprivation Index Datasets, Kash says. Based on a measure created by the Health Resources & Services Administration, the datasets use census data at the ZIP code level to denote access to key health-related resources based on 17 indicators. The indicators involve issues such as poverty, education, housing, and employment. (More information about the datasets can be found online at: https://bit.ly/2IlHU7m.)
“One of things we have realized is that those measurements need to be taken down to the census block measure because ZIP code still leaves a lot of variability in levels of poverty and health issues,” Kash says. “We’re also comparing that measure to older measures that most health service researchers have been collecting in the past, such as race, ethnicity, and insurance status, and looking for the best formula to use. Not one risk prediction model works for all hospitals and regions, so even within a hospital system, it’s still very hospital-specific.”
Commonly used measures such as Medicaid status, age over 45 years, and disease complexity are still strong predictors of an avoidable readmission, Kash notes. They can be used in conjunction with other SDOH rather than abandoning any proven use of those measures, she says.
“I would encourage those working in hospital quality and safety to consider developing hospital-specific prediction models incorporating Area Deprivation Index data at the block level,” Kash says. “Sometimes as researchers, you get stuck with your hypotheses, so you have to be careful not to get caught up in that one index that you thought was the coolest thing on earth but really isn’t as effective as the old indicators of population at risk. It’s still very important to pay attention to Medicaid, age, and the other measures that have been proven.”
SDOH play an important role in improving quality and outcomes for the members of L.A. Care Health Plan in Los Angeles, many of whom are some of the poorest in the community, says Richard L. Seidman, MD, MPH, chief medical officer. Seidman is responsible for developing and implementing strategies and initiatives to ensure quality for the health plan’s more than 2 million members.
“Assessing and determining social determinants of health is a core strategy because of the very significant potential impact on outcomes, quality, and costs,” Seidman says. “We’ve established a social determinants of health committee and recently hired a program manager for health equity who will help us target our efforts and help those in the community with traditionally lower outcomes.”
The SDOH committee has identified the determinants that are most relevant to the health plan’s members. Those include homelessness and preventing homelessness, food insecurity, income insecurity, transportation, and early childhood education.
For homelessness, L.A. Care committed $20 million in grant funding to an organization that subsidizes permanent housing for homeless members, Seidman says. The program is close to reaching its goal of placing 300 members in permanent housing over a five-year period. The health plan also partners with organizations that help prevent homelessness by identifying those at high risk.
When patients have severe asthma, L.A. Care sends healthcare staff to their home to look for triggers.
“In some cases, we have to partner with legal advocates to help negotiate and manage relationships with landlords. Mold abatement is a common concern with these patients,” he says. “The landlord may refuse to repaint or recarpet, even though the mold is the primary trigger that is preventing the patient from achieving good asthma control.”
The health plan has provided additional grants to subsidize move-in costs and costs associated with the timely discharging of patients from an acute care facility to other housing such as a recuperative care facility.
L.A. Care also has healthcare providers for the homeless that are funded through the federal government. They are designated as homeless clinic providers and included in the L.A. Care network.
“They are providers who are very skilled with the homeless population and excellent at identifying social determinants on top of meeting their healthcare needs,” Seidman says. “For income security, we work with a vendor that matches our members with available benefits and the earned income tax credit.”
One of the challenges in utilizing SDOH is identifying the organization’s business drivers and incentives, Seidman says.
“A business has to clearly understand their priorities and incentives to determine whether or not an investment in addressing social determinants may lead to returns that the organization can keep as a return on their investment, either to reinvest in the program or provide to the shareholders,” Seidman says. “Those business drivers are unique to each business. In our setting as a Medi-Cal managed health plan, there are some disincentives related to how we are funded. We have to be cautious in our investments to ensure an appropriate return, so we can reinvest those funds and sustain good outcomes, which is our goal.”
L.A. Care’s SDOH application is still too new to generate data showing improvements in outcomes, length of stay, readmissions, or other metrics, Seidman says. He expects the results to be positive and in line with research showing the benefits of SDOH.
“It is a challenge for healthcare providers, systems, and payers to step into a space that has not been traditionally considered a space for healthcare. We hear people talking about it as the medicalization of social issues,” Seidman says. “We intend to expand on our commitment in the space. We currently have a request for proposals for a community resource platform we can make available throughout the health plan but also for providers in our network.”
L.A. Care also tracks government funding programs, so it can direct the health plan’s grants to areas not adequately served by other funding. One priority identified by the health plan involves food insecurity, with L.A. Care providing $2 million over the past three years to 24 programs addressing members’ lack of access to healthy food.
With one program, L.A. Care is providing funding for an initiative that provides medically tailored meals to patients recently diagnosed with congestive heart failure.
Northwell Health, a not-for-profit healthcare network based in Great Neck, NY, that includes 20 hospitals, is creating what it calls the Social Vulnerability Index (SDI). At intake, every patient is given a “social physical” similar to the clinical physical, says Ram Raju, MD, senior vice president and community health investment officer.
“Based on that, we give them a risk index, and every time that patient comes for an encounter, the physician will be able to see that this patient not only has clinical issues but also has social risk factors,” he explains. “When they click on the notice of a high-risk factor, the record will show why the patient has been designated that way and the specific risk factors that led to that high index.”
The network already uses a resource that identifies transportation resources by ZIP code and generates an email notifying the transportation service that this patient will need assistance. The SDI will be tied into that system, as well other resources.
“The idea is that we want to give social risks as much importance as the clinical risks. If the person has diabetes and lives in an area where fresh food is never available, he will not be able to follow the diet you give him, and the diabetes will never get better despite all the medications you give,” Raju says. “If we figure out that food security is a major issue in a certain ZIP code, we should be able to use our community funding dollars to focus on areas we know need help. We will be able to measure the food insecurity risks in that area before and after a few years of funding intervention and see if the effort was successful.”
One challenge has been how to weight SDOH against each other, Raju says. Every interest group — behavioral health, substance abuse, homelessness — will campaign to have its related SDOH weighted heavily in the SDI. Raju says the decisions must be based on metrics and data, but there still will be disagreements, and decisions will have to be made.
Raju recounts the tale of a woman with breast cancer who had lived in the same apartment for years. The woman, an undocumented immigrant, said that the landlord wanted her to move out so that he could raise the rent. She said that the landlord threatened to report her to immigration authorities, and that she resisted.
The woman underwent surgery and returned home. But she said that the landlord told her that the moment she stepped outside, for any reason, he would change the locks. She could not call the police for help because she was in the country illegally, he told her.
“She had to make a decision whether to go to her follow-up chemotherapy treatment and be homeless or stay in her house and let the cancer take care of itself. She chose to remain at home,” he says. “We could have had the best world class surgeons operating on her and giving her the best medicine ever invented, but it wasn’t going to work if she faced that decision at home.”
Northwell Health responded to this SDOH by working with the New York Law Association to provide pro bono legal assistance to patients in such situations.
“We need people to understand it’s not just about the medication or how good a doctor you are. The real measure should be what happened to your patient in the end,” Raju says. “In medicine, we have a habit of measuring how well we did, when we should be measuring how well the patient got. There’s a very big difference.”
Financial Disclosure: Author Greg Freeman, Editor Jesse Saffron, Editor Jill Drachenberg, Nurse Planner Jill Winkler, Editorial Group Manager Terrey L. Hatcher, and Consulting Editor Patrice Spath report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.