One health system is finding that the state it operates in is willing to support the use of social determinants of health (SDOH) to address health issues affecting the community.

Spectrum Health in Grand Rapids, MI, is applying SDOH in two major projects. The first is called Strong Beginnings and includes a contract with the state that focuses on reducing risk factors for racialized infant mortality.

Spectrum was prompted to address the issue when a report showed that the African-American infant mortality rate was six times the Caucasian rate in Kent County, MI, notes Jeremy Moore, director of Community Health Innovations. He also is a Robert Wood Johnson Culture of Health Leader studying health equity and social determinants and looking for ways to resolve the inequities.

Initial efforts to address the problem showed some success, but scaling up those efforts was made possible by an opportunity with the state of Michigan paying for Spectrum to address risk factors for infant mortality. Spectrum determined that the key risk factors were preterm birth and rapid, repeat pregnancies, Moore says.

“The state pays on those outcomes — about $60,000 for each avoided preterm birth and $15,000 for each avoided rapid, repeat pregnancy,” he explains. “They only pay on that as we reduce from the baseline infant mortality in the community, and it requires a baseline volume of 350 women. We also have to get a capital structure to put some of our own money and some foundation money.”

Spectrum launched that program about 18 months ago with a rigorous data component, Moore says. The hospital uses a third-party evaluator, Michigan State University, and the state uses the University of Michigan to validate the data, also.

Another Spectrum project emerged a few years ago when Spectrum identified a significant number of uncontrolled asthma cases presenting to the ED and researched the causes. Some of the common findings were home conditions such as old carpeting and bug infestations, Moore says, so Spectrum launched another program for home remediation aimed at reducing overuse of the ED for asthma cases. The state also pays for improvements in that area.

Obtaining data for such projects can be a challenge for hospitals and health systems, Moore says.

“Hospitals usually aren’t set up with that kind of data. We do have demographic data through insurance companies, but that data is very protected, and it’s not easily used,” Moore says. “None of these data systems talk to each other. Being able to translate all the vital records, Medicaid data, social determinants, and geographic census data is challenging because there are a lot of legal barriers and expertise barriers, and often, it doesn’t easily translate into finance.”

Any project involving SDOH will require bringing together a large number of professionals who speak different languages and organizations that have different priorities, Moore says. A first step will be identifying the people who have access to the necessary data, followed by trying to make that data user-friendly, he says.

New York state also is supporting the use of SDOH through its 1115 Medicaid Waiver, notes Karen Meador, MD, managing director of the BDO Center for Healthcare Excellence and Innovation. The waiver is aimed at improving access, quality, and cost-effectiveness of health services for needy and at-risk residents by allowing the state to implement a managed care program.

“There is a very strong emphasis on social determinants of health as a way to provide holistic healthcare. Each of the performing provider systems is incentivized to include in their projects, for which they are being compensated, those initiatives that emphasize the importance of social determinants of health,” Meador notes.

Meador notes the example of the growing use of community health workers to help reach the state’s goal of reducing unnecessary ED visits and hospitalizations by 25% over five years.

“They have varying backgrounds, but they know their communities, the residents, and the resources. They know how to get people connected to resources that can make a difference in their health outcomes,” Meador says. “Particularly in New York state, there has been a lot of effort put into training community health workers who can be available to patients, particularly those with complex medical problems and at highest risk. They can help these patients navigate their appointments and home management, watching for red flags that mean they need to see a clinician, so they can avoid an unnecessary hospitalization or ED visit.”

Such efforts have been more difficult in the past because of the fee-for-service reimbursement system, Meador notes. A physician would be compensated for an office visit, and there was increasing emphasis on the physician discussing lifestyle and community issues that affect health, she says.

“Outside of that context, there hasn’t been a way to reimburse providers or support personnel for assisting patients outside of that office visit,” Meador says.

“But with the move toward value-based reimbursement and with physician practices increasingly taking on risk, there is financial value as well as overall social and healthcare value in providing resources and services that help patients be healthier at home and avoid unnecessary visits to the ED or hospital.”

Maryland also has emphasized SDOH. In 2014, it revised its Medicaid system to become more of a global payment model in which hospitals could benefit from decreasing utilization, notes Andy Friedell, senior vice president of strategic solutions and public affairs with Maxim Healthcare Services, a provider of home healthcare, medical staffing, and wellness services headquartered in Columbia, MD.

There also were significant goals around reducing readmissions that could result in bonus payments or penalties.

“Hospitals had strong incentives to be involved with programs that targeted readmissions. We began working with the University of Maryland on a program that is very focused on the social determinants side of nonclinical barriers to nonadherence,” he says.

“We started focusing on readmissions, but quickly realized that for a lot of patients, readmissions are only a symptom of these underlying problems. They’re suffering from socioeconomic challenges that are preventing them from following the care plan you’ve outlined, so if you can address those, the utilization comes down as a byproduct.”

Maxim’s work involves looking for patients with challenges in four areas: medical complexity, functional status, psychological issues, and social determinants.

“When we find people with those four factors in their profiles being discharged, we reach out and schedule RN visits in their homes,” he explains.

“They do assessments that focus on those four areas and build a care plan that can be used by a community health worker over 90 days to address those factors. They bring in a lot of coordination of social services.”

The program has seen approximately 3,000 patients in four years, with good results, Friedell says.

“We started with a readmission rate for this high-risk population of 25%, and in the first year, we were able to bring that down to the 8-12% range. We’ve maintained it there over time,” he says.

“The lesson from our experience is that you have to have a marriage of people and technology to see the good results,” Friedell says.

“You have to get the data in the hands of people who can go out in the community and act on it, interacting directly with the patients who need their help.”