By Jonathan Springston, Editor, Relias Media

By targeting high-risk patients, staff at NewYork-Presbyterian (NYP) have managed to provide better care to this group, possibly leading to fewer ED visits and readmissions.

At the six clinics and EDs affiliated with NYP, staff have been working with patients on addressing social determinants of health (housing, food security, transportation, utilities, and general safety). Between September 2018 and December 2019, NYP screened 22,000 patients, 25% of whom reported food and housing insecurity. Generally, this population struggles with poverty, hypertension, diabetes, and limited English proficiency. All this information was stored electronically and available to clinicians during exams.

If a patient from this group visited an NYP ED two or more times and had at least one social need (e.g., better/more reliable transportation to reach an appointment), staff connected the person with an online social service directory. If a patient recorded two or fewer ED visits, he or she received a printed, tailored resource list. An estimated 40% of the 22,000 patients have agreed to these interventions.

Although there was some resistance among patients and staff, NYP has changed its relationship to the neighborhoods it serves while potentially improving health outcomes for those residents.

“I think they’re starting to feel that they can trust us with that information and that we’re here to help,” said Dodi Meyer, MD, director of community pediatrics at NYP/Columbia University Irving Medical Center.

These efforts have been directed through a grant received in 2017 from the Addressing the Needs of the Community through Holistic, Organizational Relationships (ANCHOR) program, funded by the Centers for Medicare & Medicaid Services’ Accountable Health Communities Model. Eventually, NYP and other ANCHOR participants will calculate the effects of these interventions and report more concrete data (e.g., exact number of readmissions prevented, precise number ED visits prevented).

Across the United States, health systems are learning to screen for social determinants of health, with favorable results. A health system in Phoenix cut its ED revisit rate from 6% to 3% by designating a care coordinator to focus on frequent ED visitors and help them remove chronic barriers to care. The Richmond (VA) Health and Wellness Program helps older patients living in poverty-stricken neighborhoods access medication and other preventive care by addressing social determinants of health.

There are blind spots providers should consider. For example, psychological distress can be a social determinant of health that is not as well understood or easy to measure. Another missing determinant can be whether the patient lives alone or with someone. If a patient lives alone and struggles with mobility, how might he or she attend appointments or retrieve medication?

In one investigation, the authors found 12 social determinants (including the living alone/with someone factor) were missing from a de-identified data set of 123,697 people who visited the University of Alabama at Birmingham Medical Center ED at least once in 2017. Providers should avoid assuming one determinant is not worth asking a patient about. If a clinician sees a missing determinant during a chart review, ask the patient about it.

Check out future issues of ED Management for more information on the progress of the ANCHOR program.