Many Safety Net, Rural Hospitals Do Not Properly Address Social Needs
By Melinda Young
Safety net hospitals, critical care hospitals, and rural hospitals often do less than needed to address the social determinants of health (SDOH) of their vulnerable populations, particularly during the COVID-19 pandemic, new research shows.1
“The COVID pandemic amplified the need for focusing on and addressing social determinants of health across our country,” says José F. Figueroa, MD, MPH, lead study author and an assistant professor of health policy and management at Harvard T. H. Chan School of Public Health, associate professor at Brigham’s and Women’s Hospital, and an assistant professor of medicine at Harvard Medical School. “The pandemic made it very clear that hospitals and health systems have a critically important role in this process. A big question is to what extent are hospitals addressing the social needs of their patients and communities?”
In 2020, the American Hospital Association conducted a survey of hospital ICU beds. They captured tactics at hospitals across these three categories:
- Do you screen for social needs or use screening programs for social needs, including transportation, food security, housing insecurity, utility needs, employment, income needs, and whether people were socially isolated, experienced domestic violence, or engaged unhealthy behaviors, such as smoking?
- Do you use a program or intervention to address those types of needs? For example, if you screen for transportation, do you have a program to address transportation needs or food security?
- To what extent do you work with community organizations and community partners to address social needs? Community partners could include state health departments, churches, schools, colleges, and local social service organizations.
Researchers wanted to know how hospitals were doing across those domains.
“Some hospitals serve more vulnerable populations of rural, ethnic, and racial minorities,” Figueroa says. “How do they compare to other hospitals?”
The expectation was hospitals that served a greater proportion of vulnerable patients would take good care of their social needs. “Instead, we saw they did the same or significantly less than other hospitals,” Figueroa says. “You would expect them to have more partnerships with communities, but across the board, they were less likely to communicate in partnerships and less likely to partner with communities. It’s a big finding, and it’s concerning because we know the patients who go to those hospitals are more likely to experience less access to healthcare.”
Financial and Staffing Issues
One reason is these safety net and rural hospitals may have fewer financial resources and more staffing issues. “If you’re making fewer dollars, there are fewer dollars to invest in staff to do these programs and also to participate in community partnerships,” Figueroa explains.
There also are inequities in how federal money for low-income patients is distributed. “Every year, about $24 billion are sent to hospitals to subsidize care for low-income patients. This paper found that you would expect this funding to flow to hospitals that take care of the most low-income people and people of color who are disproportionately living in poverty,” Figueroa says. “Unfortunately, that’s not the case. Hospitals that serve counties with the largest number of Black residents receive the fewest dollars in the Medicaid program that is meant to offset care for those patients.”
Hospitals make fewer dollars and receive fewer dollars to subsidize the care they provide. “We found that larger hospitals and big academic hospitals are more likely to do all these things, and the main reason is they have more resources and money and the capacity to build and implement social determinants of health programs,” Figueroa says. “What the authors are postulating is it’s a structurally racist policy in how formulas are set, and they should re-evaluate the formula of dollars. On average, hospitals get paid less to take care of Black people and Latino people, period.”
The reason is those populations are disproportionately on plans that pay less for the same exact care. They also are disproportionately more likely to be enrolled in Medicaid across different states. “Even when they have commercial insurance, they’re more likely to work for employers with less generous benefits that potentially reimburse less,” Figueroa adds.
There also may be fewer participating community partners. This contributes to hospitals inadequately addressing patients’ social needs. “Even if they’re willing, there may not be capacity in the community, and that has a lot of implications for our findings,” Figueroa says.
Policy Solutions Are Needed
The problem is multifactorial and requires large policy solutions at the federal and state levels. “The other important thing is health systems need to look and see and evaluate how they are meeting the needs of socially vulnerable populations,” Figueroa suggests. “The ones that are not doing as much as they could need to figure out how they’re investing their resources and reprioritize some of their investments as well.”
Case management leaders who work in a health system that serves many socially vulnerable and low-income patients need to encourage their hospitals to become meaningful partners in addressing patients’ social needs. While hospitals cannot solve everything, there is much they can do to be more accountable to their patient population.
“A lot of literature describes how they can develop more meaningful community partnerships,” Figueroa explains. “For example, hospitals are a huge employer in a community, and they can think about supporting the local workforce by just supporting their own workforce with social determinants of health interventions. Local people are best suited for helping and understanding the needs of the local community, and for employing specific social determinants of health programs. Hospitals can buy locally and provide local vendors and contractors with their business.”
Instead of always buying from large national retailers, they can buy products from within their communities to support local workers because that supports the entire community.
“From the case management perspective, reach out actively for community partners,” Figueroa says. “Be creative in finding partners.”
For example, case managers could forge a partnership with local schools and law enforcement, public health agencies, and local businesses.
College students could be volunteers. “Partnering with organizations and schools is one way to increase workforce capacity, and there’s a lot of volunteerism that happens when addressing social needs,” Figueroa adds.
Go Beyond Temporary Solutions
Case managers should find comprehensive solutions, going beyond superficial cures. “Giving a cab voucher to someone with transportation problems is a pretty weak Band-Aid to the problem,” Figueroa explains. “That will not solve the actual problem of someone needing appropriate transportation.”
Health systems and case managers should find more sustainable solutions by collaborating with community partners.
“Hospitals alone cannot do this, but they can play a role,” Figueroa says. “Think about forming creative partnerships that without an active effort from the hospital side may not form.”
- Figueroa JF, Duggan C, Toledo-Cornell C, et al. Assessment of strategies used in US hospitals to address social needs during the COVID-19 pandemic. JAMA Health Forum 2022;3:e223764.
Safety net hospitals, critical care hospitals, and rural hospitals often do less than needed to address the social determinants of health of their vulnerable populations, particularly during the COVID-19 pandemic, new research shows.
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