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Study: Large Health Systems Investing in Strategic Initiatives to Address Patients’ Social Needs

July 21, 2016
by Heather Landi
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Several health systems have been investing core operating dollars to address the social needs of patients in order to improve overall health outcomes, and are integrating that work into core clinical systems, according to a new study from the Bridgespan Group.

In the study, The Bridgespan Group, a non-profit organization that provides consulting services to non-profits and philanthropic organizations, examined the efforts of several enterprising health systems to build out pilot projects addressing one or more of their patients’ social needs, with a particular focus on high need communities.

The study, titled “The Community Cure for Health Care,” specifically focused on the New York City Health and Hospitals Corporation (HHC), NYC’s publicly operated hospital system; Kaiser Permanente of Southern California, a not-for-profit health plan and provider that serves more than 4 million patients through a network of hospitals and medical offices across the region; and ProMedica, a non-profit health system based in Toledo, Ohio.

It has been widely noted, according to data from the Robert Wood Johnson Foundation, that only 20 percent of a person’s health is related to access to and quality of health care. A collaborative study between the Institute for Clinical Systems Improvement and the Robert Wood Johnson Foundation found that the remaining 80 percent is found in patients’ behaviors, socioeconomic conditions and other factors. Specifically, 40 percent of a person’s health is socioeconomic factors, such as education, family and social support, income and community safety, 10 percent is physical environment and 30 percent is health behaviors, such as diet and exercise and tobacco or alcohol use.

According to the study authors, Bridgespan partner Taz Hussein and Bridgespan consultant Mariah Collins, changes in health care financing are pushing some health systems to look for effective ways to address patients’ social needs in the communities where they reside. Public and private payers are increasingly moving away from the traditional fee-for-service reimbursement model and toward a pay-for-performance model, which ties financial incentives to improved health outcomes, the authors note.

“Based on this shift, giving a patient a CT scan, for example, may not pay like it used to; keeping the patient healthy and out of the hospital might be more profitable. As a result, forward-looking health care systems are beginning to invest in affordable housing, farmers markets, and other social needs of patients—though at the moment, the great majority of these pilots and experiments are funded through government or foundation grants, or hospital charitable giving,” the authors stated.

In fact, the US Centers for Medicare and Medicaid Services (CMS) Innovation Center recently launched the Accountable Health Communities (AHC) Model to examine whether systematically identifying and attempting to address health-related social needs of Medicare and Medicaid beneficiaries through referral and community navigation services can impact health care costs, reduce inpatient and outpatient health care utilization, and improve health care quality and delivery.

And, as previously reported by Healthcare Informatics Managing Editor Rajiv Leventhal, a Chilmark Research report noted that the migration to value-based care will require a new approach, specifically that healthcare organizations must incorporate information about social, behavioral, and environmental factors into their risk stratification models in order to better understand a patient's total active risk.

The Bridgespan Group authors noted in the study that the health systems being studied—HHC, Kaiser Permanente of Southern California and ProMedica—are each taking their own approach to this work.

The three systems serve approximately seven million patients, and are seeking ways to sustain and scale their approaches by zeroing in on four decisions—which patients and needs to focus on; whether to build or buy the capability required to address patients’ social needs; how to integrate this work into core clinical systems and processes and how to measure benefits and costs, the study authors wrote.

HHC is employing a universal screening for the general patient population on a range of needs such as housing, food insecurity, and interpersonal violence, among others and is partnering with a national nonprofit, Health Leads, to refer patients to outside community resources and social services, according to the study authors.

Kaiser Permanente is targeting a high-need population, defined as the 1 percent of people that account for 25 percent of total health care costs or “high utilizers.” Artair Rogers, senior consultant at Kaiser Permanente of Southern California, said in a statement in the study, “This is who we want to evaluate, to see if this approach can really yield a return on investment.”

The study authors note that Kaiser Permanente also is currently working with Health Leads and is piloting three initiatives to determine the best models to scale.

And, leaders at ProMedica developed a universal screening for a single need—hunger and nutrition—using a multi-pronged approach. In addition to partnering with local organizations working on the issue, they are providing food banks at two of their clinical sites that provide patients with healthy food. ProMedica also is building a supermarket in one of the low-income neighborhoods the organization serves, according to the authors.

As part of its initiative, ProMedica also has made efforts to tie its food and nutrition work to everyday clinical practice. “In 14 of its 43 primary care practices, every patient is screened for food insecurity using a validated, two-question screen built into their electronic health record (EHR). The goal is to conduct screening in every practice by the end of 2016,” the study authors wrote.

“Because the hunger screening and referral are in the patient’s health record, the organization will know who is coming in, if and when they were referred, and what their cost of care looks like over time,” the authors stated.
Collins wrote, “While these organizations’ efforts are still in an early stage and they face many challenges, their experiences to date suggest promising strategies for how health care organizations’ might help patients with some of the social needs that have the greatest impact on health.”


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