Good medicine? Health systems address patients’ social determinants of health

TO ILLUSTRATE how health systems are stepping up to address patients’ social issues, Amit Vashist, MD, MBA, senior vice president and chief clinical officer of Ballad Health, a regional health system serving parts of Appalachia, offers this anecdote: A couple was recently being screened by one of Ballad Health’s “community navigators,” a care coordinator who connects patients to social as well as clinical resources.

The couple admitted their water had been shut off and their housing was about to receive a HUD inspection, which they’d fail without running water.

“That in turn would cause the family to be homeless,” Dr. Vashist says. The navigator found a community organization to pay the overdue balance, but not the reconnection fee. That’s when the navigator reached out to the Ballad Health Foundation, the system’s philanthropic arm, which hand-delivered a check for the full payment to the utility within 24 hours.

“The water was reconnected, and the house passed inspection,” says Dr. Vashist. “We met the family’s urgent needs, and now the navigator can focus on the longer-term resolution of their health problems.”

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Why is a health system engaged in something so seemingly far afield from clinical care as overdue water bills?

“The majority of the physicians, at least in our region, have increasingly moved away from a fragmented approach where they are in charge of diseases and someone else is responsible for social determinants of health,” Dr. Vashist explains. “We are finding that our paths intertwine.”

The CMS now recommends that all patients be screened for five social determinants of health: food and housing insecurity, utility and transportation needs, and interpersonal violence. Growing evidence indicates that patients’ unmet social needs play an outsized role in determining health outcomes.

New financial incentives are also driving the focus on social determinants of health; recent federal tax changes, for instance, now allow hospitals to claim housing investments as charitable spending. And clinicians and health systems increasingly realize they can’t succeed with value-based or accountable care if they don’t address the social needs that can sabotage patients’ health.

That’s led hospitals large and small to launch an unprecedented number of initiatives that, on their face, range far from health care delivery. Last year, for instance, Kaiser Permanente committed to investing up to $200 million in housing to combat housing instability and homelessness.

Even in hospitals and systems that can’t match that level of investment, targeting social needs is gathering steam. Here’s a look at several around the country where physicians, including hospitalists, are taking the lead.

BALLAD HEALTH: Tailored community referrals

ADDRESSING social determinants of health is part of Ballad Health’s DNA. With more than 20 hospitals in northeastern Tennessee and southwestern Virginia, the organization grew out of a 2018 merger between two smaller systems that was approved by both states’ regulatory authorities.

“Our merger was made possible with active state oversight through a certificate of public advantage (COPA),” a mechanism that exempts hospitals from state and federal antitrust laws, Dr. Vashist says.

To meet COPA regulations, Ballad Health committed to spending more than $300 million over the next 10 years. Funds are benchmarked for population, behavioral and rural health, children’s services, and research and academics, among others.

“We must shift our focus away from our particular care setting to more comprehensive care. “

~ Amit Vashist, MD, MBA
Ballad Health

“One big reason we were allowed to merge was to address the most critical health care needs of our communities,” he notes. Those needs are exacerbated by low income, scarce resources and the opioid epidemic.

As part of its mission—and with a federal grant from the Center for Medicare & Medicaid Innovation—Ballad Health is piloting an Accountable Health Communities model across 11 counties.

Patients are screened both in in the ED and in inpatient and outpatient settings for ED utilization, substance use, depression and unmet health-related social needs. Qualifying patients are then randomized to either usual care or to a community navigator who connects them with community resources for help with utilities, housing, food or transportation, which is a big regional need.

“Those patients receive a tailored community referral,” says Dr. Vashist. Community organizations report back to Ballad Health if referred patients are also accessing other services. Navigators can reach out to hospitalists if discharged patients aren’t filling expensive prescriptions after discharge and request cheaper substitutes.

Cultural and clinical obstacles
Part of the success of the community navigators, Dr. Vashist notes, is that “we make sure these are local people. This part of the world has a fear of outsiders, and we need local people to overcome those cultural obstacles.”

And size—being a regional health system, not one of the two smaller legacy ones—also counts. “We now have one point of contact,” he says, “as well as some clout and leverage.”

The system is working with the Appalachia Service Project to provide housing solutions. It has launched transportation pilots with local faith-based groups and is collaborating with the School of Public Health at East Tennessee State to create a national center for rural health research.

And Dr. Vashist is pushing physicians to take a more comprehensive view of their role in the continuum of care. To that end, he plans to convene a transitional care summit next spring to bring together the system’s hospitalists, primary care doctors, and ED and urgent care physicians.

“We must shift our focus away from our particular care setting to more comprehensive care if we’re going to provide safer, more effective transitions,” he says. “That won’t happen without focusing on social determinants of care.”

DENVER HEALTH: Tackling homelessness

FOR SARAH STELLA, MD, social determinants have not only influenced her care of patients but transformed her career. A hospitalist for 12 years at Denver Health, that city’s safety net hospital, Dr. Stella notes that “a lot of our work as hospitalists is caring for people experiencing the end results of systems gone wrong.”

She found herself drawn to patients experiencing homelessness who often lack safe discharge options and have poor outcomes, including longer lengths of stay and readmissions.

“They are literally stranded in the hospital,” Dr. Stella says. “In the current spectrum of care, we don’t have a lot to offer them.” For homeless patients, she adds, “you can’t take a one-size-fits-all approach. People think the homeless population is homogenous, but it’s actually very diverse.”

“A lot of our work as hospitalists is caring for people experiencing the end results of systems gone wrong.”

~ Sarah Stella, MD
Denver Health

Her interest first led to work inside the hospital, sitting on a committee that examines long lengths of stay and complex cases. That committee deals with multiple barriers to discharge for about 30 patients a month, a subset of whom are homeless.

Her clinical work also motivated her to develop a growing number of partnerships outside the hospital. With a small grant last year from the University of Colorado, she set up an advisory panel of community stakeholders and patients who’ve been hospitalized and are homeless or have experienced homelessness. She formed that panel in partnership with the Colorado Coalition for the Homeless.

“Our panel focused on the experiences of homeless patients during hospitalization and what happens to them in the immediate post-discharge period,” says Dr. Stella. While convening the panel led to a shared vision of how to improve care, it also “changed me as a clinician, giving me a drive to advocate for this population.”

New research
Dr. Stella now divides her work time between clinical care and her research, education and community partnerships. She is lead physician on a Denver Health initiative that focuses on patients with prolonged lengths of stay due to discharge barriers. Dr. Stella is also involved in Denver Health’s first foray into housing. In collaboration with the Denver Housing Authority, the system is repurposing an unused office building on the campus into senior housing, with some studio apartments reserved for complex homeless patients transitioning out of the hospital.

She is also participating in an initiative with a national health policy center to try to identify homeless patients at rising risk for adverse outcomes to see if earlier interventions could prevent out-of-control utilization.

And she and two hospitalist colleagues lead the Health Equity Pathway, a curriculum within the University of Colorado’s internal medicine residency program. “We’re training residents to more effectively advocate for disadvantaged patients,” says Dr. Stella—training she would have loved to receive, particularly in trauma-informed care.

“Hospitalists are trauma doctors in every sense of the word,” she points out. “Pretty much everyone we see has experienced some sort of trauma.” As clinicians, hospitalists can choose to not acknowledge that, “but if you can embrace it, delivering care will be a lot less frustrating, and you’ll be more effective.”

ATRIUM HEALTH: Community care management

THIS YEAR, North Carolina made data-sharing between providers and community organization a reality statewide.

Supported by the state’s health and human services department, the NCCARE360 initiative is, its Web site says, the first statewide network to electronically connect patients to community resources and provide feedback on that connection back to clinicians.

But much of the work that went into NCCARE360—as well as into the state’s Healthy Opportunities pilot programs, which will steer $650 million in state Medicaid funding over five years to evidence-based programs targeting social needs—”was actually built on the foundation that we laid.” That’s according to Alisahah Cole, MD, chief community impact officer for Atrium Health, which has hundreds of outpatient providers and more than 40 hospitals in North and South Carolina and Georgia.

“The return on investment from working in the community is going to take time.”

~ Alisahah Cole, MD
Atrium Health

In 2016, Dr. Cole was named vice president, system medical director of community health, of what was then Carolinas HealthCare System, renamed Atrium Health In 2018. Having spent more than a decade in academics and in both urban and rural family care, Dr. Cole says that the medical directorship grew out of her earlier work on an executive committee.

“We realized we really didn’t have a strategy around our work in the community,” she notes. “That’s when I was given a formal role and we began taking a more formalized approach.”

That included creating the Community Resource Hub, a database launched in 2017 that providers and patients in Charlotte can use to find not only medical care but food pantries, housing services, job training, legal assistance and transportation. “That’s expanded the notion of care management to a community care management framework,” she notes, “not just medical care management.”

Falling readmission, asthma rates
Also in 2017, the organization’s Community Improvement Study—done in collaboration with the North Carolina Institute for Public Health—used patient data to track 12 social determinants and created a social index score for patients in North and South Carolina.

“That highlighted neighborhoods with the highest social challenges,” Dr. Cole explains. “Not surprisingly, we found a high correlation between high rates of obesity, diabetes, ED utilization and readmissions and the communities with the highest social needs.”

While Dr. Cole started her community health office with one full-time assistant, her staff has now grown to 31.

But very few are new full-time FTEs. “We realized we had many people across departments doing a lot of this work, but it was all siloed,” she says. “We just brought them together.” One key component of their work is continuous training—on available resources, for instance, and on how to leverage media platforms to educate patients—of clinicians, staff, volunteers and even patients.

Another big lesson: Create an electronic infrastructure with community organizations. When she and her team began pulling together those resources, they realized that some organizations still relied on faxed or even handwritten referrals. “Atrium’s own IT and data analytics department volunteered to go into many community-based organizations to make sure they had the right tools—and even computers—to receive referrals through this platform,” Dr. Cole says.

As for outcomes, “we’re in the very early stages,” she says. But Atrium has seen readmission rates reduced “through our food insecurity work.”

Virtual behavioral health services in primary care offices have helped both patients and clinicians. And a virtual primary care model that Atrium embedded in several low-income Title I schools in two rural North Carolina counties helped cut local ED utilization by more than half, particularly around pediatric asthma.

“The return on investment from working in the community is going to take time,” says Dr. Cole, pointing out that Atrium provides more than $5.6 million a day in uncompensated care and community benefits. “We have to be willing to commit long term.”

SOUND PHYSICIANS: Meeting rural needs

IN RURAL AMERICA, unmet needs are often due to scarce resources. According to Christoffer Spoja, DO, a regional medical director for Sound Physicians, “there is a huge need for post-acute care services in general, and home health custodial services in particular.” Dr. Spoja oversees seven hospitalist programs in Montana, Idaho and Wyoming.

That need is just as acute for insured patients because “there really isn’t a financial pathway for custodial care in the home,” he notes. Medicare doesn’t pay for that care, which is non-medical assistance with daily living activities and ambulation. And while “Medicaid occasionally does, the qualification process is so long that if you don’t have that resource in place when you’re admitted, there’s no way you will have it at discharge.”

“There really isn’t a financial pathway for custodial care in the home.”

~ Christoffer Spoja, DO 
Sound Physicians

The much costlier alternative is skilled nursing facilities. But that can mean readmission rates of 25% or 30% and, for rural patients, being 100 miles away from family. Unless patients need intensive physical therapy, such as stroke patients do, Dr. Spoja says, “we believe patients in their home have significantly better quality recoveries than in a skilled nursing facility.”

An in-home pilot
To test the viability of providing custodial care, Dr. Spoja is helping launch a pilot project this month, first at a hospital in Casper, Wyo., then at three hospitals in Montana.

In what’s known as Project Crux—for Crux Care, the vendor selected to supply custodial care—Sound will pay certified nursing assistants (CNAs) to visit patients eight hours a day for between 15 and 30 days. Most patients will be participants in one of Sound’s bundled payment for care improvement (BPCI) initiatives or direct payer relationships. Ideal candidates include COPD and heart failure patients.

While the CNAs will help patients recover from deconditioning in the hospital, they’ll also teach families how to help prevent readmissions through strategies like monitoring fluid intake and urinary output for heart failure patients. Initially, four patients from each site will be chosen for the pilot, and hospitalists, clinical performance nurses and case managers will help select eligible patients.

Dr. Spoja doesn’t yet know how far outside each community the CNAs will travel to patients, or if they can drive patients to medical appointments without running into liability risk.

And return on investment will determine whether to roll the program out nationwide. “We’re trying to see,” he says, “if we can get better outcomes for lower costs.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

The need for innovative Medicaid programs

THE CMS THIS YEAR granted North Carolina a waiver allowing that state’s Medicaid program to pilot interventions to address social determinants of health.

But since 1997, New Mexico’s Medicaid program—called Centennial Care—has maintained an HMO model, which also focuses on unmet social needs, says David Yu, MD, MBA. A former hospitalist, Dr. Yu is now medical director with the Albuquerque-based Presbyterian Health Plan, the state’s largest insurer. The plan currently manages 370,000 Medicaid members in New Mexico.

As Dr. Yu explains, Presbyterian Health Plan maintains 450 care coordinators throughout the state who “systematically interact with and develop relationships with their members who are most at risk.” Social areas addressed include housing, rent assistance, post-discharge care, transportation issues and even environmental modifications in patient homes.

“As care coordination resources decrease, social determinants become more prominent.”

~ David Yu, MD, MBA
Presbyterian Health Plan

The health plan also works with state officials to formulate Medicaid benefits that target social determinants of health. And having a Medicaid HMO care model makes a real difference to clinicians, says Dr. Yu, who’s worked in New Mexico for the past 10 years.

“I’ve practiced in states where Medicaid programs were based on fee for service,” he points out. In such states, “emergency rooms and hospitals become the Medicaid safety net, outpatient support is very minimal, and patients suffer complications of illnesses that nonmedical support may have helped prevent.”

For hospitalists, he adds, “that can be very frustrating because patients have no bridge to the resources they need.” That leaves hospitals and hospitalists “bearing the full brunt of states not investing in innovative Medicaid programs.” He believes hospitalists—as well as medical societies—should play a contributing role in modeling their states’ Medicaid programs.

And as a consultant who helps hospitalist groups set up unit-based care, Dr. Yu notes this trend: As hospitals face financial pressures, facilities tend to cut care coordination. But that’s exactly where they need to invest to get a better handle on social needs.

“You see hospitals with care-coordination ratios of one to 30 or even one to 40, which is not ideal,” says Dr. Yu. “They then wonder why their length of stay is so high. As care coordination resources decrease, the social determinants that contribute to the health issues of hospitalized patients become more prominent.”

Published in the December 2019 issue of Today’s Hospitalist