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2 Ways Houston Methodist Addresses Social Determinants

Analysis  |  By Christopher Cheney  
   August 01, 2018

To address social determinants of health, Houston Methodist makes direct interventions with grants and builds community partnerships.

Necessity spurred Houston Methodist to address social determinants of health in the communities that it serves.

Participation in Track 3 of the Medicare Shared Savings Program (MSSP) highlighted the need to address social determinants, says Julia Andrieni, MD, vice president of population health and primary care at the Houston-based health system.

"We realized that if we were not addressing nonclinical factors, we could not impact chronic condition management. Illnesses were just the tip of the iceberg—there were a lot more factors that contributed to health status when you took a holistic view of a patient," Andrieni says.

Houston Methodist joined MSSP Track 3, which features upside and downside risk, in January 2017. The Medicare program and population health efforts have prompted development of several social determinants of health initiatives at the health system, Andrieni says.

"Before MSSP Track 3, we were not addressing factors like transportation, food insecurity, social isolation, and economics such as affordability of medications. If we could not address those factors, we could not impact care," she says.

Here are two ways that the health system addresses social determinants of health in the communities it serves:

1. Grants

The Houston Methodist Community Benefits Department gives grants to federally qualified health centers and free clinics that provide primary care and mental health for the underserved.

"We give out millions in grants every year," Andrieni says.

Patients who do not have a medical home have access to Houston Methodist–supported federally qualified health clinics throughout the Houston area, which gives patients access to care in their neighborhoods. 

The health clinics coordinate care with Houston Methodist, says Janice Finder, MSN, BSN, director of population health and performance improvement at the health system. "Appointments can be made prior to discharge and reminder calls are provided by the clinic in case patients have to cancel or change appointments."

In disadvantaged communities, grant funding for the health clinics helps support essential services such as behavioral health, Finder says.

Harris County, which is the largest county in Houston, has a 21% uninsured rate and low access to mental health services, with 1 provider to 1,020 patients. The federally qualified health clinics help address a pressing need, she says.

"Behavioral risks such as anxiety, depression, stress, and substance abuse go untreated. The FQHCs as well as our community-based social workers help to alleviate a small portion of this burden," Finder says.

Another grant-supported program—Homeplate—provides food and daily checks for inpatients after discharge.

"Food is one of the primary social determinants affecting health. We have found that many patients who come out of the hospital do not normally require Meals on Wheels or similar programs, but they may need help with meals and a daily check for the first 14–30 days postop," Finder says.

Homeplate also provides meals to newly diagnosed diabetic patients so they can get used to weighed and measured portions.

Homeplate gives food to a patient's family, too.

"We have found when one is hungry many are hungry, and the patient will give their meal to other family members and even their pet. Homeplate provides meals for the entire family and the pets," Finder says.

Drivers who deliver food for Homeplate check on patients and ask basic health-related questions, such as whether appointments have been attended and medications picked up. "If there is a "no" answer, the driver calls our nursing staff, and we handle the alert," she says.

Homeplate has increased patient satisfaction and lowered readmissions, Finder says.

2. Partnerships

Community partnerships are the health system's primary focus to address social determinants, she says. "As a health system, we probably can't be providing transportation and food and actually be the resource for social determinants, but we have partnerships."

Selecting appropriate partners is essential to the success of social determinant initiatives, Andrieni says. "You need to have partners who are aligned with your goals, and you should outline those goals and the outcomes you are working for. The right partner will help you track shared goals and help manage outcomes."

Partnerships with community organizations should be formal business relationships, Finder says.

"You need to set up a legal structure and contract with the organizations you are partnering with, and make sure that you are keeping the confidentiality of your patients," she says.

Three of Houston Methodist's social determinant partnerships help close key care gaps, such as home health, care coordination, and elder resource services:


Houston Methodist has a home health partnership with Houston-based Grand-Aides, which provides health workers who support nurses in the home setting.

From August 2016 to December 2017, the partnership with Grand-Aides generated $101,000 in ROI for Houston Methodist. Grand-Aides helped avoid 18 readmissions, which garnered a cost savings of $216,000.

Golden Care Program

As part of Houston Methodist's Chaplaincy Office, the Golden Care Program connects uninsured and Medicaid patients with a primary care physician at one of the federally qualified health centers in the Houston area. Appointments are made for patients before they leave the hospital and are scheduled for seven to 10 days after discharge.

Additional patient services include coordinating community and congregational resources for at-home services, such as patient transportation and food delivery.

Baker Ripley Sheltering Arms

The Baker Ripley Sheltering Arms program helps elders who need assistance accessing general resources such as transportation, health benefits, and care needs. The service targets people with dementia or cognitive impairment who may need case management services or care consultant services for patients and caregivers.

Addressing social determinants of health has had a significant impact on Houston Methodist, Andrieni says. "It has helped us meet our goals to decrease readmissions, to decrease ED utilization, and to be proactive in managing nonclinical as well as clinical issues with our medical and clinical pharmacy staff."

Houston Methodist has more opportunities to close social determinant gaps, Andrieni says. "We have started on this journey, but there is a lot more to do. As we understand our population more and more, we are going to pick up on other gaps that we need to address."

Christopher Cheney is the CMO editor at HealthLeaders.


Participation in MSSP Track 3 spurred Houston Methodist to tackle social determinants of health.

One food assistance program has lowered readmissions and boosted patient satisfaction.

The health system believes community partnerships have the most potential to address social determinants.

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