Several physician organizations are beginning to work on what comes next.
This article was first published on Tuesday, October 1, 2019 in MedPage Today.
By Joyce Frieden, News Editor, MedPage Today
WASHINGTON -- Attending to patients' social determinants of health has to involve more than just screening for issues such as food insecurity and transportation problems, several speakers said here.
"A lot of the conversation about social determinants of health (SDOH) ... [has been] about screening and how do you screen within your organization," said Megan Reyna, of Advocate Aurora Health, in Downers Grove, Illinois. "Doing that process, we learned that there is a whole other conversation we need to talk about -- with engaging our social service agencies, engaging the community, and engaging our patients. And the next step is also looking at local policy change and how we implement this on a national level as well."
At the Physician Organization of Michigan (POM) Accountable Care Organization, the management formed a committee to develop a creative way to finance its work in the SDOH area, said Terrisca Des Jardins, administrative director of the POM Accountable Care Organization (ACO), at the annual meeting of the National Association of ACOs (NAACOS) last week.
"We really need to think about what creates health," said Des Jardins. She noted that 20% of health is attributed to clinical care, "but the balance is health behaviors, social and economic factors, and physical environment. As we start thinking about the future, we need to also start thinking about these other dimensions that may not have been top of mind [before]."
The committee's goal "is to maximize the impact of prospective community benefit investment through an inter-hospital and cross-geography coordination of community benefit donations that target specific population needs in an aligned, impactful, and measurable way. This has never been done before that we know of," said Des Jardins. "I don't know that it's going to work, but we're giving it our best."
In addition to pursuing hard dollars, they're also looking at policies in their own institution that will have impact downstream -- "for example, a policy commitment to hire individuals from the hospital community as a means to improve that community. Another example could be providing a living wage to all workers ... This is going to be a huge lift, obviously."
Des Jardins said her own awareness of SDOH began in 1998 when, while working in New Mexico to find out about the concerns of Medicaid patients there, "the group didn't want to talk about the Medicaid benefit package; they wanted to talk about running water and electricity. That was a real eye-opener for me."
Later, when she was working in a community program related to health information technology, "we found that as we talked to the 'super-utilizers' of the ED [emergency department], when we really had an examination of what was causing people -- particularly Medicare beneficiaries -- to visit the ED, we found they were lonely, or socially isolated."
She carried on this concern when she came to her current job, and implemented a pilot SDOH screening questionnaire at several ACO sites. However, as an ACO, "we don't dictate how people handle specific interventions, so each organization that took on implementing a screening used their own tool. Some included questions on social isolation and loneliness, and some did not." Regardless, that issue of social isolation and loneliness still came up as the single largest social determinant flagged, including among new moms, Des Jardins said.
The next step is to figure out a solution to the problem, she added. "We don't have a solution now, but we think we've identified a creative financing mechanism, and we've identified what could be a significant driver of utilization and success into the future."
Part of the problem in determining patients' SDOH needs is that data collection is very fragmented, said Caitlin Dunn, director of population and digital health at Inception Health, a project of Froedtert Health and the Medical College of Wisconsin in Milwaukee. Her organization, for example, found that it was collecting SDOH data in 997 places in the medical record. And because it's in so many places, "I couldn't tell the system executives the needs of our population -- how many have food insecurity, how many had experienced domestic violence, how many are homeless."
As a result, "The senior leadership team is unclear on our health system's strategy and its role in solving non-medical problems," she said. "Every year, when we go through our strategic planning process, I look for what we are putting of SDOH into our strategic plan. It never comes out like I think it should ... It always ends up being screening."
However, the organization is beginning to make some progress, Dunn added. "Over the past year, we did implement a standard screening tool. It's not perfect, but at least I can tell my executives that over the month of July, we found 17 new people with food insecurity. That's a real thing that they can connect with, and they can imagine interventions they can do because of it."
Dunn's organization is working with other community groups in Milwaukee under the auspices of the "Impact 211" program, an effort by individual communities nationwide to build a 24/7 resource for people to turn to when they have social needs such as housing, transportation, medical care, and food. "We're planning a digital tool that we could make available to our community," she said. "We're at the start of a demonstration project; three of the major health systems and one federally qualified health center have agreed to be part of it," in addition to a variety of community organizations.
"We have a goal of screening 100,000 people in the community through this tool; just imagine the power of that data if you could do it," said Dunn. However, she added, some CEOs of community social service organizations "are concerned that once we turn this tool on, they're going to get this influx of referrals and they're not going to be able to help those people. I'm going to be interested to see the community's reaction if that starts happening."
“We really need to think about what creates health.”
Terrisca Des Jardins, administrative director, Physician Organization of Michigan
Advocates for social determinants of health say it's time to take the initiative to the next step, beyond simply screening for food insecurity and transportation problems.
That next step should include advocating for local policy changes to address the issue, and engaging social services agencies, and the community at-large.
Part of the problem in determining patients' SDOH needs is that data collection is very fragmented.