A Playbook for CMOs to Tackle SDOH and Health Inequity

Boston Medical Center is a leader in addressing social needs and health disparities. Here's how they're seeing success.

With an estimated 80% of health outcomes affected by social determinants of health, CMOs are focused on tools and programs that help their clinicians identify and address those barriers to care.

Boston Medical Center has a number of strategies in place to address SDOH, including THRIVE, which was launched in 2017 to screen patients for unmet social needs and match them to the appropriate resources.

"We wanted to understand the barriers to implement programs to help our patients thrive," says Thea James, MD, MPH, MBA, vice president of mission and associate chief medical officer at BMC.

These programs enable CMOs to tackle barriers that keep patients from accessing the care they need, including food insecurity, transportation, financial insecurity, employment, family life, education, and cultural issues. Addressing those challenges and connecting patients to the right resources helps to reduce healthcare costs and adverse health issues down the road.

With the THRIVE program, a medical assistant administers a screening questionnaire to patients coming in for an appointment. If the patient indicates that they have unmet social needs, the medical assistant prints out a list of community resources that can address the needs.

The results of the screening questionnaire are also shared with the patient's physician, James says, adding doctors need to understand their patients' social needs to develop effective care plans.

"For example, if someone is homeless and they are diabetic, they are not going to be able to store insulin safely," James says. "Under these circumstances, a physician needs to create special conditions for the patient to be able to follow the recommendation to take insulin."

The THRIVE program was one of the first SDOH assessment programs in the country. BMC is currently developing THRIVE 2.0, which will close the loop on social needs referrals, according to James.

"We will follow up on the referral process and have the referral communicated back to the hospital," James says. "We want to know whether a patient was able to connect with community resources and whether connecting with community resources has impacted their health outcomes."

Another social needs program at BMC is StreetCred, which was established by the hospital's Department of Pediatrics. StreetCred provides a suite of economic services to families with infants whose annual incomes fall below the federal poverty level. The program supports economic mobility through tax preparation and financial education.

Since 2016, BMC officials say, StreetCred has returned more than $14 million to more than 6,000 families.

Thea James, MD, MPH, MBA, is vice president of mission and associate chief medical officer at Boston Medical Center. Photo courtesy of Boston Medical Center.

Addressing health disparities

In 2020, BMC launched the Health Equity Accelerator, which focuses on six areas where glaring racial health disparities were identified: maternal and child health, infectious disease, behavioral health, chronic conditions, oncology, and end-stage renal disease.

"We decided to look inside our own house and find disparities," James says. "We wanted to examine health disparities from the perspective of root causes. We decided to have patients help us interpret the data as well as help us to come up with solutions."

For example, BMC found that Black maternity patients were 1.7 times more likely to experience severe complications during birth than white maternity patients. A multidisciplinary team determined that BMC needed to address preeclampsia. The health system took several steps, including expanding the doula program, producing patient-facing videos for preeclampsia education, and expanding a remote hypertension monitoring program.

The effort has generated positive results, according to James.

"There has been a significant reduction in the readmission rate for preeclampsia," James says.

BMC has also taken steps to address the diabetes disparity, particularly among Black and Hispanic patients.

"We had two navigators who were Spanish speakers," James says. "We provided continuous glucose monitors, so that patients did not have to stick their fingers to draw blood all the time. We also added mental health services for these patients—their depression scores were high."

"The depression scores went down significantly, and 39% of patients had their A1C levels decrease in the first six months of the interventions," James says.

With more than 70 providers engaged in addressing diabetes inequities, BMC has enrolled more than 3,000 patients into health equity programs, achieving a 50% reduction in diabetes inequity in 2023, according to BMC data.

National recognition

The American Hospital Association recently awarded BMC with the Foster G. McGaw Prize for Excellence in Community Service, given annually to a healthcare organization that has shown exceptional commitment to community health and developing innovative partnerships with community organizations. As part of the prize, the health system received $100,000 toward programs that further these goals.

BMC received the award in part because of the organization's efforts to address social determinants of health and health disparities.