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4 Steps for Successful Direct Investments in Social Determinants of Health

Analysis  |  By Alexandra Wilson Pecci  
   August 18, 2020

ProMedica's president of social determinants of health, Kate Sommerfeld, shares strategies for making direct investments to help combat SDOH in the community.

While partnerships with outside organizations are relatively common among health systems working in the social determinants of health space, making direct investments is less common because it's harder to show ROI.

However, some are making direct investments, including ProMedica in Northwest Ohio and Southeast Michigan, which has been investing heavily in SDOH projects for its patients and surrounding community for several years.

"There's a handful of payers and systems that have totally bought in, are making the investment, and doubling down on social determinants," says Kate Sommerfeld, president of social determinants of health for ProMedica.

After about a decade of doing piecemeal work, ProMedica created a dedicated division and president role in late 2017.

"As a system, we made a decision that social determinants are really, truly part of our strategic plan and fundamentally how we deliver care," Sommerfeld says.

Here are four steps to help ensure successful direct investments in social determinants of health.

1. Grow the evidence base

A lack of clear evidence that SDOH investments result in improved health outcomes and a solid ROI stands in the way of many health systems making similar financial commitments. (However, progress is being made. See sidebar: "Social Determinants of Health Program Generates ROI.")

That's why ProMedica is working diligently not only to make investments, but also to demonstrate clear evidence that links certain interventions with positive outcomes for pinpointed patient cohorts.

"We're really focused on growing that evidence base," Sommerfeld says, noting that ProMedica has a number of ongoing research projects that control for different factors—ranging from age, race, and insurance type to whether a patient uses case management services—to target the effectiveness of specific interventions on specific groups, such as oncology patients.

In the meantime, Sommerfeld says overall healthcare spending continues to be "out of balance," skewing heavily toward clinical care rather than SDOH spending, despite evidence showing how much social determinants impact health outcomes.

"In fact, clinical care, while vital, is responsible for only 20% of a person's health," says Benjamin Isgur, leader of PwC's Health Research Institute. "The other 80% is attributable to health behaviors, the physical environment, and socioeconomic conditions."

Isgur points to the Health Research Institute's 2019 global consumer survey, in which one in five respondents indicated they could not afford a healthy lifestyle, and a similar share said they did not have the time to focus on healthy behaviors.

2. Understand market needs and investing

Deciding when to invest directly rather than partner with outside organizations depends on the health system's overall market and its needs.

"Food support looks very different in a smaller community than it does in a more urban environment, so it's incredibly important as we make investments that we understand local context," Sommerfeld says.

To do that, ProMedica first conducts what Sommerfeld calls a "landscape analysis" to determine which outside services the system is referring to patients. Next, ProMedica overlays that data with a community health needs assessment.

Using this system, ProMedica is able to see what the community health needs are, where existing services are to meet those needs, and the gaps in available resources. Where there's no nonprofit or other partner within the community, direct investments can fill those gaps.

ProMedica saw such a need in the realm of personal finance management. "We started to see a consistent gap around individuals struggling to pay their bills," Sommerfeld says, as well as those ensnared in other financial issues, such as predatory lending.

That's why ProMedica launched a Financial Opportunity Center (FOC) that's available to ProMedica's surrounding neighborhood in Toledo.

ProMedica funds and operates the FOC, which is based on a model from the social enterprise Local Initiatives Support Corporation and employs seven on-site financial coaches. Clients have access to housing assistance, credit-building tools, and even free tax preparation.

The program has shown success. For example, in 2019, 60% of ProMedica's FOC clients had credit score increases; 63% had net income increases; 60 clients were placed in jobs; and 93 clients had increased earnings.

3. Decide between making micro or macro investments

Health system investments in SDOH projects can be broken into two groups: micro interventions that assist individual patients and macro interventions that operate on a larger, systemic level.

"As we think about the work, it is broken down into very specific, micro-level support and investment, but also broader, more community-based, place-based investments," Sommerfeld says.

ProMedica's micro-level investments include its FOCs, as well as its food support.

The health system operates three food clinics that are co-located with primary care in medical office buildings.

When a patient screens positive for food insecurity, it's documented in the EMR, and the patient is given a prescription for food, "just like for MRI or medication," Sommerfeld says.

The patient can then walk across the hall to the food clinic to get the food prescription filled. Since food insecurity happens at a household level, the prescription allows for three days of food for an entire family.

While the food prescription provides a temporary fix, within ProMedica's primary care and food clinic settings, patients can become food secure in the long term and connected with benefits, such as WIC or SNAP. They are also directed toward local food pantries and offered FOC supports.

ProMedica is also investing at the macro level, most prominently with Ebeid Neighborhood Promise (ENP), a $50 million investment. That number includes approximately $11 million from ProMedica and $28.5 million from the family of philanthropist Russell J. Ebeid, for whom the project is named.

At the heart of ENP is the idea that "place matters" in health outcomes.

"By deploying a neighborhood-based approach, you're fundamentally shifting the environment," Sommerfeld says. "If you believe place matters, then you have to make investment in 'place,' and place is a neighborhood."

For instance, if contaminated carpeting is triggering asthma, it's a better investment to rip up the carpeting rather than to continue a cycle of medication and hospitalization, Sommerfeld says.

The ENP investment intends to answer questions such as, "How do you make investments at a neighborhood level, to not just change one person at a time? How do you [create] system-level change across a larger population?" Sommerfeld says. "How do we get mass? How do we get scale?"

ENP's 10-year commitment aims to revitalize Toledo's UpTown neighborhood with a focus on health, education, jobs, family stability, and social and educational services, using a place-based model focused on health.

Among those services is a grocery store that ProMedica owns and operates; community classes on topics like parenting and nutrition; job training; and diabetes education.

ENP is also focused on ensuring stable housing for residents and is working with a developer to build 120 units of mixed-income housing across the street from the grocery store, Sommerfeld says.

Other initiatives include working with the city of Toledo and other partners to launch a universal preschool program across the city, and a college promise program at a nearby high school to provide free college to every graduate and one parent from each graduate's families.

4. Measure results to ensure continued funding

Quantifying the ROI of SDOH direct investments can be a challenge, but doing so is crucial to build buy-in and expand funding.

Although a mix of ProMedica's community benefit expenditures—required of nonprofit hospitals, grants, and foundation funding—seeds these investments, proving the ROI of these programs can result in payers picking up the long-term costs.

"As we get data to show that an intervention is actually effective and moving the needle, we engage payers, and have a number of payer contracts to support social determinant work today," Sommerfeld says.

For instance, because ProMedica was able to show that its food interventions produce measurable clinical results, it now has two payer contracts that are picking up the cost of food supports.

Sommerfeld says that for CMS Medicare patients who were given food support, ProMedica reduced ED usage by 18%; reduced readmissions by 5%; and reduced medical cost by 6% over 12 months of data, pre- and post-intervention for a statistically valid cohort of patients.

For patients with ProMedica's insurance product, Paramount Advantage, the program reduced ED usage by 11% and reduced readmissions by 1%, she says.

While micro-investment ROI and outcomes are easier and faster to track, doing so at a macro level takes more time.

"The ROI is much longer on that," Sommerfeld says, estimating that the ROI term on ENP, for instance, is 7–10 years.

But, she says, she believes it will get there.

Alexandra Wilson Pecci is an editor for HealthLeaders.

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