Increasingly, providers, payers and community-based organizations are coming to understand the role that social determinants of health like housing, nutrition and transportation play in the health of a person and the health of communities.
Health Affairs has recently taken a look at two separate initiatives that address social determinants, each of which has produced positive results by taking different approaches: A state program in Maryland called the Health Enterprise Zone Initiative and wraparound services provided by Eskenazi Health, a safety net provider in Indianapolis.
Providers are finding it not only difficult to help patients who lack secure housing, food and a way to get to their scheduled appointments, but also costly when those patients miss appointments, wind up in emergency rooms with non-emergency conditions and are regularly re-admitted when their chronic conditions aren't managed.
Most payers have responded to providers' needs: More than eight in 10 insurers are currently integrating those factors into their member programs, according to the 8th annual Industry Pulse survey.
From both the provider and payer sides, the answer to social health needs has largely been value-based payments for more population health management programs. The studies on Marlyand Enterprise Zone Initiative and Eskenazi Health add to a plethora of existing research that shows those programs are best carried out in tandem with community partners such as local government agencies, social workers and community and religious centers.
Health Enterprise Zone Initiative
Maryland's Health Enterprise Zone Initiative shows how state funds can be used to create incentives for providers to take a proactive community-based approach to addressing social determinants, in turn cutting costs and reducing inpatient stays.
Researchers from Johns Hopkins University found that, between 2013 and 2016, the Health Enterprise Zone Initiative was associated with a reduction of 18,562 inpatient stays and an increase of 40,488 ER visits, concluding net cost savings from reduced inpatient stays "far outweighed the initiative's cost to the state."
The Health Enterprise Zone Initiative was implemented by the state of Maryland in 2013 in five geographic areas with the goal of improving access and outcomes in that state's underserved communities while reducing costs, ER admissions and hospital readmissions. To do that, the initiative deployed primary care physicians and community health workers to those communities and coordinated care between hospitals, health departments and community-based organizations.
Each zone was provided with resources to help attract private providers to medically underserved communities. Coalitions of physicians and community health workers provided an array of services to residents, specifically targeting diabetes, cardiovascular illnesses, asthma, obesity and behavioral health problems, but also providing health education, screenings, behavioral health services, dental care and access to relevant social services.
The increase in ED visits, the study notes, was unexpected. Researchers said this might have been due to hospitals sending ED patients home and referring them to Health Enterprise Zone resources rather than admitting them.
Citing the program's association with improved access to care and reduced inpatient admissions and their associated costs, the authors of the study applauded the initiative as an effective way for states to fund health partnerships.
The authors did, however, encourage health plans that benefit from the initiative's cost-savings to provide "additional support" to programs like this.
Eskenazi Health's Wraparound Services
In Indianapolis, safety net provider Eskenazi Health provides wraparound services that address social determinants in-house at outpatient clinics. Researchers from Indiana University-Purdue University Indianapolis (IUPUI) and Eskanazi executives sought to determine how effective the provision of wraparound services was in reducing costs and hospitalizations.
By measuring the association between receiving wraparound services and patient outcomes between 2006 and 2016, researchers found that the estimated cost savings from potentially avoided hospitalizations was $1.4 million annually.
Further, researchers observed a 7% reduction in the expected number of hospitalizations and a 5% reduction in the number of ED visits in the year following the receipt of a wraparound service.
The subject of the study, Eskenazi Health, offers a "complete suite of services" designed to address social determinant-related hospitalizations and ED visitations, including behavioral health, social work, dietetics and patient navigation, all of which are co-located with primary care services at outpatient clinics.
Among the patients who did receive wraparound services, dietitian services were the most common, with 49% of patients receiving counseling from a dietitian. Consultation with a social worker was the second-most common service at 29%, followed by behavioral health at 10%. It's worth noting that researchers found only 7% of patients received more than one type of wraparound service.
A recent study in the Annals of Family Medicine might help explain this. In that study, which analyzed a yearlong pilot in which three clinics tested a suite of EHR-based tools used to screen for and document social determinants of health, researchers found that the majority of patients are not interested in receiving clinical help to address those needs. Only 15% to 21% patients involved in that study indicated wanting a physicians' help in addressing it.
Some physicians might argue that, in addition to patients not indicating the need for their help addressing social factors, the burden of addressing those issues shouldn't fall on physicians. According to a recent white paper from Leavitt Partners, most physicians agree that while social determinants influence health, addressing them is not their responsibility.
Most healthcare stakeholders might agree that addressing social issues should not be the sole responsibility of physicians, but they certainly play a vital role. Under value-based payment, the researchers of the Eskenazi Health study conclude, wraparound services "may be one part of a portfolio of strategies" used to address social determinants, but should not be the only method used to address those factors that help drive poor patient health while boosting costs.
Researchers encouraged other strategies, such as patient risk stratification, health information exchange and cross-sector collaborations.