A population health program that improves healthcare access and takes into account social determinants of health (SDoH) reduced emergency department and inpatient care and lowered costs, according to a new Health Affairs study.
The study authors, who are with the Baylor Scott & White Health and Wellness Center, said the results show population health programs that go beyond traditional healthcare can benefit both the health system and patients.
Moving from “sick care” to manage and prevent chronic disease will require creativity and collaboration among multiple stakeholders to improve value and improve health outcomes, the authors said.
The paper looked at Baylor Scott & White Health’s partnership with the Dallas Park and Recreation department “to create a level-three primary care clinic integrating wellness and prevention programs in a city recreational center.”
The study examined ED and inpatient care use for on year after the program’s launch. The authors found ED usage dropped 21.4% and associated costs decreased 34.5%. Inpatient care use also decreased 36.7% and reduced costs by 54.4%.
The program hopes to reduce ED use and inpatient hospitalizations in an underserved Dallas community with SDoH issues.
It implements wellness programs and improves access to routine primary care regardless of a patient’s ability to pay. The public-private partnership gives people access to programs that help reduce chronic disease risk with physical activity and healthy food. Community health workers offer “culturally relevant patient navigation” in English and Spanish. Also, the program works with 27 churches in the area to provide a connection to the community beyond healthcare stakeholders.
These kinds of programs go beyond healthcare, involve other community stakeholders and include potential barriers to better health, including housing, nutrition and transportation. If patients don’t have steady housing and transportation and don’t have money for food, providers will have a difficult, if not impossible, task in keeping them healthy.
Recent transportation-driven population health examples include:
- Geisinger’s pilot to get patients to medical and health-related appointments.
- Lyft and Allscripts are partnering on a platform that will let doctors and hospitals offer non-emergency medical transportation to patients.
- Uber launched a new platform called Uber Health, which will allow healthcare workers to book a ride for a patient.
Evaluating social determinants of health is also helping combat the opioid epidemic. Using SDoH data, providers, payers and community groups are finding at-risk people before they fall into the throes of addiction.
"While increased opioid prescribing for chronic pain has been a vector of the opioid epidemic, researchers agree that such structural factors as lack of economic opportunity, poor working conditions and eroded social capital in depressed communities, accompanied by hopelessness and despair, are root causes of the misuse of opioids and other substances,” according to a recent American Journal of Public Health report.
Though healthcare organizations are utilizing SDoH data, a recent National Quality Forum (NQF) report said there’s room for clarification of what the term means. The report said Medicaid could play a key role in addressing social determinants. The NQF recommended state Medicaid programs need to “better assess and address social needs in healthcare.”