HAANSI 2021 #1: Asking the Right Questions to Improve Health Outcomes for All West Virginians (Part 1/3) Health as a National Strategic Imperative

Part 1: Can we Do Better? Where Do We Start?

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Introduction

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Who are West Virginia’s (WV) primary points of contact for leveraging the social determinants of health (SDOH)—understanding and shaping conditions in which people are born, grow, work, live, and ag e to achieve health equity and better health outcomes? Anyone? There is much buzz about bridging the gap between health care and social services.

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The data is clear that —80% of health outcomes are due to social, behavioral, and environmental factors, and only 20% are due to clinical care . Why are health plans such as Aetna Health suddenly interested in leveraging the SDOH ? What is the role?for communities of solutions and health plans and provider organizations in future "whole person" care models? The Robert Wood Johnson Foundation’s (RWJF) County Health Rankings Model in Figure 1 will provide you with a clue.

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Solutions?

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The solutions are not clear. The challenge for states, counties, and communities is how to organize, create a vision and plan, and then embed the inclusion of social factors and services into care coordination and management aimed at healthier outcomes.?As a benchmark, North Carolina is addressing an approach to figuring out how to leverage the SDOH. Is West Virginia?

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How do the WV health and human service systems create systems that work better—adapt best practices, formalize partnerships, work toward community-based system integration, use predictive analytics and finances with incentives to break down disconnected silos and eliminate fragmentation? How do we move beyond pilot programs and grant funding??Should WV be more proactive by exploring other models or adopt a version of the emerging Center for Medicare and Medicaid Services (CMS) Accountable Community Health (ACH) model as summarized in Figure 2??Where are WV’s “bridge organizations”?

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Why Not?

How do healthcare, public health, social services, and other sectors create an aspiration, vision, and action plan to address social determinants in the care coordination and prevention health processes? Should WV look to existing models or launch a county pilot with X- beneficiaries, clients, patients, and seekers to create an improved transparent network of organizations serving at multiple locations? Note, I said improved and transparent. If we accept the "if it is not broke, fix it" mentality, we accept the status quo. If we review the RWJF County Health Rankings Model by county and performance measure over time, we might conclude, "we can build on what we are doing or improve what we are doing" now and in the future.

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An Aspirational Future?

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What does a transparent, collaborative, and cooperative care coordination system look like??The keys to integrating social services into the value stream of care are screening, and assessment tools such as CMS’s The Accountable Health Communities Health-Related Social Needs Screening Tool.

Figure 3 provides the National Academy of Medicine’s example the Accountable Health Communities Screening Tool :

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Several healthcare institutions and organizations have similar or specific tools to address the following:?

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1.?????Real-time learning about needs (and gaps) (local assessments, assimilating data from other systems, and direct feedback at the point of service)

2.?????Incorporating social support requests into treatment plans, registries, and directories

3.?????Routinely connecting beneficiaries to the next level of care and support services (whether in their system or the community)

4.?????Following-up and motivating beneficiaries to utilize services and incorporate healthy choices.

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Adapt Best Practices?

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The question is, are they integrated? Have a technology platform to collect and report data? Have a committed team to assist and advise others??For example, Kaiser Permanente Mid-Atlantic States , George Mason University College of Health and Human Services , northern Virginia social service organizations, and a technology platform, UNITE US , have committed to improving care coordination and management to embrace beneficiary needs social support services. Other health systems across the US are piloting programs in various clinical settings—an emergency department, an intensive care unit, an inpatient unit, and two medical practices. Beneficiaries served at these locations will be assessed for social risks—nutrition, safety, and housing. Beneficiaries can choose how and when to complete the assessment—smartphone, tablet, email, telephone, their own, or with assistance from staff. While there may be pockets of innovation in locales throughout West Virginia, is there an effort to make this idea a standard practice?

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Summary

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Is it time for West Virginia to conduct a strategic assessment, perhaps establish a task force to address the SDOH and poor health outcomes holding back West Virginians? For example, according to the Rural Health Information Hub and data.HRSA.gov , as of April 2021, West Virginia had:

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1.??????21 Critical Access Hospitals

2.??????57 Rural Health Clinics

3.??????258 Federally Qualified Health Center sites located outside of Urbanized Areas

4.??????10 short term hospitals located outside of Urbanized Areas

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This summary does not include the public health departments, myriad of social services organizations, and hundreds of SDOH-related associations. It should. So, I ask again, who is West Virginia's (WV) primary point of contact for addressing the social determinants of health (SDOH) to help the workforce achieve health equity and create better health outcomes? The Robert Wood Johnson Foundation’s (RWJF) County Health Rankings Model suggests we do. Anyone? Stay Tuned for Part 2

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Douglas E. Anderson, Colonel (Ret), USAF, MSC, DHA, MSS, MBA, FACHE is a healthcare administrator with 35+ years of experience in the military, academic, and international sectors. He’s served as a CEO, project lead, consultant, mentor, and educator. Today, his passion is to develop integrated community health systems, create a culture of health, and help others succeed. Currently, he coaches executive leaders and helps community leaders to leverage the social determinants of health to improve the health of individuals, families, and communities. He is Chair, American College of Healthcare Executives Health Administration Press Editorial Board. He is co-author of Health Systems Thinking: A Primer . Contact: [email protected] /LinkedIn: https://www.dhirubhai.net/in/douglasandersonsheldr/ for more information. His thoughts are his own; they do not represent any organization. He lives in the DC-Metro are (Martinsburg, West Virginia). He’s available for part time projects.