Social determinants of health: What is the winning formula?

In a prior blog, we focused on the social determinants of health and how they negatively impact health and healthcare costs and we discussed the financial challenges in addressing these determinants.

 In this blog we will focus on the logistical challenges in developing a comprehensive, sustainable and coordinated strategy to address the social determinants of health at a community level as well as a potential winning formula to achieving success.

 ---Tom

The Centers for Disease Control and Prevention (CDC) defines social determinants of health as follows: "Social determinants of health (SDOH) are the conditions in the places where people live, learn, work, and play which affect a wide range of health risks and outcomes."

What is that winning formula?

A targeted population + a primary care medical home hub + a seamless collaborative support network of community stakeholders + a sustainable funding source and payment methodologies that incents (self-interest) stakeholders to focus on a healthy community = a winning formula for addressing the social determinants of health.

Sounds easy? I wish it was. This would have been my shortest blog yet.

We now need to break down this winning formula.

Targeted population

Medicaid recipients - As we discussed in my first blog, it is critical that we address the social determinants of health in a cost-effective manner to ensure sustainability.

Achieving cost-effectiveness will require innovation and flexibility since targeted populations and potential solutions related to social determinants of health will be different in South Dakota vs. Florida. A key component of developing this cost-effective approach is also clearly identifying the targeted population in order to make the best use of our resources.

Focusing on Medicaid recipients achieves both of those goals, that is, a targeted population and an ability to be both flexible and innovative.

As noted in a publication by the Georgetown University Health Policy Institute - Center for Children and Family Services: "What better place to innovate than in Medicaid? After all, it is the single largest health insurer in the U.S. serving more than 74 million people, including the lowest-income and most vulnerable children and families whose health is more likely to be impacted by economic, social, and environmental conditions."

The primary care medical home (hub and spokes)

A critical element needed to successfully address the social determinants of health is a primary care medical home. This medical home could be in different forms such as a primary care office, or a community health center.

Given the targeted audience is Medicaid recipients, community health centers located in inner cities or rural areas would probably be the best option to provide the needed comprehensive care. The community health centers would also need to be able to provide transportation for members on an as needed basis.

The primary care medical home would ideally provide onsite clinical and social assessment as well as foster the needed engagement and adherence by the members.

The primary care medical home would be the hub for all clinical and social determinants data on the members. In order to be more cost effective, the infrastructure and personnel needed from a data gathering and analysis perspective could be housed at a centralized location so as to support all of the community health centers in the region.

This primary care medical home hub would then have linkages (spokes) to clinical specialists as well as the support network of key stakeholders that play a role in addressing the social determinants of health within the community.

The medical home hub would house primary care providers and would ideally employ or have a contractual or referral relationship with social workers, nutritionists, mental health providers, and disease-based educators depending upon the profile of patients, etc.

Also depending upon the profile of the patients, the medical home hub could have translators, geriatric physicians, etc. If the need exists, the medical home hub could also facilitate having a farmers market on site with fresh fruit and vegetables priced or possibly subsidized at a lower cost.

A seamless collaborative support network of community stakeholders

"Seamless and collaborative" as it relates to the internal operations of any organization or entity can be very challenging, but if you are applying those adjectives to individual stakeholders who have not historically worked with each other you have additional challenges.

Multiple stakeholders play a role in addressing the social determinants of health, but I will only focus on a few key ones for purposes of this blog and my next and final blog (payers, providers, health and social services departments and agencies, schools at all levels, foundations, and non-profit organizations of all sizes and missions).

When you think about it, each of these stakeholders has its own primary mission as well as its own challenges in achieving success and survivability of its organization or entity.

How then can we harness these multiple stakeholders who have their own focused mission to be part of a comprehensive and coordinated strategy to address the social determinants of health at a community level in a sustainable manner?

Complicating factors that further impede collaboration between the stakeholders in addressing the social determinants of health:

Current provider payment systems: One key complicating factor that negatively impacts a community’s ability to address social determinants and overall population health in a proactive manner is the fact the some of these key stakeholders' (hospitals, physicians, etc.) financial success and, in turn, focus is linked to our current "sick care" system which is fueled by a "fee-for-service" payment methodology which does not pay for keeping people healthy.

Lack of connectivity of EMRs: The lack of connectivity of Electronic Medical Records (EMRs) in most communities further complicates stakeholders' ability to address clinical and social determinants of health in a collaborative fashion.

Limited ability to integrate clinical and social determinants of health in an EMR: The Electronic Medical Record (EMR) is not well suited to integrate social determinants of health factors with the clinical side of the patient, which further hampers the providers' ability to understand the health issues of the patient from a holistic perspective.

Privacy rules: Finally, adding to this dilemma are well intentioned privacy rules that make it challenging, if not impossible, to accumulate sufficient data on both medical and social factors in order to get a comprehensive understanding of the factors impacting a person's health to proactively design appropriate interventions. 

The secret sauce - unleashing the power of "self-interest"

Using a health economics concept that we have discussed extensively in prior blogs, I believe that unleashing the power of "self-interest" can take us a long way in achieving the necessary seamless collaboration between the support network of community stakeholders, as well as efficient use of resources and, ultimately, sustainability.

 Consequently, it is critical to align goals and have payment systems that would incent, from a self-interest perspective, stakeholders to work together to address the social determinants of health. The results, if designed appropriately, would be a win-win for all parties, but most importantly the community.

As noted previously, I am recommending that communities initially target the Medicaid population from a social determinants of health perspective. Both the Federal government and the states, from a self-interest perspective, are incented to address Medicaid healthcare costs. What better way for the government to address these healthcare costs than to support innovative programs that focus on developing a healthier Medicaid population.

CMS has promoted two programs that could positively impact the social determinants of health within a community:

Accountable Health Communities (AHC) Model :

"The Accountable Health Communities Model will promote clinical-community collaboration through:

1. Screening of community-dwelling beneficiaries to identify certain unmet health-related social needs;
2. Referral of community-dwelling beneficiaries to increase awareness of community services;
3. Provision of navigation services to assist high-risk community-dwelling beneficiaries with accessing community services; and
4. Encouragement of alignment between clinical and community services to ensure that community services are available and responsive to the needs of community-dwelling beneficiaries.

To implement each approach, bridge organizations will serve as ‘hubs’ in their communities, forming and coordinating consortia that will:

1. Identify and partner with clinical delivery sites (e.g., physician practices, behavioral health providers, clinics, hospitals) to conduct systematic health-related social needs screenings of all beneficiaries and make referrals to community services that may be able to address the identified health-related social needs;
2. Coordinate and connect beneficiaries to community service providers through community service navigation; and
3. Align model partners to optimize community capacity to address health-related social needs.

Federal funds for this model support the infrastructure and staffing needs of bridge organizations."

Accountable Care Communities:

“Accountable care communities are a new health model that involves multiple stakeholders working together to improve the health and well-being of their communities by addressing social determinants of health. Stakeholders include health care delivery systems, public health organizations, and community organizations. In an accountable care community, the stakeholders commit to share responsibility, resources, and data to improve community health indicators.”

“Successful ACCs are partnerships between health care providers and community agencies to address population health issues. The most common collaboration is generally between health care providers and social service organizations, where each works to improve the lives of community members in a way that also improves health outcomes and reduces medical expenditures.”

“In the ideal setting, ACCs have the ability to inventory existing and needed community resources, proactively target individuals within the community and guide them towards needed resources, and allow and facilitate navigation across community and health system services. Each of these functions is dependent upon the ability to share identified and de-identified data that improves coordination and efficiency of service delivery, provides an understanding of the community's social and health needs, and allows all participants to evaluate their impact on health utilization and population-based outcomes.”

My thoughts on Accountable Care Communities:

Accountable Care Communities show much promise in not only addressing the social determinants of health on a short-term basis, but the ability to integrate it with the state's Medicaid program to enhance the likelihood of sustainability.

Approximately 38 of the 50 states utilize Medicaid Managed Care organizations. These Medicaid Managed Care organizations contract with the state (usually in a form of a risk/capitated arrangement) to administer the program either regionally or for the entire state.

As noted previously in this blog, I am suggesting that the Targeted Population be Medicaid recipients. As also noted previously in this blog, Medicaid historically has been a great testing ground for innovative approaches to better serve their members.

As part of their risk arrangement with the Managed Care organization, the state could incorporate payment flexibility to further allow the Managed Care organizations to pay for services that would positively impact the social determinants of health for their members.

There would also need to be clear benchmarks relating to social determinants identified in the contract. Ultimately, from a self-interest perspective, the Medicaid Managed Care organization would be financially incented to collaborate with providers and social service organizations to achieve its profit expectations as well as their social determinant goals as identified in its contract with the state.

A great vehicle to facilitate this collaboration could be Accountable Care Communities within various regions of the state. Medicaid Managed Care organizations' payments would then be the life-blood of the Accountable Care Communities 

Accountable Care Communities are starting to be adopted by a number of states in different forms as noted in an article in the North Carolina Medical Journal.

In addition to the Accountable Health Communities (AHC) Model and Accountable Care Communities  the Agency for Healthcare Research & Quality (AHRQ) has initiated the Pathway Community Hub Model (HUB) to improve care coordination to individuals at highest risk for poor health outcomes.

"The Pathways Community HUB (HUB) model is a strategy to identify and address risk factors at the level of the individual, but can also impact population health through data collected. As individuals are identified, they receive a comprehensive risk assessment and each risk factor is translated into a Pathway. Pathways are tracked to completion, and this comprehensive approach and heightened level of accountability leads to improved outcomes and reduced costs."

Where do we go from here?

All of the above models show promise, and I am sure there are even more models currently in use or in the planning stages, but it is also important to not dilute the overall objective of addressing the social determinants of health within a community. It is then critical for each community or state to determine what model works best for them in achieving their goals of better health for their community in a sustainable manner.

I believe that Accountable Health Communities (AHC) Model while a step in the right direction, it does not go far enough to address the social determinants of health. It's main focus is on screenings and referrals to appropriate clinical or social services settings which is important, but it stops there.

Accountable Care Communities appear to be a more proactive model as it relates to addressing the social determinants of health and as noted above has the ability to integrate with Medicaid Managed Care in order to have a potentially sustainable funding source.

"The Pathways Community HUB (HUB) model shows much promise because of its focus on high risk factors at the level of the individual. High risk individuals in any population, but especially the Medicaid population, need focused attention from both a clinical and a social determinants perspective. The Pathway program could also be linked to the Accountable Care Communities.

While the type of the model is important, it is critical that the facilitator organization associated with the model be competent in its ability to enhance collaboration between the stakeholders, and also trusted in the community.

Concluding comments:

We have repeatedly addressed in prior blogs the historical lesson learned, that is, a "healthcare system is shaped by what you pay for and how you pay for it". 

In my next and final blog in my series on the social determinants of health, I will dive deeper into the "what and how" of payments.

These payments, from a self-interest perspective, will act as the glue to ensure sustainability of the community initiatives that are focused on addressing the social determinants of health in a cost-effective manner as well as provide incentives to break down the silos within and outside the walls of healthcare.

I will also share examples of innovative programs that are being implemented in communities thoughout the country to address the social determinants of health with varying degrees of success.

Thomas Campanella is the director of the Health Care MBA and an associate professor of health economics at Baldwin Wallace University near Cleveland, Ohio.

If you are interested in receiving a monthly summary of all of my healthcare blogs, you can respond to me on LinkedIn or e-mail Tom Campanella ([email protected]) with your contact information.

Source of pictures: pixabay.com & pexels.com