BY: INDU SPUGNARDI
Finding ways that health care organizations can address the social determinants of health is a hot topic in health policy circles these days. It long has been known that social and economic factors have a significant impact on health, but addressing these factors traditionally has been the purview of government and philanthropic organizations, not health care providers. Why are policymakers now looking to health care to play a role?
Since the Affordable Care Act was passed in 2010, the roles of all players in the health care delivery system have been evolving to achieve the legislation's goals of better quality care, lower costs and healthier populations.
As Melinda K. Abrams and Donald Moulds of the Commonwealth Fund noted in their July 5, 2016, Health Affairs blog post, "The Affordable Care Act has expanded health insurance to millions of low- and modest-income Americans, many of whom have social, environmental, and behavioral concerns that often define their health. Additionally, the spread of alternative payment models — accountable care organizations (ACOs), bundled payments, components of the Medicare Access and CHIP Reauthorization Act (MACRA) — increasingly hold health care providers financially accountable for patients' health and the cost of treatment."
Health care providers are realizing they need to look beyond clinical interventions to balance providing high quality care to more people for less money.
Another driver to re-examine the role of health care is research showing that spending large amounts of money on health care services might not be the best way to make communities healthier. Although the United States spends more on health care than any other nation in the world — more than double the amount that some industrialized countries do — our nation's health outcomes are comparatively worse.1 In fact, research shows the social determinants of health have a much more significant impact on the health of a population than clinical interventions.2 Given these facts, policymakers are asking if health care providers should be allocating some of their resources to addressing the social determinants of health.
Although there is a compelling case for health care organizations to take on a greater role in addressing the social determinants of health, the evidence base for what works is still evolving. Many national initiatives and demonstrations are underway to help health care organizations understand how they can have a positive impact on economic and social factors in their communities. The following are a few examples:
Health Leads — Works with health care organizations to connect patients with community-based resources they need to be healthy — from food to transportation to health care benefits. The organization advocates that the health sector can address social factors in three ways: 1) collecting data on patient social needs at intake or during a risk/health assessment to help target the organization's efforts; 2) having payers incentivize and reward effective provider interventions aimed at meeting patient's social needs; and 3) building social needs and workflow into electronic health records and medical technology.3
"Culture of Health" initiative — Established by the Robert Wood Johnson Foundation in 2013, this wide-ranging national effort is attempting to build a culture of health in which everyone, regardless of background, has the opportunity to make healthy choices and has access to quality, affordable health care. RWJF partnered with The Health Research & Educational Trust, a not-for-profit affiliate of the American Hospital Association, to study the approaches hospitals and health care systems are taking to build a culture of health. Among them are identifying community health needs and priorities; partnering with schools, local public health departments, businesses and community nonprofits on obesity initiatives and with community health centers on issues of access, behavioral health and substance abuse; and using successful approaches such as obtaining clear commitments from leadership, aligning with stakeholders on shared goals, allocating resources and measuring results and sustainability.4
Democracy Collaborative — This research center at the University of Maryland has been analyzing the role anchor institutions can play in helping low-income communities, with a focus on university- and hospital-led community development. A recent report, How Hospitals Can Heal America's Communities, describes ways hospitals and health systems can use more inclusive local hiring, more intentional systems of local procurement and more targeted use of their investment capital to drive local economic development.5 The Democracy Collaborative has released the first tool kit in its Hospitals Aligned for Healthy Communities series, which focuses on local hiring. It can be accessed at http://hospitaltoolkits.org/workforce/.
Accountable Health Communities — A demonstration project sponsored by the Center for Medicare and Medicaid Innovation is examining whether systematically identifying and addressing health-related social needs of beneficiaries will impact total health care costs, improve health and quality of care.6 The model includes screening to identify unmet social needs, referral to increase awareness of community services and navigation services for high-risk beneficiaries when accessing community services. The demonstration also will examine how alignment between medical and community services can help ensure that community services are meeting the needs of beneficiaries.
Visit the community benefit section of CHA's website for a more complete listing of national initiatives, tools, reports and ministry examples related to the social determinants of health: www.chausa.org/communitybenefit/social-determinants-of-health.
As these initiatives are carried out, health care leaders need to stay engaged and informed. Among the actions to take are:
Assess your organization's efforts to address the social determinants of health in your community. A good place to start is with your organization's community benefit leaders. If your organization has started to engage in efforts to address the social determinants of health, it is important to know why those efforts have been successful or, if not, what barriers are preventing them from moving forward. Just as important is finding out why the organization has not started to engage in these types of efforts. Is this issue on the leadership's radar? Are the organization and community prepared to participate effectively in these types of efforts? Knowing the answers to these questions can help health care leaders advocate for informed policies.
Stay engaged in policy discussions. At this time, these initiatives and demonstrations are voluntary and of an exploratory nature, but it would not be unexpected to see proposed requirements in the future, along with possible measurement and reimbursement implications. The National Quality Forum, the organization that endorses measures used in value-based purchasing programs, has formed committees to identify measures around health and well-being and population health. The measurement categories include community-level indicators of health and disease and modifiable social, economic and environmental determinants of health.7 Health care leaders need to engage in these policy discussions now so that proposals are informed by organizations experienced in navigating the complex path of addressing the social determinants of health.
Stay connected with your community. It is very important for health care leaders to know what issues their communities are struggling with, even if there isn't a clear health connection. New payment models are putting more risk and accountability on providers. Keeping communities healthy is one way to manage that risk. Another, and some would say more important, reason is mission. Catholic health care is called to serve those who are most in need. Health disparities are stark between those who lack access to a good education, stable income and housing and healthy food, and those who do not. As respected advocates for social justice, Catholic health care is well positioned to call for the significant systemic changes needed to impact community health.
As Thomas Frieden, director for the Centers for Disease Control and Prevention, observes, "The biggest obstacle to making fundamental societal changes is often not shortage of funds but lack of political will: The health sector is well positioned to build support and develop partnerships required for change."8
Health care is in flux, and health care leaders need to prioritize their efforts in order to keep up with the constant stream of changes. They also need to keep an eye to the future. Investments in efforts to address the social determinants of health may not have an immediate impact, but they position the organization and its partners to build the foundation of a healthy community.
Leaders will learn from their failures as much as they learn from their successes. For many, this uncharted territory will call for new skill sets and relationships. As Ashish Jha notes in his January 27, 2016, JAMA Forum post on addressing the social determinants of health, "… we should be clear-eyed about the difficulty of the work ahead and ensure that we learn as much as possible with each step and iterate to improve. For more than 150 years, health care leaders have wondered how to address the 'defects in society' that both cause illness and hamper our efforts to treat it. Although social ills will always be with us, we can surely do better at mitigating their harmful effects on health."9
INDU SPUGNARDI is director, advocacy and resource development, the Catholic Health Association, Washington, D.C.
- Commonwealth Fund, Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally. www.commonwealthfund.org/~/media/files/publications/fund-report/2014/jun/1755_davis_mirror_mirror_2014.pdf (accessed Sept. 30, 2016).
- Thomas R. Frieden, "A Framework for Public Health Action: The Health Impact Pyramid." American Journal of Public Health 100, no. 4 (April 2010): 590-95.
- Rocco Perla, "It's Time to Incorporate Social Needs into Patient Care," STAT (Aug. 1, 2016). www.statnews.com/2016/08/01/social-needs-health-care/ (accessed Sept. 30, 2016).
- Health Research & Educational Trust, Hospital-Based Strategies for Creating a Culture of Health ( Chicago: Health Research & Educational Trust, 2014) www.hpoe.org/Reports-HPOE/hospital_based_strategies_creating_culture_health_RWJF.pdf.
- Tyler Norris and Ted Howard, Can Hospitals Heal America's Communities? The Democracy Collaborative, December 2015, http://democracycollaborative.org/content/can-hospitals-heal-americas-communities-0.
- Centers for Medicare and Medicaid Services, "Accountable Health Communities Model," https://innovation.cms.gov/initiatives/AHCM.
- National Quality Forum, "Health and Well-Being Measures 2014," www.qualityforum.org/ProjectDescription.aspx?projectID=77856.
- Frieden, "A Framework for Public Health Action."
- Ashish K. Jha, "JAMA Forum: Tackling the Social Determinants of Health: Small Steps on a Long Journey," https://newsatjama.jama.com/2016/01/27/jama-forum-tackling-the-social-determinants-of-health-small-steps-on-a-long-journey/ (accessed Sept. 30, 2016).
| WHAT ARE THE SOCIAL DETERMINANTS OF HEALTH?
The World Health Organization defines the social determinants of health as "the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems."1
Healthy People 2020, a federal initiative that sets 10-year goals for improving health, highlighted the importance of addressing the social determinants of health by including "create social and physical environments that promote good health for all" as one of the four overarching goals for the decade. Healthy People 2020 also developed a "place-based" organizing framework, reflecting five key areas of social determinants of health:
Economic Stability — Poverty, employment, food security, housing stability
Education — High school graduation, enrollment in higher education, language and literacy, early childhood education and development
Social and Community Context — Social cohesion, civic participation, discrimination, incarceration
Health and Health Care — Access to health care, access to primary care, health literacy
Neighborhood and Built Environment — Access to healthy foods, quality of housing, crime and violence, environmental conditions
- World Health Organization, "Social Determinants of Health," www.who.int/social_determinants/en/.
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