Community Benefit - Social Determinants of Health

July-August 2019
By: Howard Gleckman

BY: HOWARD GLECKMAN

Moving Beyond the Buzzwords

The goal of medicine is not just to treat the conditions that doctors diagnose, but to improve the well-being of patients. That has increased focus on social determinants of health, and prompted health systems to change how they care for those they serve. Many are working to support safe housing or preventing social isolation as well as pursuing advances in clinical medicine. But confronting those challenges isn't easy for health systems. It requires them to better understand social supports and how to deliver them — or partner with those who do. And they must learn how to pay for services that government and private insurance often don't compensate.

The payment structure is beginning to change. For example, in 2018, regulatory changes at the Centers for Medicare and Medicaid Services, or CMS, and new federal legislation called the CHRONIC Care Act allowed Medicare Advantage plans to offer, for the first time, supports such as meals, transportation, home renovations and adult day services. Medicare Advantage, or Medicare managed care, currently covers about one-third of all Medicare beneficiaries.

Still, the evidence about specific interventions remains mixed. It appears that housing supports,1 care management and improved nutrition can improve health outcomes and reduce costs. Transportation, income supports and early childhood education may also improve health outcomes. But it is not clear that they result in cost savings, in part because they have been less well studied.

Here are a few examples that do work: Community Aging in Place — Advancing Better Living for Elders (CAPABLE) was created by the Johns Hopkins School of Nursing with the goal of improving quality of life for low-income older adults living at home with functional limitations. It is built on teams that include a registered nurse, an occupational or physical therapist and a handyman. Published studies found that participants in this program had lower levels of disability (reporting less difficulty with daily activities) and fewer hospitalizations, emergency department visits, or skilled nursing facility stays.2 An initial demonstration of 281 participants in 2012-2015 saved Medicaid more than $20,000 per recipient over two years, net of costs. It now has been adopted in 22 cities and rural communities in 11 states.

Eskanazi Health is a community health center in Indianapolis that has been offering a suite of wrap-around services to its low-income, high-risk patients since 2011. Services include behavioral health, social work, nutrition and medication education, patient navigation, financial counseling and a medical-legal partnership.

Researchers found a 7% reduction in expect- ed hospitalizations in the year following receipt of a wraparound service and a 5% reduction in the number of emergency department visits. The program saves between $1.4 million and $2.4 million in hospital costs annually.

The University of Maryland St. Joseph's Medi- cal Center in Baltimore County is partnering with Maxim Healthcare Services, a home health agency, to reduce hospital readmissions among high-risk patients. Non-medical community health workers help participants find transportation, housing and even employment.

Thirty-day readmissions for the 1,200 participants in 2017-2018 were less than half that for simi- lar patients who did not participate. Ninety-day readmissions were one-third lower.

Be There San Diego and The United African American Ministerial Action Council partnered to improve cardiovascular health in southeastern San Diego. Their goal was to use community resources to improve diet, exercise and health screenings. The program served over 2,000 people in more than 20 churches and a mosque. The partnership led to new relationships that continue between health care providers and churches to improve health, according to Be There San Di- ego's executive director, Kitty Bailey.

StreetCred was created by two Boston-based pediatricians to help low-income families claim federal tax benefits such as the earned income tax credit and the child tax credit. Internal Revenue Service-qualified volunteers help parents with tax filing while they are at their children's medical appointments.

In its first two years, the program helped 1,700 families claim $3.3 million in refundable credits. It now also provides enrollment assistance for pro- grams such as Supplemental Nutrition Assistance Program (SNAP - food stamps) and Head Start, and has expanded to cities in Connecticut, North Carolina and Texas.

Notwithstanding these modest success stories, health systems struggle to build programs aimed at improving the social determinants of health. To succeed, they must confront several challenges:

Cultural change. They must recognize that improving a patient's living conditions, access to transportation or diet can enhance quality of life as much as medical treatment, and sometimes more. Prescribing such interventions should be- come standard medical care.

Finances. Some hospital financial officers treat the return on a program to prevent an admission as less valuable than the return on a new service line. In addition, a hospital that invests in social services may reap only a fraction of the benefit, while payers receive the rest. As a result, many hospitals limit investments in social supports to their community benefit programs rather than building them into their business model. To be truly effective, this care should be included in the operating budgets of hospitals.

Quality measures. To fully integrate social supports into the practice of medicine, we will need to rethink quality. Measuring improvements in someone's well-being is much harder than counting falls or infections, but it may be as important. And until we get those quality measures right, we will never fully get social determinants into the health care mainstream.

HOWARD GLECKMAN is a senior fellow at the Urban Institute, where he is affiliated with the Tax Policy Center and the Retirement Policy Program. He writes a column about aging policy for Forbes. com and serves on the boards of Suburban Hospital in Bethesda, Md., and the Jewish Council for the Aging of Greater Washington.

NOTES

  1. See for example Lauren Taylor, "Housing and Health: An Overview of the Literature," Health Affairs Health Policy Brief, June 7, 2018, https://www.healthaffairs.org/ do/10.1377/hpb20180313.396577/full/.
  2. Sarah l. Szanton et al, "Home-Based Care Program Reduces Disability and Promotes Aging In Place" Health Affairs 35, no. 9 (September 2016): 1558–63.