The emergency intervention was part of a Sinai program launched in 2011 to help patients better manage the chronic conditions that lead to frequent hospitalizations. But as the care coordination team members quickly discovered, their efforts had to reach well beyond phone calls to make sure Banks took her medicine or to remind her about doctor appointments.
In addition to fixing elevators, they helped her pay for her drugs and assist her with transportation to see her doctor. Team members even guided Banks through the paperwork needed to move to another senior-living facility.
Sinai is one of a growing number of health systems across the country that have begun tackling the social, economic and environmental conditions in the communities they serve as part of their programs to reduce hospital readmissions and improve outcomes. They are responding to the well-documented association between poverty, joblessness, inadequate housing, poor nutrition and chronic stress and poor health outcomes. Only by addressing these social determinants of health, they say, will they be able to get better outcomes and improve the overall health of their local populations.
“Some extremely large studies have shown engaging in health behaviors, like diet and exercise, and even our blood pressure, is affected by conditions in our home, neighborhood and workplace environment,” said Tamara Dubowitz, a senior policy researcher for the RAND Corp. “Ultimately, putting our resources into (improving) these things will give us a better bang for our buck.”
But such efforts pose an immediate financial risk to systems under current payment regimes. At a time when providers remain stuck in a fee-for-service payment model that rewards the quantity of services and not results, programs that address the social determinants of health come right out of a provider's bottom line.
“There is no business case really for quality or improving the social determinants of health at present time,” said Kelly Devers, a senior fellow in the Health Policy Center at the Urban Institute. “We still have a very fragmented healthcare system whose training and mindset has been focused for decades toward acute care and intervening once someone is sick—not necessarily preventing them from getting sick or keeping them well.”
Income is the single largest social factor driving overall health. A recent report from the Robert Wood Johnson Foundation's Commission to Build a Healthier America found that 23% of African-Americans who earned less than 100% of the federal poverty level had a health status that was “poor to fair” compared with 6.8% of blacks with incomes that were more than 400% of the poverty level.
Among whites, the disparity was even greater. Twenty-one percent of whites earning below 100% of poverty reportedly had “poor to fair” health compared with only 4% of whites making more than 400% of poverty. Education level is another indicator of health. According to the report, a 25-year-old college graduate can expect to live up to nine years longer than a 25-year-old who has not completed high school.
At Sinai, where about 15% of the patients are uninsured and 60% are covered through Medicaid, half of the $1.1 million a year that has been budgeted for the disease-management program comes from foundation grants. Without that support, such care would be extremely difficult to provide because Sinai does not receive reimbursement for many of the program's services.
“We let them (patients) see a dietitian (even though) public aid doesn't pay for a patient with bad diabetes and really high blood sugar to see a dietitian,” said Tina Spector, vice president of clinical integration for Sinai Health System. “If I want to arrange transportation for someone, if it's not always reimbursed, we either have to donate it or people don't necessarily get in to see their doctors.”