Addressing patients' unmet needs

Main Line Health's Lankenau Medical Center sits on the border of two Pennsylvania counties with wildly different average health outcomes. The realization of that stark divide galvanized the hospital's focus on population health.

Lankenau is in Montgomery County, which is consistently among the top 10 Pennsylvania counties in the Robert Wood Johnson Foundation's annual rankings evaluating quality and longevity of life, access to clinical care and health-related behaviors. But the medical center also serves nearby Philadelphia County, which consistently ranks toward the bottom of the state's 67 counties. In 2015, it was dead last.

Main Line launched its focus on population health in 2009, but its hospitals began conducting community health needs assessments after the first RWJF rating in 2013. They surveyed patients and community leaders, and used state, local and federal quality data to uncover the challenges that affected patient outcomes.

Lankenau found that patients sometimes skipped routine breast and colon cancer screenings because they did not have transportation or access to child care. Obese and diabetic patients did not improve their diets because they were unfamiliar with healthy nutrition, or could not afford healthier food choices.

“We learned about patients' competing priorities,” said Chinwe Onyekere, the hospital's associate administrator. “Then we developed a robust implementation plan based on the data we collected.”

Main Line started an annual colloquium, an event in which staff and leadership share updates on community needs. By late 2013, Lankenau had started a partnership that allows medical students to act as advocates. The students connect patients with unmet needs to resources, follow up with them, and document their progress in an electronic health record.

As Medicare and other payers increasingly reward or penalize providers on their quality metrics performance, those incentives have come under scrutiny because it's unclear how much healthcare providers can counter socio-economic factors and how to properly adjust for them in quality metrics.

All other things being equal, “the performance of a given healthcare system can undoubtedly be affected by the social composition of the population it serves,” the National Academies of Sciences, Engineering and Medicine concluded in a recent report.

Socio-economic factors seem to play a significant role in readmission rates and overall healthcare costs, which may depend on patients' access to transportation, and their ability to afford medications and read discharge instructions.

Hospital leaders feel a great responsibility to address these concerns, said Nancy Foster, the American Hospital Association's vice president for quality and patient safety policy. “They know the dangers if they don't,” she said. But for many, it's a matter of figuring out where to put their resources.

Main Line's community needs assessment helped Lankenau pinpoint where to start. In 2013, 44 women took advantage of the medical center's free breast and cervical cancer screenings. But when students began connecting the women with free rides, child care services, and reminding them about the no-cost program, use increased 43%.

The hospital also purchased coupons from a state program that lets low-income families get fruits and vegetables from farmers' markets. At-risk families received the coupons during office visits, and students helped them arrange transportation. Also, nutrition educators counseled them on choosing and preparing healthier foods. Redemption rates for the coupons rose 31%.

National readmission rates for conditions targeted under an Affordable Care Act program fell from 21.5% in 2007 to 17.8% in 2015, according to data HHS published last week in the New England Journal of Medicine.

The CMS, which has said hospitals can overcome challenges posed by certain patient populations, released a guide in January to help hospitals curb readmissions among ethnically diverse patients.

The National Academies of Sciences, Engineering and Medicine plans to highlight best practices for addressing social determinants of health in a series of reports.

Hospitals that want to start a similar program should focus on language barriers, transportation and food insecurity, which are closely linked to higher hospitalizations and readmissions, said Akin Demehin, senior associate director of policy for the AHA.

Addressing social determinants of health is an achievable goal, and it doesn't have to be expensive, Onyekere said. The students who participate at Lankenau are volunteers, and only one full-time staffer was added to oversee the initiative.

“You just have to think differently; there's so much you can do,” she said. “It's a good charge for us as an industry to take on.”