Addressing the social determinants of health

Most of what determines how healthy you are isn't medical—it's social and behavioral.

Researchers at the University of California at San Francisco have found that behavior accounted for roughly 40% of all deaths in the U.S.

Making patients healthier through pre-emptive interventions rather than relying solely on medical treatment can significantly decrease health risks.

That idea drives Healthify, a software suite that gives providers and others resources to connect patients with community organizations that can help address such issues as food insecurity and affordable housing.

After working in Baltimore health clinics and seeing how healthcare failed to address the social determinants of health, four recent graduates of Johns Hopkins University founded the company; they've since moved to New York. “What we saw on the ground was that the biggest needs families had were not clinical needs,” said Manik Bhat, co-founder and CEO. “They were social needs.”

These social needs started coming to the forefront of medicine after the passage of the Affordable Care Act, which put a greater emphasis on patient outcomes and population health. But attention hasn't necessarily meant success, and organizations have struggled to figure out how best to improve health through unconventional means. Healthify is out to help in that struggle.

“This is one of the best ways to reduce costs over time for the most at-risk populations,” Bhat said.

But figuring out which problem to tackle first isn't easy. Very often, patients dealing with unhealthy diets live in so-called food deserts and likely face limited transportation options. It's also difficult figuring out which patients have which needs. What's more, once a connection is made with a social services organization, it's tough to know if the patient follows through and if there was any substantive resulting change.

Healthify attempts to answer all of those questions. The platform includes search, for finding providers and community organizations; tracking, for keeping track of referrals and patients' needs; and coordination, for getting multiple partners involved. The company currently has 25 enterprise clients, a mix of providers, government organizations and health plans, many of which are Medicaid managed-care plans. “We're growing very rapidly,” Bhat said, drawing on the $2.5 million in seed funding the company raised in 2016.

When a patient comes into a care setting, a care manager can screen the patient using the Healthify platform, figuring out what the patient's social needs are, and then help connect them to the proper service, using the search tool, and make a referral. The Healthify platform, which integrates into electronic health records, then takes over, sending the patient text-message reminders about the referral and letting the care manager know if the patient showed up. “These bidirectional referrals let you coordinate with multiple different partners,” Bhat said.

AccessHealth Spartanburg, a South Carolina not-for-profit that helps connect low-income, uninsured people to physicians, uses Healthify in its screening process. The software is integrated into its case-management software, and it links patients to organizations that might help with social determinants. “If you don't have transportation to get to your doctor's appointment, it's not that much of a help to get a doctor's appointment,” said Carey Rothschild, director of AccessHealth Spartanburg. During the screening, Healthify not only identifies that need but also identifies resources to address it and then texts that information to patients. “This has made the process easier and our communication and workflow more streamlined,” Rothschild said.

All of this electronic searching, tracking, and coordination yields plentiful data. “The data we collect is pretty powerful,” Bhat said. “We're kind of the sole people who understand what the services are in a community, how that compares with what the need is, where the gaps are, what referrals are made, what referrals are successful, and what the changes in outcomes and spend are when those referrals are made.”

Healthcare organizations relish this data, Bhat said, because it gives them a competitive edge and helps them reduce spending and emergency department utilization. And, of course, it makes patients healthier. “Our eventual goal,” Bhat said, “is building a world in which these social needs aren't hindering their health.”