It's an admirable effort on a small scale, but the ultimate goal of social programs is to reform healthcare into well care that changes both the health and economic outlooks of an entire community for generations to come. That's not a small or easy task.
Understanding that they can't do it alone, providers have looked to community and municipal partners to make a more lasting impact that may require less direct investment.
Kaiser Permanente, for example, has engaged government agencies to create policies aimed at improving public health.
“We're absolutely thinking about the upstream interventions that we need to do with our community partners to see what really is impacting the fabric of our communities—things that impact poverty and race inequities,” said Dr. Bechara Choucair, Kaiser's senior vice president and chief community health officer.
The Oakland, Calif.-based integrated system also has invested $200 million to fight homelessness and housing instability through its Thriving Communities Fund.
Choucair said the work Kaiser has done with cities has led to the creation of policies that address healthy eating, active living and early childhood education. Kaiser also is the only healthcare provider member of the Billion Dollar Roundtable, a consortium of large companies that each spend a minimum of $1 billion every year supporting minority- and women-owned firms.
Other systems, such as ProMedica, based in northwest Ohio, have focused on solving food insecurity by working to revitalize local communities. The system in 2015 co-founded the Root Cause Coalition, a not-for-profit collaborative of health systems, insurers and advocacy organizations dedicated to addressing the causes of health inequity.
Such lobbying efforts on the part of health systems have led to higher taxes on sugar-sweetened beverages and cigarettes, cities working to promote walking and bicycling, and interventions to reduce violence.
In still another unique example, the Cleveland Clinic recently handed over its laundry business to the Evergreen Cooperative, which builds community wealth by allowing employees to share business ownership in historically impoverished areas. The move created 100 local jobs.
“We see this as an important step we can take to support the health and well-being of our neighbors,” said Ralph Turner, executive director of patient support services at the Cleveland Clinic.
The city of Cleveland exemplifies how wealth can impact health. The median household income in the inner-city neighborhood of Hough is $18,500, while eight miles east in the more affluent suburb of Lyndhurst, the median is $63,000. Hough is 98% African-American and the average male life expectancy is 64 years. In Lyndhurst, which is 86% white, men can expect to live up to 88 years.
Leveraging purchasing power
The Democracy Collaborative is a community development organization that helped start the Evergreen project and has in recent years set its sights on the healthcare industry as a willing and capable sector of the economy to tap for investment opportunities. The group even published a paper, titled Can Hospitals Heal America's Communities?
David Zuckerman, director for healthcare engagement at the collaborative, said initiatives like Evergreen show how providers can more effectively address social needs by leveraging their enormous purchasing power to help combat poverty.
“It's a tremendous way of illustrating that you can as a health system, in an era of tight margins, get the quality and price that you need while also having this tremendous social impact in the neighborhoods in a way that will really be a game-changer,” Zuckerman said.
Evolent's Cattrell said the healthcare industry needs to see investments in social determinants as not just a financial benefit but as a public good shared by all.
“Right now, ROI is almost all monetary,” Cattrell said. “When you think about providing some of those larger initiatives like supportive housing or legal assistance, they have a much broader effect beyond just healthcare costs—there's not a good framework yet to really think about it more holistically.”
Unlike other developed countries with more robust social safety nets, healthcare providers in the U.S. are stepping in to find the right supports to address patients' social needs, and in some cases, they must provide those supports themselves. Yet the majority of providers and payers have made small investments. For not-for-profit hospitals, much of that investment has been tied to community benefit requirements to maintain their tax-exempt status.
The hospital's role
A 2017 survey by the Deloitte Center for Health Solutions of 300 hospitals and health systems found the vast majority, 88%, were committed to addressing social determinants and were screening patients for social needs. The survey also found 72% of hospitals had not made any investments. Nearly 40% of hospitals surveyed said they were not measuring the outcomes of their initiatives. Most systems have limited their activities to target a small subset of their patient populations, such as high utilizers, or those who are at risk of becoming frequent ED visitors.
Many initiatives going on today serve as “pilot projects.”
“The reality is that this is a field that needs to continue to be built and a field that needs to continue to grow,” Choucair said.
In addition to its policy work, Kaiser has invested in ways to benchmark and improve its social programs. Last year, Kaiser launched the Social Needs Network for Evaluation and Translation, known as Sonnet, which evaluates the success of the system's social interventions. Kaiser also partnered with the Robert Wood Johnson Foundation to create the Social Intervention Research and Evaluations Network, or SIREN, with the goal of building consensus on common measures and methods to address social determinants of health.
Such tools have been used over the past two years to address how well Kaiser identifies and then addresses food insecurity among members. Sonnet surveyed Kaiser Medicare Advantage plan members in Colorado and found many members were food-insecure, yet the majority of that age group had not been screened. The research also found a lot of those members may have been slipping through the cracks because those patients did not have a higher rate of utilization than members who were not food-insecure, which indicated a need for broader screening.
Those findings helped Kaiser employ the screening tool Your Current Life Situation, a survey used in Kaiser's primary-care and emergency department settings. Within the health system's Northwest region, survey responses are included in patients' electronic health records, which are then used by a patient navigator to help them find community resources to meet their social needs.
Independent research points to an economic rationale for addressing social needs. For example, homelessness is tied to greater use of emergency care. A recent examination of the economic impact of medical respite programs, which provide temporary medical care for homeless persons who don't need to be admitted to a hospital, found the programs reduced ED visits by 45% and readmissions by 35% for a savings of $1.81 for every dollar spent.
“We see more economic return in providing our services than maybe some folks who don't have the same mission that we have,” said Ruth Krystopolski, senior vice president of population health for Charlotte, N.C.-based Atrium Health. The system spent $306 million in 2017 on uninsured care as a safety-net provider, a figure that Krystopolski said pushes the system to find ways to reduce costs.
In 2015, Atrium began collecting demographic data from various sources including local universities and public health departments with a goal of identifying, cataloging and documenting patient social determinant information to then connect them with community supports.
Atrium's recent pilot project involves screening food insecurity among senior patients at highest risk for readmissions. The system then provides emergency food services and helps them complete SNAP applications. So far, Atrium has reduced readmissions 60% in this group.
But not everyone sees the value of these efforts.
Consultancy Leavitt Partners in May published a survey of 600 physicians that found the majority believed fixing inequality in income, transportation, food access and housing did benefit patients' health, but they didn't think it was their responsibility to fix those issues. “I don't think systems have adopted this en masse, but I think there has been an uptick, and that it has been driven by an increasing sense of the economics,” said David Smith, co-founder of Health Care Council of Chicago, a collaborative of Chicago healthcare businesses to address health disparities.
The road ahead
Sinai's Ignoffo has not found sustainable funding to meet the upfront costs involved in running the community health worker program. It's currently funded through public and private grants.
The lack of payment from private or public payers for those services is a challenge. “There's a little bit of money out there for providers, but it's not significant and there's also not a lot of infrastructure,” said Dr. Gail Cunningham, senior vice president and chief medical officer at the University of Maryland St. Joseph Medical Center.
Sinai has not found sustainable funding to meet the upfront costs involved in running its community health worker program. It's currently funded through public and private grants. (Bill Healy)
The University of Maryland uses community health workers to address social ills so discharged patients won't return to the hospital. The program has reduced readmissions by 65% among at-risk patents living at home.
But Maryland's payer system is unique in that hospitals in the state every year receive a fixed amount to care for patients. That motivates them to reduce unnecessary utilization.
“In other markets where every case you see you bring in more money, it may not make as much sense unless there are other pressures, rewards or penalties within in the state to drive change behavior,” Cunningham said.
Cattrell said as hospitals and health systems take on more risks and develop their own insurance plans, the incentive to provide care in the most cost-effective and potent manner will only continue to underscore the importance of social determinants.
“The idea and the transformation of late is how do we integrate social determinants in a way that is not something that is just being done to the patient off to the side but is truly part of their care plan,” Cattrell said. “I think the perception of what a social need is and how it relates to the broader person is where the real transformation is happening.”