Hospitals test ways to address social needs

For years the South Dallas neighborhood, located near the Texas city's downtown, has ranked as one of the leaders in Dallas County in all the wrong categories.

The predominantly African-American population has consistently experienced one of the county's highest rates of unemployment, poverty and lack of health insurance.

The area also has had one the county's highest rates of death from breast cancer. Nearly 40% of area women with breast cancer received their diagnosis in a late-stage of their disease, according to a 2015 Susan G. Komen study.

The disparities set off alarm bells at Parkland Health & Hospital System, which is putting money and time into addressing the area's poor health outcomes.

“We really need to address the social determinants of health and move upstream to try to postpone the onset of disease and eventually prevent disease if we're going to be successful,” said Dr. Esmaeil Porsa, Parkland Health's executive vice president and chief strategy and integration officer. In breast cancer care alone, the health system receives roughly 20% of the county's cases. “At some point we're going to be drowned by the number of folks who are going to be needing treatment of the illnesses,” Porsa said.

Parkland has partnered with the CMS since 2017 as part of a five-year, $4 million initiative aimed at finding ways to better connect patients identified as having unmet social needs with community resources.

That work led the system to focus on breast cancer broadly, and in September it was one of 10 health systems selected to take part in a yearlong initiative being led by the American Hospital Association.

Dr. Jay Bhatt, senior vice president and chief medical officer for the AHA, said the project's goal is to study the participating hospitals' various approaches toward improving health equity and to share information and develop a blueprint that other healthcare providers can one day adopt.

“We hope that there will be not only results that will improve outcomes and lower costs, but we hope that we will have strengthened hospital community partnerships not just for a moment but for the long term,” Bhatt said.

Other participants in what is known as the Hospital Community Cooperative include University of Vermont Medical Center, Holy Name Medical Center in Teaneck, N.J., and Tacoma, Wash.-based MultiCare Health System.

Each participating hospital receives $10,000 and guidance from subject matter experts and technical support, and will file a report on their findings near the end of the year. The Aetna Foundation provided financial support. In studying breast cancer care and access, Porsa said, the AHA initiative will provide the tools that will allow Parkland to address the other health inequities that exist throughout the community.

“If we were trying to be simplistic about this we would just send a couple of mobile mammography units and that would take care of the problem,” Porsa said. “But I really think the issue is much deeper.”

Other hospitals taking part in the AHA cooperative will study their existing initiatives for tackling health inequities with the goal of pooling together and examining their collective information to develop evidence-based strategies toward population health management.

“All of us who have worked in the community and worked with patients who have struggled or are highly complex people know that the drivers of care don't happen in the doctor's office,” said Stefani Hartsfield, manager of community health improvement and outreach at the University of Vermont Medical Center in Burlington. “People need to be where life happens; that's where we need the help if we want to change the health outcomes of Americans.”

Hartsfield heads up the medical center's pilot project for the cooperative, which focuses on helping patients secure temporary and permanent housing as well as addressing underlying factors that lead to housing instability.

The medical center's housing effort began five years ago when the system entered into a partnership with a local housing organization and other community groups to invest in 30-day, temporary housing for homeless patients who needed a stable place to recover after being discharged from the hospital.

The system then bought a 20-unit apartment complex to provide patients experiencing housing instability with a permanent place to stay. Facility residents also have access to an on-site case coordinator as well as a primary-care clinician.

The health system's third housing investment was buying a motel and converting it to provide additional temporary housing for discharged homeless patients, a service more commonly known as medical respite.

Medical respite programs have gained popularity among healthcare providers in recent years. Most hospitals involved in such initiatives contract with third-party organizations that operate medical respite programs in their communities in an effort to reduce readmissions among homeless patients. Such patients have a high risk of returning to the emergency department after being discharged because they were unable to manage their recovery. Such cases add to the complexity of the patients' health conditions as well as to the cost of their treatment.

As part of its project with the AHA, the University of Vermont will examine ways to streamline its care coordination to make it more efficient in addressing the needs of patients who lack stable housing, Hartsfield said.

“We're looking at unstable housing from a couple of different perspectives,” he said. “How can the hospital further its investments in long-term housing, and how do we really look at the best ecosystem of care coordination, which really combines the medical social service and the continuum of care for people who are providing housing stability for that complex patient population.”

Like the University of Vermont Medical Center, other hospitals participating in the cooperative see effective community engagement as a key priority of their projects. Their outreach campaigns aim to target individuals who do not normally come to a healthcare setting for screenings, physical exams, and other preventive care interventions.

“Culturally, preventive care is not high on their agenda,” said Kyung Hee Choi, vice president of the Asian Health Services program at Holy Name Medical Center in New Jersey. Choi is referring to Bergen County's Asian-American population, which has grown exponentially over the past decade so that Asian-Americans now make up more than 14% of the population. “They really culturally don't think much about the fact that they can rely on us in getting preventive care and early detection of cancer.”

Holy Name's work on changing perceptions about preventive care among its Asian-American patients has been the cornerstone of the program's mission since it started in 2008, Choi said. Since then, Holy Name's Asian Health Services has become known throughout the Asian-American community as the go-to facility to receive culturally competent care. But, Choi noted, selling the community on the importance of accessing preventive health services has remained a challenge despite the strong community relationship.

To that end, Holy Name is looking at how to improve outreach efforts to increase colorectal cancer screening, the second most common cancer among Asian-Americans and the third leading cause of cancer-related deaths. Asian-Americans have one of the lowest colorectal cancer screening rates among any ethnic and racial group, with an estimated 52% of adults reported to be up to date on screening compared with 66% among white adults, according to a 2017 issue brief conducted by the University of Chicago.

Despite having a lower incidence rate compared with other ethnic and racial groups, Asian-Americans are one of the only populations in which cancer is the leading cause of mortality, accounting for 27% of all deaths in 2012, according to a 2016 report by the American Cancer Society.

“For a lot of Asian-Americans, there are big language barriers and cultural barriers,” Choi said. “And it's also difficult for them to understand the American healthcare system and in seeking that kind of help.”

Choi said the project will focus on developing best approaches for educating Asian-Americans on the importance of screening for colorectal cancer. Educational seminars and lectures will be provided throughout the community in Korean, Chinese and Japanese languages to raise awareness. The medical center will also distribute 300 home colorectal screening kits at community events over the course of the year. The program will reach out to those patients who test positive from the home exams and will connect them with healthcare services.

“This project dovetails nicely with our mission,” Choi said. “We are a natural fit for this type of project.”

Similarly, MultiCare Health System in Washington state is conducting a pilot project for the cooperative that is based on its ongoing community outreach work, and that also has a focus on breast health.

Jamilia Sherls, director of health equity at the MultiCare Center for Health Equity & Wellness, said the project will seek to expand breast health education among black women. The system has employed a team of volunteers to serve as community health workers to improve breast health education and help women become comfortable with talking with their providers about their health issues.

Nationally, black women were less likely than white women to go for mammography screenings just a decade ago but have since gotten tested more frequently. By 2015, 55% of black women age 40 and older were found to have had a breast cancer screening in the past year, the highest share among any ethnic or racial group, according to the American Cancer Society.

Yet black women overall continue to die from breast cancer and be diagnosed at later stages of the disease more frequently than any other ethnic or racial group. Sherls said several factors continue to limit healthcare access for black women, including lack of insurance and cost concerns, as well as fear and distrust of the medical system.

Sherls said trained community health workers will go out to hold educational sessions with women in target ZIP codes to address their concerns and make them feel comfortable enough to go get screened.

As with other cooperative projects, MultiCare plans to track its results until around the end of the year and then present the findings to the rest of the cooperative with the expectation that its model may be replicated.

Sherls said she believes the effort has been a positive step toward strengthening trust in the health system among community members.

“I think a lot of times communities see healthcare organizations as corporate entities within their neighborhoods,” Sherls said. “We really want our community to see us as a community healthcare system that cares about everyone, not just those who are coming into our hospitals for service.”

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