Think Like a Business
Organizations should take a business-like approach to resolving health disparities by focusing on “supply” and “demand,” recommends Brillman. Too often there is a lack of coordination among healthcare and social service providers (supply) and those who need those services (demand). Local care networks can help bridge this gap but only if they can agree on a standard of what clinical and demographic information they will share and how they will share it.
Unite Us has used this business concept to develop a model infrastructure for health systems, managed care providers, state governments and social service organizations that uses predictive analytics to identify individuals in need of services and link them to the appropriate agencies and resources.
“Our biggest problem is that we can’t get to the right people who need services early enough,” says Brillman. “As a health system, we are focused on the reactive—when it’s almost too late. We use a social opportunity index to tell our customers—our communities—who we should be getting into our networks. This is powerful for insurance companies, which do a lot of risk stratification and modeling. It gives us a better picture of our client and allows us to engage with them early—not at the hospital, but at the food pantry.”
Data Is Key
To identify where there are gaps in services, community organizations and networks need to measure the impact of the services they provide. Data is key to providing insights that will allow communities to coordinate supply and demand and close service gaps. The data and insights can also be shared with government and private payers to determine fair and accurate payment for services.
Petee agree that strong data shared among parties can go a long way toward improving access to healthcare and advancing the quality of life. “You need to be able to show what works and what doesn’t work,” she said. “We can’t just keep (going) down a road that doesn’t have proven value. People will invest in what works. And from the data, we’ve learned that an ounce of prevention really is worth a pound of cure.”
“The data allows us to see where we should be investing,” adds Brillman. “There is so much money being put out in community-based organizations, but it is still very fragmented. We need to bring community-based organizations into a new model of care and consider social services as being a partner in the efforts to help patients at the same priority level as medical care.”
Using Incentives to Drive Action
Identifying incentives that are important to all the participants in a community network is key to driving action, says Petee. For example, if inpatient admissions for low blood sugar typically increases at the end of the month when SNAP benefits run out, there are incentives for all involved to change that dynamic because addressing the issue proactively helps not only patients but also the care providers in utilization predictability and cost management. Hospitals have an incentive to improve their quality measurement reports, healthcare providers have an incentive to improve the health of their patients, insurance companies have an incentive to keep their costs down and social service organizations have an incentive to keep their clients out of the hospital. While the incentives may be different for all involved, the target is the same – ensuring that people have consistent access to food throughout the month so their sense of well-being increases and care utilization decreases. Funding can be targeted to address a specific issue, such as food insecurity.
“We have to help people with the dollars figure out the right places to put those dollars,” says Brillman. “There is an ROI element to this. That’s where the data and the insights come in. We can identify the care gaps and show payers or donors where their money can really make a difference.”
Leveling the Playing Field
Enabling the same access for services regardless of your Zip code starts with creating and standardizing infrastructure, governance and interoperability. Policies that level the playing field and create a better care delivery model are essential to addressing disparities in health care and ensure equity in care.
According to Petee, the key is to invite key stakeholders to a round table with no one at the head. “Everyone needs to be there. There is an ebb and flow to the work that needs to get done. At some point, the hospital might be at the lead, but then the food bank might be stepping up with a certain project. Then the housing coalition might be critical for a period of time because it’s winter time. It’s also important to include the people you are trying to assist so you are sure to meet them where they are. They are the most important people at the table, ultimately. This is something we have always kept at the forefront of our work.”
“Ultimately, key to affecting change in this critical area is learning together—what works and what doesn’t work—so that those who are just getting started don’t have to start from scratch. Someone in Iowa can learn from someone in North Carolina. It’s all about helping each other.”
