Forging community bonds to address social needs

COVID-19 has highlighted the need for healthcare organizations to build stronger ties with their communities to better address both the short-term rise in social needs brought on by the pandemic as well as long-term challenges.

From tapping into community health workers to harnessing data, leaders speaking at Modern Healthcare’s Social Determinants of Health Symposium, held virtually on April 29, showcased how providers can move the needle on tackling health inequities within their neighborhoods.

Partners in Health CEO Dr. Sheila Davis said the organization for the past several years has prioritized making community health workers and social service supports an important part of their workforce.

More than 11,000 of Partners’ 19,000 employees work as community health workers, with most hired from the same neighborhoods where they serve as healthcare navigators.

Community health workers have played an important part in Partners’ COVID-19 response, which includes leveraging their cultural and linguistic competencies to become points of contact and giving residents a go-to source when they have questions about how to minimize their exposure to the virus.

“Although I know we need good hospitals and good clinics to provide the most care for complex medical issues, by far, a lot of healthcare can happen within the community,” she added. “Community health workers can be a piece of the multidisciplinary team.”

Partners in May 2020 launched the U.S. Public Health Accompaniment Unit to provide technical expertise for state and city leaders and community stakeholders who want to adopt a version of the community health worker model within their areas as part of their COVID-19 response. Davis said community health workers have gone door-to-door to help patients schedule appointments to get tested. Program workers also answer questions about the efficacy and safety of the vaccines and coordinate transportation for residents to get to vaccination sites when needed.

In addition, Partners has employed a team of care resource coordinators who work with patients to connect them to social supports during the pandemic, like arranging food and medication deliveries.

“We really need to break the cycle of neglect, panic, response and repeat,” Davis said. “We know there will be a much higher payoff in making sure that we have an adequate public health workforce, which includes community health workers.”

A lingering question facing many healthcare providers is how to pay for interventions that address such social needs as poverty, food insecurity and homelessness.

A new pay model proposed by Dr. Matthew Davis, chair of the pediatrics department and executive vice president and chief of community health transformation at Lurie Children’s, involved payers reimbursing providers at a higher, per-diagnosis rate for patients with higher social needs. That could be tweaked to allow payers to give hospitals a set of quality metrics to follow to ensure adequate care quality standards were followed.

Another approach would reimburse at higher rates for patients with higher social needs to providers that serve as “anchor institutions” within their communities by being major employers of local residents and purchasers with local businesses. Payers could get involved by working on initiatives that address factors that influence health outcomes.

Creating a payment model designed to incentivize connecting clinical care with social supports for communities at risk is the impetus behind a CMS-backed project that Lurie and seven other pediatric-care providers are participating in between 2020 and 2027. Lurie will build on Illinois’ existing Medicaid managed-care system to create an incentive program that will pay providers for meeting cost and quality performance measures.

In early 2018, Atrium Health launched a yearlong effort to “clean up” its race, ethnicity and language data and expand the number of options patients had when submitting their demographic information.

The move allowed patients to more clearly capture how they identified themselves racially and ethnically, according to Kinneil Coltman, Atrium’s senior vice president and chief community and social impact officer. The result has been a reduction in the proportion of patients whose race and ethnicity were previously listed as being “non-specified” from 12% to 2% by 2019.

Having more accurate demographic data resulted in a stronger analytics platform that has enabled the health system to identify population health trends and care disparities within certain communities, Coltman said.

Atrium for several years has also been investing in building connections with local community organizations for the purpose of including them within the health system’s social care referral platform.

Coltman was hopeful that one day such data would be used to inform Atrium on how it can partner differently with community-based organizations to address social needs. The health system has embarked on a study in which its data is included into an integrated analytics system run by the University of North Carolina at Charlotte. Information from other local health systems, social service organizations, Mecklenburg County, and public health and criminal justice departments will be crunched to better understand which combination of social care referrals are most effective in improving clinical outcomes

Rush for the past five years has used its power as an economic engine to try and improve the health of communities.

The move came after a community health needs assessment found the life expectancy of residents living in the more affluent downtown area was 16 years greater than those living 7 miles away in the poorer community on the city’s West Side. Chronic diseases, not violence, was the leading cause for the wide gap.

Rush began by adopting an “anchor mission” that included hiring more individuals from within the community, purchasing from local businesses, and supporting projects that focused on creating more affordable housing, greater access to nutritious food, and economic revitalization, Dr. David Ansell, senior vice president of community health equity at Rush, explained.

Rush reached out to the six major healthcare organizations in the area to form West Side United in 2018, an initiative designed to close the life expectancy gap between low- and higher-income communities by 50% by 2030.

Early in the COVID-19 pandemic, Ansell said Chicago Mayor Lori Lightfoot reached out to Rush and West Side United for assistance in addressing the disproportionate mortality rate occurring within predominantly Black communities. In April 2020, Rush joined community groups and other healthcare providers to take part in the city’s racial equity rapid-response team that focused on expanding testing, conducting contact tracing, and distributing personal protective equipment in Black and Brown communities.