Addressing social determinants of health

November 14, 2018
Deborah Abrams Kaplan
Volume 95, Issue 22

There are often social factors influencing a patient’s lack of adherence. They may struggle with basic survival needs like housing and food, lack transportation, or not understand their health condition and how they can improve it.

Clinicians see the results of patients not following their treatment plan, whether it’s medication adherence, lifestyle recommendations, or attending follow-up visits. But there are often social factors influencing a patient’s lack of adherence. They may struggle with basic survival needs like housing and food, lack transportation, or not understand their health condition and how they can improve it.

About 40 percent of factors contributing to a person’s health are social and economic, according to Health Research and Educational Trust, and only 20 percent are related to clinical care. Healthcare systems around the country are realizing that addressing these social determinants of health can improve patient health, while also sometimes saving the medical system money by reducing treatment costs. Here are three programs to watch, and ways that health systems can implement something similar.

Food is health: program for Patients with diabetes

Physicians at Riverside Family Practice in Columbus, Ohio, rarely asked patients about food insecurity. That is, until the Mid-Ohio Food Bank reached out to them to pilot a food and health initiative. The practice sampled its patient population, which includes many patients with diabetes, to see if food insecurity was an issue. It turned out to be a much larger problem than they expected: 43 percent of patients said they had problems getting healthy foods to eat.

Laurie Hommema, MD, a primary care doctor and program director of Riverside Methodist Hospital family medicine residency, says they were surprised by the results, because any who responded positively have private health insurance, full-time jobs, and own their own homes. The USDA estimates that Ohio has a 16 percent food insecurity rate, compared to a U.S. average of 13.66 percent. In Franklin County, which encompasses Columbus, the rate is 32.2 percent, according to a 2017 study by The Ohio State University.

In May, 2018, the practice started its “Food is Health” program for its patients with diabetes, adding a food bank inside their practice . They give participants fresh produce each week, along with recipes, cutting boards, peelers, and a short nutrition-related class.

Miriam Chan, PharmD, a certified diabetes educator and director of research and evidence-based medicine education at OhioHealth Riverside Methodist Hospital, devised 12 sessions that residents teach, on topics like portion size, eating less sugar, and choosing healthy fats. They introduce produce like butternut squash, explaining how to cut it up and cook it. After the class, patients choose their own produce, though residents often suggest items, encouraging them to take and try more. “Avocados were the big hit,” Hommema says. “A lot of people had never tried an avocado.”

One program goal is to increase the amount of healthful and fresh foods patients and their families have access to, though they also offer foods like whole wheat pasta, canned beans, and canned vegetables. Family members can come to the group education sessions to learn and pick out food. “Seeing the next generation of patients getting that benefit is really rewarding,” Chan says.

Clinicians don’t weigh patients or do testing at these sessions, but at clinic visits they monitor weight, blood pressure, and hemoglobin A1C levels. They want patients to recognize the impact of eating healthier foods on their own. “They see changes in their health,” including lower weight, Chan says.

Food is Health sees 40-50 patients a week, also providing fresh produce for families, which means serving around 110 individuals weekly. When reviewing medical charts from the first four months of the program, 12 patients showed reduced A1C levels after participating, with seven patients experiencing more than a 1 percent reduction, and two patients reducing theirs by 1.5 percent. Anecdotally, Chan says patients enjoy coming to the sessions and have a high attendance rate, but it’s too early to know if the program has reduced hospitalizations or emergency department visits, but they are going to track these trends.

The program costs about $7 per person per week, with a $40,000 yearly budget, which comes from the residency program’s operating budget. The residency program can sustain this amount for now, says Hommema, but their ultimate goal is to get funding from Medicare and Medicaid, as it can save them treatment money. “Insulin is way more expensive,” Hommema says. One of her patients is already on the verge of stopping her oral diabetes medication as a result of the healthier eating. “She’s out of that range now where she needs them. That’s our goal.”

One unanticipated benefit is that the program is increasing physician satisfaction and reducing physician burnout. Residents and medical students appreciate the meaningful interactions with patients. “One resident said, ‘This is why I got into medicine. This is exactly what my heart needed, and I didn’t realize it,’” Hommema says.

Practices who are not able or ready to start their own food bank can still screen patients for food insecurity as part of the intake process, and counsel them on food issues. MedStar Health in the District of Columbia uses the website AuntBertha.com, which has an accurate database of support systems, including food banks, searchable by ZIP code. Of course the problem with food banks is that you don’t always get fresh food and you’re at the mercy of whatever is donated/purchased by them. Not all the food is healthful.

Pete Celano, MBA, director of consumer health initiatives at MedStar Institute for Innovation says that nurses and social workers can quickly access the site, print out resource lists, refer patients to the organizations, and save search results for specific patients in the HIPAA-compliant website. That way they can follow up with patients during subsequent visits and even ascertain whether the patient visited the recommended organization.

Health literacy house calls

OhioHealth Doctors Hospital in Columbus, Ohio also, started the pilot Health Literacy program focusing on patients hospitalized with congestive heart failure (CHF) and COPD. Nationally, 20 percent of patients over age 40 who are hospitalized have a COPD diagnosis, according to the Agency for Healthcare Research and Quality. Of those hospitalized with COPD complications, 20 percent will be readmitted to the hospital within 30 days. The national readmission rate for those with CHF is about 22 percent.

OhioHealth’s program reduced its 30-day readmission rates with participating patients with these diagnoses from 18 percent to 10.3 percent. “This tells me that people aren’t noncompliant, but that we haven’t done a good enough job meeting patients where they’re at. They’re able and willing to adhere to information they can understand,” says Joseph Geskey, DO, an internist and vice president of medical affairs at Doctors Hospital.

Participating patients admitted to Doctors Hospital with a COPD or CHF diagnosis are given the Newest Vital Sign screening. Patients answer six questions about an ice cream nutrition label, requiring them to read the label and sometimes perform basic calculations relating to allergies, fat and daily percentage of calories.

Geskey says that when introducing the screening, his colleagues scored six out of six, while half the patients scored zero or one, showing a high likelihood of impaired health literacy. “That’s incredibly illuminating to the physicians,” he says, and the staff couldn’t predict which patients did poorly. Without understanding a patient’s health literacy level, doctors may not change their communication styles or realize that their patients may be missing necessary information for their care and follow up.

Nationally, only 12 percent of Americans have proficient health literacy, according to the U.S. Department of Health and Human Services, and more than one-third have difficulty with common health tasks like following prescription medication labels.

They also screen patients with PAM13 (patient activation measure), a 13-item tool assessing patients’ self-management skills and knowledge. These screenings have helped clinicians become more empathetic toward hospitalized patients who, for a variety of reasons, are unable to process health information given to them.

Doctors Hospital has admitted 125 ­individuals into the program, who meet the criteria of a COPD or CHF diagnosis, low health literacy and low activation screening scores, and Medicare homebound criteria. The program includes one-hour home visits once a week for four weeks. They ask the patient to pick something they want to do but can’t, due to their illness. A patient might say she wants to attend a grandson’s baseball game. Once the patient reaches the goal, they can see how their actions are positively affecting their health, motivating them to ­continue.

Clinicians use a teach-back method, asking patients what they understand about their disease, and how to take their medications. They may teach the patient how to set up a weekly pill box, or discuss dietary or exercise issues. The last visit focuses on problem solving and how patients can advocate for themselves. The program measures success by whether the patient is readmitted to the hospital in 30 days, and if they’re motivated to take charge of their care.

“Many with lung or heart disease can’t explain their disease, understand what medications are, and how take them, let alone what they need to do when they get sick,” Geskey says. When clinicians write hospital discharge summaries, they overestimate people’s skills and understanding about their chronic disease therapy. “We end up seeing them back in the emergency department or in our clinics, and we label them as noncompliant. That immediately turns off our creative ability to meet patients where they’re at.”

The program is funded completely through philanthropic grants. Geskey attends the initial home visits during the pilot, but they’re generally handled by a health coach or nurse, often one who lives in the community. They’re trained for motivational interviewing and patient education.

Large health systems that treat CHF or COPD patients could potentially see large cost reductions from lower readmission rates, especially if they’re receiving bundled payments from Medicare, says Geskey. The savings can more than pay for the program costs. More than half of healthcare systems pay penalties to Medicare for hospital readmissions, according to JACC.

Ride-hailing programs

Healthcare facilities have historically arranged taxi rides for some indigent patients for non-urgent clinical care. What is new is the lower cost, trackability and increased flexibility of doing so through ride hailing companies. Earlier this year, Uber Health and Lyft Concierge rolled out programs with secure, HIPAA-compliant web-based dashboards for healthcare providers to hail rides for their patients.

MedStar Health has seen the Uber Health program help patients keep appointments that otherwise might be missed or rescheduled. “The use of Uber Health for qualifying patients who lack transportation reliably helps enable an appointment that otherwise could not happen, for a minimum cost,” says Pete Celano, MBA, director of consumer health initiatives at MedStar Institute for Innovation.

Since the healthcare organization is principally fee-for-service, Celano says MedStar Health’s cost is balanced by the additional revenue they bring in from keeping those appointments. MedStar determines which indigent patients are habitual cancelers or reschedulers. Using the ride hailing programs, MedStar can still bring patients in whose appointment is within an hour. Patients don’t need a smartphone or ride code.

For practices that already provide rides to indigent patients, instituting one of the ride hailing platforms should be an easy switch, especially since it’s web-based. Confirming appointments by phone is time consuming, but can pay off if there are fewer cancelled appointments that can’t be filled last minute.

Finding community resources

In addition to food banks, sites like AuntBertha.com compile resources including housing assistance options, low-cost or free transportation programs, health services, financial resources for low income individuals and families, support for navigating social services and other areas.
Without a stable foundation, these are all areas that impact a person’s ability to care for their own health and their family’s health. Talk to patients about what struggles they have and what stands in the way of them fully focusing on their health. This can be done by a nurse during the intake, or by a physician when discussing a care plan or prescribing a medication. Even telling a patient that if the medication isn’t covered by their insurance or if they have trouble paying for it, to let the physician know. There are community resources and pharmaceutical resources available to help patients with some drug costs.

Programs addressing social determinants of health can be replicated and scaled at other healthcare systems, and don’t have to be a financial drain on the system. Experts say that reaching patients through creative programs such as the ones covered in this article engage patients more in their own health, helping them to attain lifestyle and health goals. Much of the daily work with patients can be done by healthcare extenders and residents whose cost to the healthcare system is lower than physicians, but who are also already intimately involved in patient care.

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