A growing movement argues physicians must address the economic and social forces behind patient health
The drive toward value-based payments in healthcare means that doctors will have to pay more attention to the social, economic and environmental factors that affect their patients’ health.
Collectively, these factors are known as “social determinants of health.” If a patient can’t afford his or her medications, for example, this is a social determinant of health that could possibly be addressed by finding a pharmacy that sells that drug at a lower price.
Where practices have access to outside support, some physicians are beginning to make a dent in addressing issues related to social determinants of health-and say they are providing better care as a result.
For example, in Vermont, 85% of primary care practices participate in the Vermont Blueprint for Health, a state program that has organized community health teams (CHTs) to help practices deal with social determinants of health.
Gregory King, MD, a partner in a small family practice in Bennington, Vermont, says the specialists on these teams-including nurse care managers, social workers, behavioral health counselors, dietitians and health educators-help him care for complex patients in ways that were previously impossible.
Before King’s practice joined the Blueprint, he says, he’d encourage patients with socioeconomic and other non-medical challenges to get in touch with various community agencies. But his office didn’t have time to look up contact information for the patients or to introduce them to the right people at the agencies. So his advice had little effect.
“But now with the CHT, I can delegate it to the team, and they know where to send the patient,” King says. “And now those issues are getting addressed.”
Some healthcare organizations, recognizing that a proactive strategy for social determinants of health can help reduce the cost of caring for high-needs patients, are also beginning to address these factors, says Eric Schneider, MD, senior vice president of policy and research at The Commonwealth Fund, a New York-based healthcare research and advocacy foundation.
Among the healthcare providers that have started programs for social determinants of health is Montefiore Health System in New York City. Montefiore has hired about 600 care managers, including nurses, social workers and health educators, who address the chronic diseases of high-cost patients and link them with community resources.
Some Montefiore physicians have high praise for the program. For example, Asif Ansari, MD, medical director of the Montefiore Medical Group’s Grand Concourse practice, says that he and his colleagues know the
socioeconomic cards are stacked against their poorer patients, many of whom have trouble paying for their medications, and lack transportation and access to healthy food.
“Our physicians understand that we need this collaboration, this support and these resources to impact our patients’ lives and their health,” he says, referring to the social workers and other non-medical professionals at Montefiore. “When I compare practicing here 10 years ago and now, the difference in what I can do for my patients is significant.”
Doctors need help
Most physicians believe that unmet social needs lead to worse health, according to a 2011 national survey by the Robert Wood Johnson Foundation. They think it’s important to address factors such as fitness, nutrition and transportation; doctors in urban areas also stress the need to provide assistance with employment, housing and adult education.
But 80% of the respondents were not confident of their capacity to deal with patients’ non-medical needs.
Physicians in social determinants of health programs say that before they received outside assistance, they were reluctant even to ask patients about some of these topics, because they knew there was little they could do about them.
“Now I’m not afraid to ask questions like ‘do you know how to eat and are you taking your medicines,’” says Jennifer Gilwee, MD, an internist in Burlington, Vermont, who participates in the Vermont Blueprint for Health.
“Before, I could only counsel them on how to eat,” she adds. “But now, I can refer them to a dietician. If they need help in finding a better place to live or arranging transportation for a visit, I’m going to ask a social worker to help them.”
Behavioral healthcare is usually part of this strategy, because mental health is affected by social determinants of health and has a major impact on an individual’s physical health. All of the primary care practices involved in the initiatives Medical Economics looked at include behavioral health professionals or have easy access to them.
These practices are patient-centered medical homes
(PCMHs), which means they have established care teams to improve care coordination. But unlike most PCMHs, which have formed clinical care teams only within the practice, those participating in the social determinants of health programs have expanded the definition of a care team to include non-medical professionals both inside and outside their practices.
Participation in the Vermont Blueprint for Health is voluntary for providers, but most primary care practices in Vermont have joined the program. One reason is that participants receive about $3 per member per month from private health plans and Medicaid and $2 per member per month from Medicare. The CHTs get an average of $2.77 per member per month from payers.
But a bigger motivation for physicians, program administrators say, is the availability of the CHTs, which help them take care of and obtain community assistance for their most complex patients. Primary care doctors like the CHTs because “we’re lightening their load,” says Laural Ruggles, MBA, project manager for the Blueprint in St. Johnsbury, Vermont.
The same holds true for physicians at Montefiore Medical Center. When one of her patients has a problem tied to a social determinant of health, for example, Sybil Hodgson, MD, medical director of five clinics that are part of the Montefiore group, asks the patient to see the social worker in her practice while the patient is still in the office.
After this handoff, the social worker does a quick intake and figures out what can be done to help the patient. The social worker might connect the patient with a community agency, or might tap into Montefiore’s Care Management Organization, which employs the care managers. Hodgson herself contacts particular care managers either by phone or through the group’s EHR regarding more complex patient issues.
Each of the clinics has a psychologist or a psychiatrist who collaborates with the social workers. These mental health professionals address the immediate issues of patients, referring them out for problems requiring long-term therapy.
Wide array of resources
The 16-doctor Grand Concourse clinic, where Ansari is the medical director, includes two licensed clinical social workers who provide short-term counseling and connect patients with community resources for their social and economic issues.
The practice also has an onsite health educator. This professional may link patients with outside agencies, such as a city asthma program that does home-based interventions and environmental assessments, Ansari says.
The Care Management Organization provides the practice with two diabetes educators, including a nurse and a pharmacist, four days a week. If a prescription Ansari has written is too costly for a patient, he’ll work with the pharmacist to find a medicine the patient can afford.
“Primary care physicians have very limited time to spend with each patient,” Hodgson says. “To have people who are equipped to handle things like housing and food and security helps the provider to be more focused on the medical aspect and also to be more sensitive about what kinds of treatment plans we’re going to create for this person.”