Challenges and Opportunities, Part II: Responding to Health Care’s Evolving Landscape

Addressing patients’ social determinants of health (SDOH) and developing ways to improve patient engagement are two significant strategies hospitals are pursuing to evolve and innovate in a changing healthcare landscape.

These strategies represent just two of the ways hospitals are responding to the challenges they are facing in the value-based care environment, and the discussion of them here continues the May On Point column’s analysis of specific actions some hospitals are taking to adapt to the changing context: redesigning care to align with new payment arrangements and leveraging telehealth to provide improved care to patients.

The Case for Addressing the SDOH

Clinical care accounts for only about 20 percent of an individual’s health. The nonmedical SDOH—factors such as an individual’s access to affordable, safe, and stable housing; healthy foods; clean water; areas to exercise; and information about their health insurance and health care—determine much of the other 80 percent. ^a

Venturing beyond patients’ clinical needs is an undertaking fraught with complexity. Hospital and health system leaders can reasonably question whether there is a viable business case in tackling patients’ SDOH. Although the majority of 621 physician respondents to a 2017 survey said they considered SDOH important for a patient’s health, barely any of them considered it their responsibility to address these nonmedical needs. ^b

Nonetheless, with the advent of new approaches to paying for care—such as accountable care organizations (ACOs), in which providers must take on risk and change how they deliver care—addressing these factors has become more important. Mike Leavitt, former secretary of the U.S. Department of Health and Human Services, and Karen DeSalvo, MD, former head of the Office of the National Coordinator for Health IT, suggest that success in value-based care will increasingly depend on attention to SDOH. ^c They also believe community stakeholders—including clinical sites, not-for-profits, and local leaders—should build alliances across the spectrum of care to improve the community’s health. 

Examples in the Field

ProMedica, a health system and ACO in Toledo, Ohio, has been successfully addressing the community’s SDOH for several years. Through a robust community needs assessment, ProMedica was able to ascertain that the community’s root problem was hunger and food insecurity. Irregular eating patterns and low access to healthy foods were contributing to multiple problems, including obesity. To tackle this issue, ProMedica started a “food pharmacy” in April 2015, where physicians prescribed food as medicine so patients identified as food insecure could visit the pharmacy to pick up healthy food. ProMedica screened 57,244 patients for food insecurity in 2016; 2,243 screened positive, with half of those becoming new food pharmacy clients. As of 2016, ProMedica’s emergency department usage dropped 3 percent, readmission rates dropped 53 percent, and primary care visit rates increased 4 percent. ^d

Elsewhere in Ohio, Nationwide Children’s Hospital in Columbus has been tackling insufficient affordable housing in the city for 10 years. In 2008, the hospital partnered with Community Development for All People, a not-for-profit organization committed to improving the social and economic lives of Columbus residents. The partnership led to the development of the Healthy Neighborhoods Healthy Families Realty Collaborative, which helped reduce vacancies in the homes located in the collaborative’s target area by nearly 50 percent between 2008 and 2012. ^e Investing in community social and economic efforts can benefit hospitals and health systems by moving interventions upstream to prevent some of the factors—including unstable or unsafe housing—that can contribute to costly health problems.

Other hospital systems are successfully collaborating with community organizations to address patients’ SDOH. Since 2015, Northern Arizona Healthcare (NAH), a successful ACO, has partnered with local not-for-profits to form “community collaboratives” to discuss county needs, identify resources for NAH patients, and connect organizations with overlapping priorities. These collaboratives formed working groups focused on three initiatives deemed essential to improving the community’s health:

• A housing program for the previously incarcerated population
• An “aging in place” program that allows seniors to stay in their homes longer
• A public transportation voucher system program for patients in need of transportation to NAH’s regional hospitals, developed in partnership with the Northern Arizona Intergovernmental Public Transportation Authority ^f

Engaging Patients

Another way hospitals are responding to the changing healthcare environment is through more effective consumer engagement. Patient activation and engagement has long been recognized as a key pillar in the effort to improve healthcare quality and lower costs. With numerous studies showing a relationship between more engaged patients and improved outcomes, patient engagement offers a promising strategy for hospitals, especially in a value-based ecosystem. ^g

There are many ways to try to engage patients. The Agency for Healthcare Research and Quality provides a substantial list of free resources that providers can use as they seek to involve patients in their health care more effectively. ^h The resources include a guide for establishing a council composed of patients and family members who can help hospitals listen to the voice of the patient; information to provide to patients after they receive a certain diagnosis; and a prep card for patients to fill out with questions before their visits. 

An important aspect of meaningful patient engagement is meeting consumers where they are in their lives. Many patients have low health literacy, and some may view online tools such as online scheduling or portals as impersonal. Strategies that encourage and empower patients to be more involved in their care and that consider different populations’ needs have the potential to improve outcomes and even rein in costs by promoting healthy behaviors such as regular exercise and a nutritious diet, more regular primary care visits, and better management of chronic conditions. 

Summing Up

With the transition to value-based care, hospitals and health systems are facing a new set of challenges and pressures. As hospitals enter into new payment arrangements that reward value over volume and participate in programs that penalize hospital readmissions, they will require new approaches to care, and the two strategies described here are important ones for them to consider.

Footnotes

a. “County Health Rankings Model,” County Health Rankings & Roadmaps, March 29, 2016.
b. Winfield, L., DeSalvo, K., and Muhlestein, D., “Social Determinants Matter, But Who Is Responsible?,” Leavitt Partners, May 9, 2018.
c. Leavitt, M., and DeSalvo, K., “Guest Commentary: Value-Based Care’s Success Hinges on Attention to Social Determinants,” Modern Healthcare, Sept. 23, 2017.
d. Morrison, I., “Taking on the Social Determinants of Health,” Hospitals and Health Networks, Oct. 24, 2017.
e. “Healthy Neighborhoods Healthy Communities,” Nationwide Children’s Hospital.
f. Ferguson, T., Foster, R., and De Lisle, K., “Developing Partnerships to Strengthen Individuals and Communities: Northern Arizona Healthcare’s Approach,” Accountable Care Learning Collaborative, 2017.
g. Laurance, J., Henderson, S., Howitt, P.J., Matar, M., Al Kuwari, H., Edgman-Levitan, S., and Darzi, A., “Patient Engagement: Four Case Studies that Highlight the Potential for Improved Health Outcomes and Reduced Costs,” Health Affairs, September 2014.
h. “Engaging Patients and Families in Their Health Care,” Agency for Healthcare Research and Quality, Page last reviewed April 2018.