social determinants of health

Integrating patient care and social determinants of health (SDoH) — the conditions in which people are born, grow, live, work and age – is vital to improving population health, according to a recent article in Managed Healthcare Executive that uses Humana’s work as an example.

The author spoke with Humana’s Caraline Coats, MHSA, vice president of Bold Goal and Population Health Strategy, and Andrew Renda, MD, MPH, associate vice president of population health.

Humana “has made strides in incorporating SDoH into their population health strategies with their Bold Goal initiative, a unique program to help better care for patients with chronic medical conditions,” the article said. “Humana aims to improve the health of the communities they serve by 20% by 2020. Part of that strategy is considering SDoH factors like food insecurity and social isolation in their population health programs.”

“We understand that food insecurity, social isolation, transportation security, and housing are all directly related to health,” Andrew said.  “This program allows us to bring those things into the mainstream of healthcare so we can start treating SDoH for what they are—clinical gaps in care.”

Caraline said healthcare has been too medically focused for too long. “Today, as an industry, we only spend 4% of every healthcare dollar on social health. Everyone knows it’s important to health outcomes, particularly the clinicians. But we needed to find a way to provide the data and resources providers needed so they could treat social health factors too.”

The article said, “After only a few years, Bold Goal is seeing clinical gains. The integration of SDoH information helped to increase the number of self-reported “healthy days” by Medicare Advantage members in Humana communities by 2.7 days. While 2.7 days might not seem like much, Medicare Advantage beneficiaries in communities who did not participate in the Bold Goal program saw a decrease of 0.6 healthy days for the year.”

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A group of physicians and healthcare leaders at a recent event convened by Humana aimed to to understand what the medical practitioner’s role should be in addressing food insecurity as part of improving patient outcomes. This article appeared in Healthcare Innovation.

By Drs. Toyin Ajayi and Andrew Renda

It’s an unfortunate truth that in our current healthcare system, too-short, too-packed appointments often mean that providers do not have time to understand all that is going on with their patients beyond the walls of their practices.While the treatments we prescribe address their physical symptoms, we know little about the social, economic and environmental challenges our patients face that impede their health. These social determinants of health (SDoH)—like reliable transportation, nutritious food, stable housing, community and human connection—are critical to health and well-being. Yet, the way that medicine is still widely practiced, especially in lower-income communities, is extremely costly, fragmented, and fails to produce the health outcomes and cost efficiencies we all want.

One of the most prevalent and harmful barriers to good health is lack of access to enough nutritious food. Food insecurity leads to higher rates of chronic disease, emergency department visits and hospitalizations, driving $77.5 billion in related healthcare costs. We cannot expect to improve health and reduce costs if we do not first ensure that patients eat well. This is no small issue: adults experiencing poverty, who presumably lack consistent healthful food, have a higher risk for diabetes, heart disease and stroke, depression, disability—even premature mortality.

So why is food insecurity not considered a clinical gap in care? Shouldn’t all providers have a responsibility to diagnose social determinants of health, as they would other medical conditions?

These were the questions posed to a group of physicians and healthcare leaders at a recent TEDMED event convened by Humana, aiming to understand what the medical practitioner’s role should be in addressing food insecurity as part of improving patient outcomes.

This will require a major restructuring of the roles and responsibilities of healthcare providers. Beyond that, we need to implement interventions using technology platforms, validated screening tools and referral sources, as well as new code sets and payment models, to enable physicians to make it standard practice.

How do we make this work?

Community provider-driven care teams. For physicians to feasibly address SDoH requires a significant shift to a team-based approach that reaches well beyond the walls of the medical practice and into the communities where patients live.

This team-based, flexible approach is the foundation that Cityblock Health is built on. Multidisciplinary care teams are led by Community Health Partners – individuals from within the community who understand the experiences of people living there. Community Health Partners meet members where they are, taking time to understand what is going on in patients’ lives and connecting them to the right resources. They enhance the clinical team’s understanding of members’ realities and design interventions for their specific needs. Team-based models necessitate a significant role change for physicians, one that embraces working closely with non-medical, community-based partners.

Value-based care. Few reimbursement systems are currently set up to adequately pay medical practices for time and resources spent treating social determinants of health like food insecurity. Value-based models, where reimbursements depend on patient outcomes, encourage and allow room for care teams to address all aspects of health—from medical and behavioral health conditions to social needs— as equally critical in every patient’s care.

In value-based care models, we then need to develop clear measures tied to addressing social determinants of health and their impact on outcomes.

Evidence and outcomes. Currently, there is limited evidence of which approaches are most effective at improving health outcomes and providing a return on investment. However, one example showing real benefits are medically-tailored, home delivered meal programs for the elderly. These programs have been shown to improve clinical outcomes including blood pressure and diabetes control, and help to curtail emergency department visits and inpatient admissions for adults who are dually eligible for Medicaid and Medicare.

It’s critical we establish methods and metrics to expand evidence-based programs and measure various approaches that address SDoH. As part of that effort, Humana is currently working with the National Quality Forum to define quality measures around food insecurity. This will enable us to standardize benchmark measurements and expectations to help physicians effectively address food insecurity; and to incentivize and reward based on validated measures tied to patient outcomes.

We’re in the early stages, but there is growing momentum for treating these issues as clinical gaps in care. To make real progress toward that end, decision-makers across healthcare—from policymakers to health plan and health system executives— will need to align on a shared vision and efforts to address patients’ comprehensive health and social needs. Physicians alone cannot cure food insecurity; but we can be powerful partners in holistically addressing the needs of our patients and communities.

Toyin Ajayi, M.D., is the chief health officer at Cityblock Health and Andrew Renda, M.D., is the corporate strategy director, population health, at Humana.

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