Abstract
Introduction
I
Bradley et al found that US states with a higher ratio of social spending to health spending had significantly better subsequent health outcomes. 1 However, it is unlikely that the United States will embrace increased social spending as a strategy to improve health. Instead, health care payers are continuing to build value-based payment systems that transfer accountability for health and cost outcomes from the payer to the provider. 2
More than two thirds of health care organizations report that they now assess populations for SDOH as part of ongoing care management. 3 The 2 most frequent interventions cited are referral to community service agencies (78.1%) and help with navigation of services (76.6%). 3 Notwithstanding this self-reported activity, many health care organizations are still early in their journey to build an effective overall system for SDOH screening, intervention, and measurement.
The Robert Wood Johnson Foundation 2016 report, Using Social Determinants of Health Data to Improve Health Care and Health: A Learning Report, 4 cited some of the challenges faced by health care organizations. These include: (1) Lack of multi-sector collaboration within and across social services and health care sectors, (2) Lack of flexible technologies and interoperable information technology (IT) systems, and (3) Lack of standards, tools, best practices, and research evidence.
The case studies that follow speak to these challenges and were contributed by organizations participating in the Epic Population Health Steering Board over the past year, representing both US and Scandinavian health care delivery systems.
Multi-sector Collaboration
Children's Health Dallas: catalyzing stakeholders through a formal alliance
Screening for and addressing SDOH effectively requires the efforts of both health care and community service organizations. However, the differential in size, power, and resources between these sectors can be a barrier to collaboration. To build trust and effective working relationships, Children's Health in Dallas invested significant time in a formal relationship-building approach followed by a structured Collective Impact process. The process built on the newly-formed Health and Wellness Alliance for Children (the Alliance), a separate 501(c)3 organization in Dallas, comprising more than 90 community stakeholders that provide services to children and families. The Alliance Steering Committee adopted a shared leadership structure and chose childhood asthma as its first target.
The Alliance became the integrator in the community for children's health and well-being at the individual, organization, and policy levels. Through these efforts, the number of children who visited the Children's Health safety net emergency room with a primary diagnosis of asthma was reduced by 49% and sustained over the last 4 years. 5 A key success factor was using principles of design thinking to support the agency – or capacity to act in one's own interest - of families whose children experienced frequent asthma symptoms. This experience reflects 1 approach for integrating health care systems and community stakeholders within a larger population health strategy to address both medical and nonmedical determinants of health with families themselves. 6
Spectrum Health: investing directly in the community
Spectrum Health is an integrated health system serving 13 counties in Western Michigan. A community-based population health program called Healthier Communities was born out of the merger of 2 independent health systems in the early 1990s that formed Spectrum Health. Healthier Communities, funded by Spectrum Health, reaches out to its neighbors and the underserved people whose demographic, economic, or cultural characteristics place them at risk for poor health outcomes. Spectrum dedicates $6 million annually to Healthier Communities, and an independent community board, the Community Commitment Advisory Committee, monitors funding. Healthier Communities has evolved from a type of community foundation focused on activities and volumes of persons touched to an outcome-focused initiative – complete with a competitive grant funding process and a data analytics team responsible for identifying and measuring the health and non–health outcomes of the services and programs. Healthier Communities not only works closely with community partners but also invests in building community-based infrastructure in schools, churches, and neighborhoods. Additionally, it seeks to develop leadership skills and competencies of partner agencies in the community.
Interoperable IT
Reliant Medical Group: building an Epic-based interoperable IT system
Reliant Medical Group is a 500+ member multispecialty group practice in central Massachusetts, encompassing 30 medical specialties that serve 300,000 patients. Reliant began building its interoperable IT system approximately 25 years ago as a response to the challenges of sharing financial risk with third-party payers and as a catalyst to advance the health status of individuals and communities through data exchanges and enhanced stakeholder communication. The system connects foundation Epic structures and tools with carefully selected private and public interfaces to achieve a comprehensive and integrated information system that enables both medical and SDOH interventions.
The Reliant journey began with the creation of “push” interfaces with local hospitals through a subscription service focused on the Reliant patient population. Reliant sends to the local hospitals all the national provider identifier numbers for their clinicians, establishing a “subscription” to data on any hospital patient who identifies her/his primary care physician, referring physician, attending, or consultant as being one of these clinicians. In return, the hospital sends admission/discharge/transfer data on these Reliant patients upon their presentation at the hospitals to build encounters in the Epic electronic health record system. Over time, the hospitals have added other patient-specific information, such as laboratory, radiology, and dictated notes, to create a more holistic patient profile.
Reliant's interface with emergency rooms (ERs) illustrates the importance of technology smoothly integrating with the workflow processes of providers. Initially, Reliant had installed a separate computer with Epic access in the ER; however, the additional steps that were required limited regular, effective data exchange. A revised process was developed to streamline the workflow and reduce the turnaround time of information exchange to within 90 seconds of patient registration.
Implementing Standard Processes
Cedars-Sinai: implementing consistent and standardized processes
Cedars-Sinai Medical Network (CSMN), a division within the Cedars-Sinai Medical Center, a nonprofit, tertiary 958-bed hospital and multispecialty academic health center in Los Angeles, CA, has built a carefully coordinated set of processes across the medical center to assess patients with SDOH needs. CSMN developed its own screening tools in house and ensured that each intake point was using a consistent screening tool and consistent internal referral processes to refer patients to social work or ambulatory care management for further interaction with the patients, coaching, and triage to community services. Consistency and standardization are keys to the successful SDOH system that has been scaled across the entire medical center. Because spreading SDOH expertise and knowledge broadly across the medical center is viewed as a key to sustainability, social work and ambulatory care management provide a broad-based training and communications program. The SDOH assessment process was built across the medical center such that all documentation needed for the National Committee for Quality Assurance review processes was already incorporated and available. To complement the universal SDOH process for all patients, Cedars-Sinai has developed unique, centralized, high-touch processes for selected high-utilizer patient cohorts.
Experiences in Two Scandinavian Countries
In Denmark and Finland, health care and social care are both publicly funded and delivered by separate departments. Social welfare programs and services in Denmark and Finland are provided equally to all citizens in need and not just to underserved populations.
Denmark is divided into 5 geographic regions, which are divided into 93 municipalities, where cross-sector collaboration between medical and social care occurs. In Finland, social and health care reforms are moving the responsibility for arranging the health and social care services from more than 350 municipalities to 18 counties, with long-terms goals of common social and health care electronic records, more tightly integrated services, and improved standardization.
Although most US health care organizations screen patients for selected SDOH and then execute a handoff to a social services provider(s), the approach in Scandinavia goes beyond providing for immediate needs to include an emphasis on building self-sufficiency, social networks, and self-supporting families. For example, a Finnish hospital might refer patients to the municipality, where social workers conduct a detailed analysis of the citizen's life and develop a comprehensive social care plan, provide curated resources, and implement a closed-loop data-sharing process to continuously improve the plan and outcomes. The plan outlines the responsibilities of all the partners, including the citizen, family members, the social worker from the municipality, and the social welfare agencies. More advanced organizations have teams working in the same facility and, if needed, even in the same room under common leadership.
Challenges are similar to those in the United States: • Determining the appropriate size and focus of the investment in social care; • Implementing sound data governance; • Navigating differences in terminology used by health care and social care providers; and • Variability in each sector's facility and use of technology, service delivery protocols, and measurement.
Insights
Given the lack of analytic evidence regarding the differential impact of SDOH interventions on health, health care utilization, and cost, it is likely that health care payment systems that acknowledge and fund SDOH will evolve slowly. However, these case studies offer insights into how health care providers can progress apart from explicit payment systems.
1. Collaboration between the health care and social service sectors across a community is a sequential and incremental process; thus, it is important to begin with a dialogue and not with a fully developed plan in place.
2. To be maximally effective in addressing SDOH, health care and social care agencies need to reorient their staff, infrastructure, and organizational culture to a collective community of health through:
• Shifting the lens from the organization to the citizen and family;
• Experimentation with new approaches such as design thinking;
• Aggressive and continuous communication campaigns; and
• Leadership training and discussion around evolving new business models.
3. The first stages of SDOH system development tend to focus on identifying selected SDOH needs and making a referral based on personal relationships. Further evolved models from Europe provide more detailed and holistic analyses of the individual and family lives, cocreated life plans, curated resources with a care navigator, and a closed-loop communication process.
4. The value of a “community integrator” function is evident in leveraging multi-sector coalitions in the United States and municipalities in Scandinavia. The integrator links the medical and social sectors, enables the cocreation of shared goals, and aligns shared resources.
5. Some of the approaches to building the collaboration include:
• Investing in formal and informal relationship building;
• Leveraging opportunities presented by smaller projects and grants to build trust and working relationships;
• Utilizing the multi-sector platform of a coalition, a government agency, or a formal 501(c)3 corporation to bring parties together in a purposeful manner; and
• Building standard interoperable IT systems to share data and communicate between sectors.
6. Communities need a sustainable financing plan for SDOH activity. Many local communities build a braided funding plan involving grants and contracts, philanthropy, city/county/state funding, the local hospital, social impact bonds, health insurers, and local banks/employers. In some cases, a local hospital and/or insurance company with financial responsibility for a population can capture the financial return on investment from SDOH investments.
7. The shift from a narrow focus on the provision of services, commonly found in the United States, to a balanced focus on helping people achieve self-sufficiency and building social networks is most well developed in the Scandinavian countries. US health care providers can use design thinking and other tools to engage patients and families as cocreators instead of merely service recipients. Bridging Health & Community calls for such an explicit focus, stating“There is a risk that initiatives resulting from the health sector's growing enthusiasm for influencing social determinants will be too limited to meet the mark because they leave out the knowledge and power of those most affected by the very challenges they intend to address.” 7
8. Wherever possible, health care organizations are placing a priority on using standard tools and documented processes to achieve consistent and reliable results.
Footnotes
Author Disclosure Statement
The authors declare that there are no conflicts of interest. All authors served on the Epic Population Health Steering Board during 2017 and developed this work as a part of their volunteer Steering Board activities. Their work also resulted in a companion article that is focused on the technical aspects of SDOH supported by the Epic company. Epic has posted that whitepaper on its website; it is available only to Epic clients. The authors received no financial support for this article.