Social Determinants of Health: A Case Study
The term “social determinants of health” (SDOH) is inescapable in the healthcare industry. But despite the ubiquity of the term, integrating SDOH into front-line medical care remains largely out of reach.
Why? Because there persists a “wicked problem” in the U.S. healthcare system; an unfortunate disconnect between the actual problem – meeting the complex health and wellness needs of unique individuals – and our approach to that problem – a complicated and inflexible system doling out prescriptive responses to those needs.
Changing our approach and creating a system that values health seems nearly impossible, given the sheer size of the healthcare industry alone. But innovative programs around the country are showing that it is possible – and the results are mutual “wins” for individuals, point-of-care providers, payers and communities
An extreme example of how SDOH significantly impact healthcare costs, homeless people who are un- or under-insured often forego preventive care and depend on the emergency room to manage major medical issues. Once their acute conditions are addressed, recovery is hindered by lack of stable housing and access to follow-up care, while substance abuse and mental health issues may further interfere. The result is a high rate of complications necessitating costly re-hospitalizations - with little or no improvement in overall health or quality of life in the end.
Seeing the inefficiency and meanness of this cycle, ShelterCare, a nonprofit human services organization in Eugene, Oregon, sought change. In collaboration with Community Health Centers of Lane County (a Federally Qualified Health Centers), Trillium Community Health Plan, the local coordinated care organization, and Peace Health Sacred Heart Medical Center, the local hospital, they developed a medical respite care program that meaningfully improves wellness while decreasing costs by integrating SDOH into the care of homeless individuals.
The ShelterCare Medical Recuperation program opened in 2013 and has grown to 22-beds. The 30-day program gives residents a safe, stable housing environment in which to recover, while a community health worker provides medical care coordination and an on-site case manager helps residents connect to community resources to help them regain long-term stability.
As an example, Phil, a homeless man, visits the hospital emergency department with an infected wound. After receiving immediate medical treatment, the hospital refers him to the ShelterCare program, where he is given a small apartment and three meals a day. The medical caregiver on site dispenses medications, checks dressings and arranges for follow-up appointments and transportation. She helps Phil establish care with a primary care provider, who identifies that he has an untreated mental health disorder and a substance abuse problem and is referred to both counseling and an addiction treatment program.
Meanwhile, a case manager advocates for Phil with other social service and government agencies, guiding him through the process of applying for Medicaid, Social Security, food stamps, rental assistance, unemployment benefits and other services for which he may qualify. He is given a bus pass and ShelterCare staff take him shopping for clothing and toiletries. He takes part in on-site training workshops that help him create a resume, apply for jobs and learn basic budgeting skills.
While at the end of his month-long stay Phil still has much work to do to regain full stability, he is one of the 80 percent of program participants who leaves the program to move into permanent housing. And, by addressing the SDOH rather than continuing the cycle of emergency department visits, Phil’s coordinated care and wraparound services cost 34 percent less while helping him – and by extension, the greater community - make progress toward a significantly better quality of life.
The ShelterCare Medical Recuperation program has saved its community $1.26 million in hospital costs alone since 2014. It is an excellent micro-example of how an adaptive network with shared purpose and responsibility – the health and wellness of individuals– can effectively, efficiently collaborate to manage complex problems. And while the ShelterCare program is focused specifically on those experiencing a pre-determined set of conditions, (homelessness and the need for acute recovery assistance), it illustrates both the value and feasibility of an outcome-based, SDOH-integrated network approach to healthcare for all.
"When we change how we look at things, the things we look at change." - Wayne Dwyer
Restoring the type of cooperation, adaptiveness and humanity exemplified by the ShelterCare Medical Recuperation program to our greater healthcare delivery system will first require a major shift in how we value healthcare. We must value – and therefore monetize – outcomes, not procedures. And because health outcomes are, in reality, messily influenced by more than biology and physiology, healthcare delivery has to incorporate SDOH if we hope to contribute to meaningful improvements in community health.
This is one reason universal healthcare is not in itself an adequate solution: we will not solve the problem by simply offering more of the same. Today’s reimbursement methods take our focus away from individuals and their unique needs and imposes cumbersome restraints on those who would care for them. Instead, insurance companies, social service agencies, the government, and other stakeholders must come together to enable nimble, patient-focused decisions at the point-of-care.
A self-organized, learning network that engages providers and payers across disciplines will create more options for better outcomes at a lower cost. Curandi’s networking platform will enable community-focused initiatives to grow and serve a wider swath of the population. But first we must be willing – like those involved in ShelterCare’s respite program – to set aside the entrenched but ineffective standards of healthcare delivery and commit to seeking innovative solutions.