Looking Upstream for Impact: Social Determinants of Health & the Role of

Health Care

Reproductive health coordinators meeting – October 23, 2017

Carly Hood-Ronick MPA, MPH

Oregon Primary Care Association

Session outline 2

• Review of terminology

• Role of the broader health system in promoting equity

• Relevance to the clinic

• Why this work is critical

• Questions

• Group discussion

Session goals

• Define the difference between health disparity, inequity and social determinants of health.

• Explore how systems impact health outcomes downstream.

• Hear about a national tool to screen for SDH in the clinic and WHY it’s relevant to do so.

• Further explore the clinician’s role in impacting the SDH and discuss value in your clinical setting.

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Oregon Primary Care Association

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Our Mission is to lead the transformation of primary care to achieve health equity for all.

Why We believe that all people, in Oregon and beyond, have the right to good health and equitable health care.

How: OPCA supports health center sustainability while working to inspire and spread innovative approaches to providing better primary care to more people at less cost.

What:We connect, build the capacity of, and advocate for community health centers across Oregon.

What are the social determinants of health?

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Definitions

Sources: ASTHO 2000, HW2020, WHO

Health inequity

Health equity

Differences in health outcomes between groups of people that are considered preventable, unjust or unfair.

Fairness in the distribution of resources and the freedom to achieve healthy outcomes between groups with differing levels of social disadvantage.

Differences in health outcomes between groups of people.

Health disparity

Social Determinants of HealthThe social determinants of health (SDH) are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.

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1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 2013

US (17.1%)

FR (11.6%)

SWE (11.5%)

GER (11.2%)

NETH (11.1%)

SWIZ (11.1%)

DEN (11.1%)

NZ (11.0%)

CAN (10.7%)

JAP (10.2%)

NOR (9.4%)

AUS (9.4%)*

UK (8.8%)

Notes: GDP refers to gross domestic product. Dutch and Swiss data are for current spending only, and exclude spending on capital formation of health care providers.

Source: http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective OECD Health Data 2015.

Health Care Spending as a Percentage of GDP

Percent

Despite this spending…

• Source: OECD Health Data 2009

9Health and Social Care Spending as % of GDP

Notes: GDP refers to Gross Domestic ProductSource: http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspectiveE.H. Bradley and LA Taylor, The American health Care Paradox: Why Spending More is Getting Us Less, Public Affairs, 2013.

Pop Quiz #1

What Impacts Health?

IncomeEducation

Clinical care

Insurance

Housing Neighborhood

Social support

Health behaviors

FamilyCulture

AgeDoctor

Race

What Impacts Health?

Social Determinants of Health (SDoH)

Oregon by county…

Source: http://www.countyhealthrankings.org/app/oregon/2017/overview

2017 Health Factors 2017 Health Outcomes

Social determinantsRoot causesAre services addressing SDH incentivized and sustainable?

How well do we know the needs of our patients and what’s truly impacting their health?

Unnatural Causes

• http://www.youtube.com/watch?feature=player_embedded&v=Btqq1yfk-9g

The 4 P’s

Source: Multnomah County Office of Diversity & Equity http://www.multco.us/sites/default/files/diversity-

equity/documents/lens_handouts-09272013.pdf

Intergenerational

Reproductive health & the cycle of poverty 17

Raised in poverty

Can’t afford an abortion

Lose pay short term (unpaid

medical leave)

Lose salary/wages

long term“For a woman who is already

struggling to make ends meet, being able to end an unintended

pregnancy is a critical component to her and her family’s ability to get out of

poverty.”

$435,049“Lost earnings of a full

time femaleworker over 40 years

due to thegender pay gap.”

Sources: National Women’s Law Center, “Employment: Fact Sheet: How the Wage Gap Hurts Women and Families,” April 2015, http:// www.nwlc.org/sites/default/ files/5.11.15_how_the_wage_gap_ hurts_women_and_families.pdf

Guttmacher Institute, “Fact Sheet: Unintended Pregnancy in the United States,” February 2015, http://www.guttmacher.org/pubs/FB-Unintended-Pregnancy-US.html

More inequality = less mobility

Higher inequality

Less

mo

bili

ty

Source: Journal of Economic Perspectives, Corak http://pubs.aeaweb.org/doi/pdfplus/10.1257/jep.27.3.79

Clinicians and the SDH

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What impacts health?

Individual

Interpersonal

Institutions/Organizations

Community

Structures, policies, systems

Local, state, federal policies and laws to regulate/support health actions

Social networks, norms and standards

Rules, regulations, policies and informal structures

Family, peers, social networks and associations

Knowledge, attitudes, beliefs and behaviors

Largest impact

Smallest impact

Why should clinics care? 21

physicians believe that unmet social needs are leading to worse health among Americans.

physicians feel unable to address their patients health concerns caused by unmet social needs.

Social and economic

factors, 40%

Physical environment

10%

Clinical care, 20%

Health behaviors,

30%

Sources: Oregon Health Authority and Portland State University: https://www.oregon.gov/oha/pcpch/Documents/PCPCH-Program-Implementation-Report-Final-Sept-2016.pdf

RWJF 2011 http://www.rwjf.org/content/dam/web-assets/2011/11/2011-physicians--daily-life-report

Return on Investment = $13 to $1

What can clinicians do?

Meet legislator(s)

Engage with media

Be involved in local community organizing

Share SDoH with professional associations

Link patients to community services

Record social, economic patient information

Listen, empathize, connect

Source: Health Affairs Blog 2013 http://healthaffairs.org/blog/2013/02/22/the-us-health-disadvantage-and-clinicians-an-interview-with-paula-braveman/

“As a physician, I generally cannot discuss health with a patient who lives in poverty without talking about the areas where community development works: affordable housing, access to nutritious food, and safe places to play and exercise.”

~Risa Lavizzo-Mourey, MD MBAPresident and CEO, Robert Wood Johnson Foundation

Screening for social factors

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Protocol for Responding to and Assessing Patient Assets, Risks, and Experiences

SDH screening tool + implementation/action process

PRAPARE 24

Overall Project GoalTo create, implement/pilot test, and promote a national

standardized patient risk assessment protocol to assess and address patients’ social determinants of health (SDH)

+Assessment

Tool to Identify Needs in EHR

Protocol to Respond to

Needs

PRAPARE DOMAINS

Spanish and Chinese (Mandarin) translated versions

Find the tool at: www.nachc.org/prapare

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Core

UDS SDH Domains Non-UDS SDH Domains (MU-3)

1. Race 10. Education

2. Ethnicity 11. Employment

3. Veteran Status 12. Material Security

4. Farmworker Status 13. Social Isolation

5. English Proficiency 14. Stress

6. Income 15. Transportation

7. Insurance 16. Housing Stability

8. Neighborhood

9. Housing Status

Optional

1. Incarceration History

3. Domestic Violence

2. Safety 4. Refugee Status

PRAPARE domains

• 16 core questions

• 9 of which already collected by health centers through federal reporting (UDS)

• All align with national initiatives

• Design

• Vetted and stakeholder engaged development process

• In the EHR to facilitate assessment & interventions (free templates)

• Common core yet flexible: • Able to make more granular and/or add questions

• Focus on standardizing the need/data, not question

• Can be used in combination with other tools/data

• Conversation starter and patient-centered

26PRAPARE is unique and feasible

PRAPARE nationally….

• Health centers and/or PCAs in every state including AK have expressed interest in PRAPARE

• Health centers in over 30 states including AK downloaded PRAPARE EHR Templates

• 600 CHCs or health systems are using PRAPARE

• National team just kicked off Train-the-Trainer Academy in August!

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Free tools

online!

29Sample Workflows: A Variety of Approaches!

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31Immediate uses for the data

Challenge: Inability to Address SDH

Solution: Message “Have to start somewhere and do the best we can with what we have. Collecting information will

help us figure out what services to provide”.

Incorporate PRAPARE into other aspects and initiatives at health

center: QI meetings, board meetings, ACO discussions so

staff see value in this work

Models to Address SDH:1) Referrals with partnerships

2) Active/Formal Collaboration of multiple agencies under one

funded mechanism3) Co-location

4) New members of the care team

Catalog current resources available to address SDH needs, both in-house and in

community (community resource guide)

Identify resources that need to be developed

and/or community partnerships that need to

be initiated or strengthened

Opportunities and other plans to use the data

Inform Care and Services:

Inform services provided in Collaborative Consortia Model and Co-Location Model

Build/strengthen partnerships with local orgs. Ex: Negotiate bulk discounts and new bus routes

with local transportation agency

Build on SDH and “Touches” work

Inform Payment

Guide work of co-located foundation to pay for non-clinical services

Inform both Medicaid and Medicare ACO

discussions and care management policies

Inform payment reform discussions with state Medicaid

agency

Inform Risk Adjustment

Create SDH risk score for risk stratification and risk adjustment

Streamline and expand care management plans

Assign weights: Put every PRAPARE

element in regression model with certain

outcome or cost

Inform APM discussions at state

level

Listening is an inherent good for patients and professionals.

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© Oregon Primary Care Association

Why this work matters

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Public health models

Traditional model Equity model

Surveillance, healthy behavior promotion Policy development, policy analysis, upstream interventions

Home visits, immunization clinics, health education

Community capacity building

Narrow policy focus (e.g., seat belts, smoking)

Social systems, policies, & practices

Collaborations: • Health care providers • Social service agencies

Collaborations: • Organizations who work on policy and

advocacy on social, economic and environmental issues

• Community organizers who work on civic engagement

• Community planners

Priorities

Medical services 88%

Other 8%

Health behaviors

4%

Physical Environment 10%

Clinical care 20%

Health behaviors 30%

Socioeconomic factors 40%

What Makes Us Healthy What We Spend On Being Healthy

Source: RWJF County Health Rankings Source: Derived from information from the Boston Foundation (June 2007).

Discrimination

Sexism

Power

Source: Patters, Boston Public Health Commission presentation

Classism

Policies affect SES and SES affect health

Policies, institutions, systemsEg: Labor sphere, education sphere, social inclusion,

racism/discrimination

Health determinantsEg: Income, education, housing, childcare,

employment/vocational training, social support

Mediators of healthE.g: Lack of resources and access, constraints on

healthy behaviors, chronic stress

Health outcomes & health inequities

“Sharpening our focus on social & economic opportunity, enhancing the environments in which we live, and setting new priorities for policies and spending that optimize those conditions are our best hope for improving health…” – The Health of the States Report 2016

Source: VCU https://societyhealth.vcu.edu/media/society-health/pdf/HOTS-SummaryReport-FINAL.pdf

We often say…

My work includes health equity because:

Degree of Impact

I don’t discriminate against anyone

I serve vulnerable populations impacted by these disparities

I plan my work in a way that ensures it addresses the factors leading to health inequities

Source: Patters, Boston Public Health Commission presentation

How can we all get here?

Degree of Impact

I don’t discriminate against anyone

I serve vulnerable populations impacted by these disparities

I plan my work in a way that ensures it addresses the factors leading to health inequities

Source: Patters, Boston Public Health Commission presentation

Reshaping the model

Source: Braveman,P et al. The Social Determinants of Health: Coming of Age. Annual Review of Public Health 2011; 389-98.

Questions?

Carly Hood-Ronick MPA, MPHchood@orpca.orgSocial Determinants of Health Manager

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Group questions

• What are the biggest social determinant of health issues impacting the patients your clinic sees?

• Why do you believe these issues exist?

• Can you see value in screening patients for their SDH?

• What might this look like in your clinical setting? Who asks the questions? Where in the visit/workflow? Is it recorded in the EHR? What do you envision doing with that data?

• What are some barriers you envision encountering?