Social Determinants of Health 101 - Advisory€¦ · operations, service offerings •Unsustainable...

Population Health Advisor

Social Determinants

of Health 101Addressing patients’ non-clinical risk

factors in ongoing management

Darby Sullivan

Senior research analyst

[email protected]

© 2019 Advisory Board • All rights reserved • advisory.com

6

Get up to speed on two population health priorities

Two-part webconference series lays out path to success

Source: Population Health Advisor and Health Disparities Initiative interviews and analysis.

Targeted efforts drives societal shifts towards health equity

Building an

equitable, healthy society

Access the recording here.

Focusing efforts on historically

marginalized communities

Addressing structural inequalities

that impact health outcomes

Health Equity 101

Learn best practices to design a data-

driven framework to identify and prioritize

equity efforts across the system and

incorporate them into patient care.

Social Determinants of Health 101

Learn how to partner with community-

based organizations to provide quality

non-clinical support and impact

community economic strength.

Thursday, June 13th, 2019 • 1:00pmReview the webconference recording here.

http://www.advisory.com/

https://www.advisory.com/research/population-health-advisor/events/webconferences/2017/address-patients-non-clinical-risk-factors-in-ongoing-management/ondemand

https://www.advisory.com/research/population-health-advisor/events/webconferences/2019/population-health-101/health-equity-101

https://www.advisory.com/research/population-health-advisor/events/webconferences/2019/population-health-101/social-determinants-101



ROAD MAP7

The impact of the social determinants

of health1

2The role of community partnerships in addressing patients’ non-

clinical risk factors

3 Key considerations for promoting long-term sustainability



8

Key drivers of risk are often non-clinical in nature

Must meet certain needs before care can inflect positive change

Source: McLeod, “Maslow’s Hierarchy of Needs,” Simply Psychology,

https://www.simplypsychology.org/maslow.html; Population Health Advisor interviews and analysis.

Applying Maslow's hierarchy of needs to population health management

Self-actualization

Esteem

Within a provider

organization’s

sphere of influence

Physiological

Belongingness

• Community

• Social relationships

• Trust

Safety

• Security

• Stability

• Law and order

• Food

• Shelter

• Warmth


https://www.simplypsychology.org/maslow.html


9

Five major interlocking non-clinical risk factors

Economics EducationInterpersonalFood Housing

• Under-

employment

• Insufficient

wages

• Lack of

insurance

coverage

• Health

illiteracy

• Lack of

language skills

• Quality of

public schools

• Social isolation

• Discrimination

• Adverse

childhood

events

• Trauma

• Inaccessible

affordable,

healthy food

• Disconnection

from benefits

(e.g., SNAP)

• Housing

quality and

instability

• Neighborhood

violence

Most pressing social determinants of health to inflect to drive equity

Source: Heiman, “Impact of Different Factors on Risk of Premature Death,” Kaiser Family Foundation, https://www.kff.org/disparities-policy/issue-

brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/; Population Health Advisor interviews and analysis.

“Social determinants of health are the conditions in which people are

born, grow, live, work, and age that shape health.”

KAISER FAMILY FOUNDATION


https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/


10

Undeniably critical impact on patients’ lives

Food Housing Interpersonal EducationEconomics

Patient

impact 66%

Food insecure

households had to

choose between

paying for food and

medical care

26-36Years reduced life

expectancy for

those experiencing

homelessness

26%Increased risk of

mortality resulting

from loneliness

9 yearsGap in life

expectancy for

those without a

high school

diploma vs. college

graduates

Greater mortality

risk for Medicaid

beneficiaries vs.

private insurance

2.13x

Scale of non-clinical challenges impact health systems’ financial strength

Pro

vid

er

impact

$155BAnnual health-

related costs

directly attributed to

food insecurity

1.8xMedian LOS for

patients

experiencing

homelessness

compared to those

with secure

housing

60%Higher risk of ED

utilization for

patients requiring

language services

$32KAverage per patient

cost for those with

inadequate health

literacy over three

years

Higher likelihood of

readmission for

patients dually-

enrolled in

Medicare and

Medicaid

24-67%

Source: See appendix for full sources; Population Health Advisor interviews and analysis.



11

Social needs complicate clinical care and outcomes

Care teams unable to provide full range of services alone

Source: Heiman, “Impact of Different Factors on Risk of Premature Death,” Kaiser Family Foundation, https://www.kff.org/disparities-

policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/; “Health Care’s Blind

Side,” Robert Wood Johnson Foundation, http://www.rwjf.org/en/library/articles-and-news/2011/12/health-cares-blind-side-unmet-

social-needs-leading-to-worse-heal.html; Population Health Advisor interviews and analysis.

Physicians reporting that unmet

social needs lead directly to

poorer health outcomes

85%

Physicians who are confident

in their ability to address

unmet social needs

20%

Interlocking social determinants of health inform clinical outcomes

20%

10%

30%

40%

Social and

environmental

factors

Health

care

Genetics

Individual

behavior

Impact of different factors on risk of

premature death


https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/

http://www.rwjf.org/en/library/articles-and-news/2011/12/health-cares-blind-side-unmet-social-needs-leading-to-worse-heal.html


12

Partner for sustainability and efficacy

Don’t reinvent the wheel to address non-clinical needs

Source: Population Health Advisor interviews and analysis.

1 2 3

• Play minimal role in

operations, service

offerings

• Unsustainable funding

model if addressing all

social determinants

of health

• Demands large scale

time and resources

• Outside scope of staff

skills, experience

• Delayed ROI

• Deepens community

connections, network

• Low-cost investment into

existing successful

services

Build

• Dedicate hospital

resources and staff

• Construct programs

from ground-up

Buy

• Contract out to social

services organizations

• Devote hospital funding

to addressing nonclinical

risk factors

Partner

• Distribute resource

investment across

multiple partners

• Tap into existing

services and

relationships

Imp

lica

tio

ns

De

scrip

tion



13

Tremendous innovation driven by partnerships

Focus on determinants of health driving short- and long-term impact


1) The BUILD Health Challenge is an

initiative designed to foster and

expand meaningful partnerships

among health systems, community-

based organizations, local health

departments, and other organizations

that impact health in the community.

Overview of the BUILD Health Challenge1 communities

Healthy Hill Initiative

Spurring economic

development and

improving public safety

Healing Together

Empowering youth

leaders to stand

against violenceThe Healthy

Ontario Initiative

Developing “health

hubs” to foster

strong bodies and

communities

The Harris County BUILD

Health Partnerships

Mitigating food insecurity

by redesigning the local

food system

Increasing Access to

Behavioral Health

Screening and Support

Eliminating health

disparities by age five

BUILDing Health

and Equity in East

Portland

Expanding access to

affordable housing,

green space, and

health food

Building a Healthy

and Resilient Liberty

City

Breaking the cycle of

violence at all ages



14

Members can’t ignore shift to fee-for-value for long

Source: HHS, “Progress Towards Achieving Better Care, Smarter Spending, Healthier People,” available

at: http://www.hhs.gov/, accessed February 2015; Health Care Advisory Board interviews and analysis.

20%30%

50%

2015 2016 2018

Aggressive targets for transition to risk

Percent of Medicare payments tied to risk models

80%

85%

90%

2015 2016 2018

FFS increasingly tied to value

Percent of Medicare payments tied to quality

Medicare Shared

Savings Program

Patient-Centered

Medical Home

Bundled Payments for Care

Improvement Initiative

Exam

ple

s o

f qualif

yin

g

risk m

odels

Hospital-Acquired Condition

Reduction Program

Hospital Readmissions

Reduction Program

Hospital Value-Based

Purchasing Program

Merit-Based Incentive

Payment System

Exam

ple

s o

f qualit

y/

valu

e p

rogra

ms

Majority of Medicare payments now tied to risk models and quality



ROAD MAP15

The impact of the social determinants of health1

2The role of community partnerships in

addressing patients’ non-clinical risk factors

3 Key considerations for promoting long-term sustainability



16

Addressing non-clinical needs to improve outcomes

Identify structural barriers that contribute to health disparities


Map major community health needs to partner organizations with tools for success

Decreasing resource requirements and severity of need

Engage disconnected

patients at-risk of

clinical escalation

Meet fundamental

needs critical to clinical

success

Remove barriers to

access based on

severity of need

• Community health workers

• Health literacy support

• Congregational liaisons

Resources

to achieve

health equity

aims

• Safe, stable housing

• Healthy foods

• Economic support

• Language services

• Transportation services

• Mobile health clinics

Address baseline needs

(e.g., hunger, housing)

that must be met before

patients can begin to

prioritize health care

Enhance engagement and

reduce the trust gap by

aligning with community-

based organizations

serving at-risk, disengaged

patient populations

Increase access to health

services, from preventive

to specialist care, for

patients facing logistical

barriers (e.g., work hours,

lack of transportation)

Opportunities

to partner



17

Prioritize needs that preclude health improvement

Review evidence to surface community’s most pressing barriers

Opportunity #1: Meet fundamental needs critical to clinical success

Source: See appendix for complete sources; Population Health Advisor interviews and analysis.

LowAcuity:

26% increased risk of

mortality resulting from

loneliness

• Leads to increased

rates of behavioral

health problems,

dementia, hospital

readmissions, and

mortality

• Reduces ability for the

elderly to live

independently

Social isolation

10% increased

annual visits to the

doctor

26-36 years reduced

life expectancy


rates of physical

trauma, chronic

diseases, dental

issues, behavioral

health problems, and

exposure

• Reduces access to

primary care and

ability to self-manage

$44K average annual

cost per highest-

volume ED patient

experiencing

homelessness

Housing instability

HighAcuity:

Food insecurity• Leads to increased

rates of chronic

diseases, dental

issues, behavioral

health problems,

stress, and

hospitalizations

• Influences purchasing

decisions between

food and: medicine

(74%), transportation

(67%), utilities (59%),

and housing (57%)

$179B annual direct

and indirect health-

related costs attributed

to food insecurity

HighAcuity:

HighAcuity:

2.13x increased risk

of mortality for

Medicaid vs. private

beneficiaries


rates of distress and

behavioral health

problems

• Reduces access to

clinical care and

increases likelihood of

living in a resource-

poor area

Economic insecurity

24-67% increased

risk of readmission for

dual-eligible patients



18

Collaborate to make big community investments

Vermont’s housing offerings meets range of needs with tangible ROI


1) University of Vermont Medical Center.

UVMMC¹ develops housing portfolio through partnership

Services

Case management: UVMMC funds 1 onsite FTE Case Manager from CHC¹ who

connects patients to CHC provider and fulfills additional needs (e.g., insurance)

Mental health services: Howard Mental Services dedicates one case manager to each

site (1 FTE), who is reimbursed separately

Additional clinical services : Various providers (e.g., Visiting Nurse Association,

physician house call) visit each site as needed

Short-term Permanent

Results

Decreased inpatient admissions:

Reduced from 95 to 30 stays

Decreased ED utilization:

Reduced from 161 to 94 visits

Decreased annual cost of care:

Dropped health care from $750K to

$250K for permanently housed patients

Infrastructure

Harbor Place Rooms: 22 family units, 34

single units with an average stay of 8 days

Beacon Apartments: 18 single units

across an indefinite stay

Funding

Pay per diem rate for patients

Guarantees minimum number of nights

Helped fund purchase and

renovation of motel and pays

operations amount per patient



CASEEXAMPLE

University of Vermont

Medical Center

562-bed medical center located in Burlington, Vermont

and sole tertiary hospital in the state

• Developed a partnership with Champlain Housing Trust, a

non-profit that creates and preserves affordable housing in

Vermont; UVMMC pays to house their patients in

Champlain Housing Trust’s buildings and funds additional

case management services by the Community Health

Centers of Burlington

• Additional services are provided onsite (e.g., Howard

Mental Services, Visiting Nurse Association) and

reimbursed independently

• Started with short-term housing, expanded to include

permanent, and developing intermediate housing that will

include additional onsite services in mid-2017




20

Universalize screening to unearth food insecurity

Source: Population Health Advisor research and analysis.

ProMedica’s cross-setting screening process

Households

served in 2017

3.3KReduced

readmission rates

53%Reduced health

care costs

15%Patients

screened in 2017

781K

Short-term response

to inpatient admission

Patient discharged from hospital with

one day’s worth of calories,

information on follow-up support (e.g.,

federal programs, food banks), and

PCP appointment

RN performs initial food insecurity

screen using two-question Hunger

Vital Sign™

LCSW or discharge planner follows

up with identified patients to validate

need and connect to any additional

psychosocial services

Primary care staff across all

practices screen for food insecurity

and PCPs refer appropriate

patients to the system’s food clinic

Patients visit food clinic for healthy,

condition-specific food once a

month for six months before

needing new referral, encouraging

regular preventive care

Long-term support

embedded in primary care

ProMedica offers emergency support and longer term food prescriptions



CASEEXAMPLE

ProMedica

Not-for-profit, 13-hospital healthcare organization based in

Toledo, Ohio serving communities in 30 states

► System-wide food insecurity screenings prompted by food

insecurity prevalence and link to obesity; patients are screened

for food insecurity in both the inpatient and outpatient setting,

with differing interventions

► In 2017, ProMedica conducted more than 781,000 food security

screenings and the food clinic served 3,260 unique households

► Preliminary data from a small group of Medicaid patients

showed those who screened positive and visited the food clinic

had 3% reduction in ED usage, 53% reduction in readmission

rates, 4% increase in primary care usage, and 15% reduction in

healthcare costs compared to those not using the program

Source: Population Health Advisor research and analysis.



22

Form coalitions to elevate economic opportunity

Phipps neighborhoods’ workforce development tackles economic barriers


Career Network: Healthcare program relies on expertise of three major players

Phipps Neighborhoods

• Career development

community-based

organization that connects

participants to education

and training for health care-

related jobs

• Community members

eligible to apply are 18-26

years old with a GED or

high school diploma

• Phipps hosts intensive

induction boot camp week

to identify final roster based

on professional qualities

(e.g., punctuality, attire)Hostos Community College

Local community college hosts

the nine week educational

component, including:

• Health care labor market

• How to navigate a higher

education environment

Montefiore Health

• Local health system hosts the

four week externship component,

preparing students for roles like:

– Patient care technician

– Dietary worker

– Community health worker

– Medical assistant

– Research coordinator

• Montefiore guarantees

participants an interview at the

end of the program

Participants secure

employment

80%



CASEEXAMPLE

Phipps Neighborhoods

Workforce development nonprofit in the Bronx, NY

► Partnered with Montefiore Health System and a local

community college (Hostos Community College) to create a

workforce development program called Career Network:

Healthcare

► Program offers a pathway to health care jobs by providing

participants with a 13-week training program. Upon

completion, Montefiore guarantees candidate interviews for

all participants across one or more of the health system’s

1,500 existing vacancies

► To ensure stability in employment, Career Network also

helps to solve participants’ pressing employment barriers

(e.g., housing insecurity, childcare needs)

Source: Population Health Advisory and Health Disparities Initiative interviews and analysis.



24

Design program to address root cause of care gap

Stabilize at-risk with consistent touchpoints to health system

Opportunity #2: Remove barriers to access based on severity of need


Lack understanding of

health status and care

plan next steps due to

limited English

proficiency

Disconnected patients face three common access barriers that threaten outcomes

1 2 3

Map program to community’s most pressing access barriers and level of care required

Miss appointments

due to a lack of

adequate transport or

logistical barriers (e.g.,

clinic location)

Lack key resources to

manage health and

access care (e.g.,

housing, economic

stability, insurance)

Offer language-

concordant care

• Hire providers who

speak common

community languages

• Contract for telephonic

or virtual interpretation

Arrange transit and

convenient care

hotspots

• Coordinate with

rideshares, taxis

• Launch targeted

health fairs

Bring full scale

services to targeted

locations

• Invest in mobile

health clinic for

community hotspots

• Set up worksite clinics

Low HighProvider integration into the community



25

Connect patients with care they can understand

Cambridge Health Alliance offers multiple language support options

Source: Hacker, K, et al., “Exploring the Impact of Language Services on Utilization and Clinical

Outcomes for Diabetics,” PLoS ONE 7(6); Population Health Advisor interviews and analysis.

39%

Lower likelihood of

hospitalization or ED

utilization related to diabetes

compared to those receiving

no language services

• What is your primary language?

• In what language do you prefer to communicate

with your provider?

• Would you like to use interpreter services for

your visit?

Importance of understanding language

preferences

How to connect patients to interpretation services

Annual testing on CHA language policies and how

to implement them

Language-concordant providers

for diabetes management led to:In-person

interpretation

Language-

concordant

provider

Telephonic

interpretation

Language line

interpretation

service

In-visit interpretation offerings

Training and standardized screening critical to program success

Staff training components Standardized questions assessed at check in


http://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0038507&type=printable


CASEEXAMPLE

Cambridge Health Alliance

Massachusetts-based community health system serving a

diverse patient population

► To meet the needs of patients with limited English

proficiency (LEP), CHA developed robust language

services across health care settings. Over half of CHA

patients report speaking a language other than English at

home and 42% of CHA’s primary care patients have limited

English proficiency

► On the system’s website, patients can search for a doctor

that speaks their preferred language. When patients check

in for an office visit, CHA registration staff screen patients

for language preferences. Patients identified as having LEP

are supported by language-concordant providers, in-person

or telephonic interpretation, or language line interpretation

services, based on availability

Source: Hacker, K, et al., “Exploring the Impact of Language Services on Utilization and Clinical

Outcomes for Diabetics,” PLoS ONE 7(6); Population Health Advisor interviews and analysis.


http://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0038507&type=printable


27

Getting patients to, rather than through, the door

MedStar teams up with Uber to bring qualifying patients to appointments

Source: Syed, Samina T., Ben S. Gerber, and Lisa K. Sharp.

“Traveling Towards Disease: Transportation Barriers to Health

Care Access.” Journal of community health 38.5 (2013): 976–

993. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4265215/.

Population Health Advisor interviews and analysis.

Case manager

calls patient up

to 90 minutes

before

appointment

Patient makes

appointment

Case manager

schedules ride

through

UberCENTRAL

U

Patient

indicates no-

show due to

lack of

transportation

Case manager

identifies

qualifying

patient at-risk

for no-show

3.6M

People miss

medical

appointments

due to lack of

transportation,

annually

25%

Of low-income

patients report

missing

appointments

due to lack of

transportation

11-30%Average clinic

no-show rate

Average daily revenue capture <100%

Case managers use Uber to help patients overcome transportation barrier


https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4265215/


CASEEXAMPLE

MedStar Health and Uber

Health system based in Columbia, MD and serving

Maryland, Washington, DC, and Northern Virginia

► Uber is a national ride-hailing company based in San

Francisco, California

► In January 2016, MedStar and Uber formed a partnership to

improve access to transportation for MedStar patients




29

Clinic brings care to CBOs¹ serving the homeless

Parkland’s mobile clinics eliminate barriers to care and medications


1) Community Based Organizations.

2) Homeless Outreach Medical Services.

Patients served in 2015

9,377Patients uninsured

78%Annual program budget

$5M

HOMES² program addresses needs of patients experiencing homelessness during and

after visit

Specialty, emergent care

22-person shuttle loops around

central business district to Parkland

main campus for additional care (e.g.,

x-rays, ED care, Class A pharmacy)

Needs addressed

after clinic visit

Needs

addressed on

the clinicPsychosocial services

Supplemental services vary by

site and population need

(e.g., staff health educator,

interpreter, psychologist when

visit domestic violence shelter)

Clinical care

Mobile clinic staff provide

acute and chronic disease

care, education, check-ups,

immunizations, mental health

counseling, and dental care

for children and adults

Medication access

Pharmacy supplies 35

medications for patients free

of charge to enable patients to

start regimen immediately

Referrals to other programs

Staff connect patients to other

programs (e.g., specialty

clinics, housing support)



CASEEXAMPLE

Parkland Health & Hospital

System’s HOMES Program

862-bed safety-net and teaching hospital system,

including 20 community-based clinics and 12 school-

based clinics in Dallas County, Texas

• Established mobile HOMES program to increase access to

medical, dental, and behavioral health care for homeless

children and adults

• Five medical and one dental mobile clinic visit 31 different

community partners to serve existing concentrations of

individuals with unstable housing; partners are chosen

based on logistical factors

• Nurse, physician or advanced practice provider, and driver

deliver immediate care supplemented by an on-site Class D

pharmacy; additionally, a 22-person shuttle transports

homeless patients to Parkland’s main campus for specialty,

emergent care, and prescriptions

• In 2015, the HOMES program served 9,377 patients, 78% of

whom were uninsured, with an annual budget of $5 million




31

Select trusted partners with deep community ties

Supplement programs with partner expertise to jump start engagement

Opportunity #3: Engage disconnected patients at-risk of clinical escalation


• Build a longstanding

relationship by catering

to the specific needs of a

particular population

• Promote top-of-site

utilization by connecting

patients with appropriate

services

• Embed a health system

staff member in the

community to build

patient loyalty

• Choose partners based

on existing positive

relationships with target

population

• Augment partner

expertise with health

system resources

• Build rigorous

partnership agreements

based on joint principles

of collaboration

Time, resource commitment

High LowHealth system control

Collaborate with trusted

community partners

Devote staff to strengthening

community relationships



32

Use CHWs to capture disconnected patients

UNM Health System achieved long term funding with targeted pilot

Source: Source: Johnson, D. et al, “Community Health Workers and Medicaid Managed Care in New Mexico,” Journal of

Community Health, June 2012; UNM Health System, Albuquerque, NM; Population Health Advisor interviews and analysis.

1) Managed Care Organization.

2) Control group not managed by CHWs had 53% fewer inpatient admissions.

3) Data measured 12 months after the start of the six month intervention.

CHWs show promising ROI with highest-risk Medicaid patients

Results

• High-risk MCO members

• People returning from the

criminal justice system

• Undocumented immigrants

• Children at-risk for abuse

Target

patients

6 months of didactic training (e.g.,

health coaching, service

coordination) paired with 6 months

of field workTraining

Local MCOs¹ needed help

identifying their high-risk members,

provided funding to UNM to hire,

train, and deploy CHWsImpetus

Address social needs: offer

interpretation services, connect with

social services, communicate with

cultural humility

Support disease self-

management: reinforce basic

disease education, address health

literacy, navigate to clinical care

Services

Program costs vs. savings

Costs Savings

$521K

$2M

83%Fewer inpatient

admissions²³

4:1ROI



CASEEXAMPLE

University of New Mexico Health System

Three-hospital academic health center in

Albuquerque, NM

► University of New Mexico Health System (UNM) deploys

CHWs to establish trusting relationships with disengaged,

high-risk patients attributed to a local managed care

organization (MCO)

► After a successful pilot, UNM obtained stable, long term

funding from internal stakeholders and from additional

MCOs to expand programming. While UNM continues to

serve the highest-risk, they’ve expanded support to

vulnerable subpopulations (e.g., undocumented immigrants,

children)

► UNM Health’s efforts resulted in a 4:1 ROI with 83% fewer

inpatient admissions¹²

Source: Source: Johnson, D. et al, “Community Health Workers and Medicaid Managed Care in New Mexico,” Journal of

Community Health, June 2012; UNM Health System, Albuquerque, NM; Population Health Advisor interviews and analysis.

1) Control group not managed by CHWs had 53% fewer

inpatient admissions.

2) Data measured 12 months after the start of the six month

intervention.



34

Embed targeted health literacy approach with rigor

Initiating effort with Rx adherence goals to achieve trackable success

Source: Meyer D, “The Health Education and Adult Literacy (HEAL) Program,” Healthy Tomorrows Partnership for

Children Program, http://mchlibrary.jhmi.edu/downloads/file-7146-1; “Heal - Health Education and Adult Literacy

Program,” NewYork-Presbyterian, http://www.nyp.org/clinical-services/ambulatory-care-network-programs/heal---

health-education-and-adult-literacy-program; Population Health Advisor interviews and analysis.


Improving health literacy necessitates standardized, community-inclusive process

Repeat research process as

necessary to adapt curriculum

with changing community needs

Train health and community

leaders to use effective health

literacy techniques

• Medical center staff (e.g.,

pediatricians, residents, and

family support/ community

health workers)

• Staff from seven participating

CBOs¹ (medical students,

volunteers)

Perform individual patient

interventions across all partner

organizations

• Perform teach-back

• Provide visual and written

educational materials

Develop culturally-relevant and

evidence-based health literacy

curriculum

• Incorporate community input

on unit topics

• Use data from needs

assessments or studies


http://mchlibrary.jhmi.edu/downloads/file-7146-1

http://www.nyp.org/clinical-services/ambulatory-care-network-programs/heal---health-education-and-adult-literacy-program


35

Leverage community as program design lab

Columbia university’s three step HEAL¹ curriculum based on research

Source: Meyer D, “The Health Education and Adult Literacy (HEAL) Program,” Healthy Tomorrows Partnership

for Children Program, http://mchlibrary.jhmi.edu/downloads/file-7146-1; “Heal - Health Education and Adult

Literacy Program,” NewYork-Presbyterian, http://www.nyp.org/clinical-services/ambulatory-care-network-

programs/heal---health-education-and-adult-literacy-program; Population Health Advisor interviews and analysis.

1) Health Education and Adult Literacy.

• Community pediatrics unit initiated health

literacy program targeted towards parents

• Staff researcher performed an

observational study on communication

quality between patients and providers

• Included patient exit interviews

Provider role

• Key nonprofit partner gathered 22

community members to form three focus

groups in Spanish and English

• Groups offered input on patient

communication with providers, medication

use, and home remedies

Community role

• Seven-unit course developed on a 5th grade

reading level and a train-the-trainer manual

• Spanish versions created by speakers

native to countries represented by patients

• Unit topics include:

• Doctor’s appointment preparation

• Over-the-counter medications

• Prescription medications

• Home remedies

• Medication management

• Upper respiratory infections

• Antibiotic use

Health literacy curriculum

Shape curriculum according to community-sourced needs and provider-led analysis





36

Results indicate improved health literacy is viable

Incorporate applicable lessons into nascent efforts

Source: Meyer D, “The Health Education and Adult Literacy (HEAL) Program,” Healthy Tomorrows Partnership for

Children Program, http://mchlibrary.jhmi.edu/downloads/file-7146-1; “Heal - Health Education and Adult Literacy

Program,” NewYork-Presbyterian, http://www.nyp.org/clinical-services/ambulatory-care-network-programs/heal---

health-education-and-adult-literacy-program; Population Health Advisor interviews and analysis.

1) Columbia University Medical Center.


Patients approached in

waiting rooms indicating

interest in program

83%

Increased knowledge/attitude

score for parents receiving

upper respiratory infection

education

61%

Pediatric faculty, residents,

and family support workers

trained at CUMC¹ clinics

145

Key lessons to guide health literacy programs

Use partners to expand program reach

Extend health literacy programming outside the

health system into community health clinics and

social service organizations

Leverage networks of CBOs² to build course

Local social services and nonprofits can connect

providers with community representatives who help

guide topic development

Base program on explicit, quantifiable goals

Strong vision for health literacy intervention (e.g.,

improved medication adherence) spurs metric

tracking to prove efficacy and sustain funding

Inform clinical staff of proven best practices

All patient-facing staff should be aware of and

trained on health literacy best practices to improve

communication protocols





CASEEXAMPLE

Columbia University Medical Center

738-bed academic medical center in New York, New York,

part of NewYork-Presbyterian

►In 2007, Columbia University Medical Center’s Community

Pediatrics department and NewYork-Presbyterian Hospital

launched the Health Education and Adult Literacy (HEAL)

program in collaboration with seven local community

partners

►The program’s goal is to reduce medication errors and

increase compliance by improving the health literacy of

children and parents in the Washington Heights and Inwood

communities

►The program to date has trained 184 providers, residents,

medical students, family support workers, and volunteers

with their health literacy curriculum, serving 180 patients’

caregivers at Columbia University Medical Center

ambulatory care clinics




38

Pillars of community can help breach the trust gap

MedStar brings care to barbershops to reach the disconnected


Surfacing undiagnosed issues

54%

9%Previously undiagnosed participants

with elevated blood sugar

19%Participants with uncontrolled BP

referred to and tracked for follow-

up care

Previously undiagnosed participants

with hypertensive

or pre-hypertensive BP readings

Barbers trained to promote diabetes and

hypertension screening, provide health

education

• Receive 8-hour training on informed

consent, measuring height and weight,

and collecting data

RN, Dietician, Diabetes Educator perform

follow up appointments on-site

• Do not travel for regular screenings

Health navigators conduct blood pressure

and blood glucose screenings on-site

• Present in rotating, high-traffic

barbershops from 2-7pm five days/week

Staff perform screenings through the “Hair, Heart and Health” program to identify

Black men at-risk for hypertension and diabetes



CASEEXAMPLE

MedStar Health

10-hospital health system based in Columbia, Maryland

• In 2008, MedStar established “Hair, Heart and Health”

program to screen for diabetes and hypertension in local

barbershops

• The program was designed to reach African American men

who previously had infrequent contact with the system to

screen them for cardiovascular disease and diabetes




ROAD MAP40

The impact of the social determinants of health1

2The role of community partnerships in addressing patients’ non-

clinical risk factors

3Key considerations for promoting long-term

sustainability



41

Select potential partners based on internal gaps

Avoid duplicating services for program sustainability


Common resource gaps mapped to potential partners

Po

tential P

art

ners • Local government

• Social services (e.g., food

banks, schools)

• Behavioral health facilities

• IT vendors

• Medical schools

• Local pharmacy

• Mental health or substance

abuse providers

• Academic institution

• Community organizations

• Social service providers

• Housing, transit services

• Social service providers

• Local clergy/chaplains

• Legal services

• Local businesses (e.g.,

supermarkets, barbershops)

Infrastructure Staffing Reach

Ga

ps

• Funding

• Facility space and utilities

• Data sharing and analytics

• Clinical and non-clinical

expertise (e.g., social

workers)

• Grant-writing assistance

• Volunteers (e.g., peer

coaches, medical students)

• Expanded clinical services

(e.g., expanded hours)

• Expanded social services

(e.g., housing, food)

• Connection with at-risk

populations



42

Value to patients, system must be critically assessed

Partner relationships a two-way street, success not guaranteed

Source: Health Care Advisory Board interviews and analysis.

Conveniently located near crowded,

high-Medicaid system EDs

Articulates clear value to system,

with demonstrable ROI

Provides high quality services

valuable to Medicaid population

Maintains open, transparent

communication channels

Willing to meet clinical

standardization expectations

Willing to progress toward

risk-based arrangements

Hallmarks of effective relationships

Sustainable infrastructure for

stakeholder engagement, feedback

Enthusiastic buy-in from leadership

and frontline staff

Clear metrics for measuring ROI,

transparency, accountability

Shared mission and culture

Aligned back office capabilities for

data transparency, continuity

Community partner checklist:



43

Set expectations with detailed goals, responsibilities

Non-binding contract outlines responsibilities of providers, clinic staff


Hospital-employed navigator and community liaison collaboration starts at admission

Memorandum of understanding designates party responsibilities for care support

Navigator visits

patient once

identified upon

admission,

obtains

permission to

contact liaison

Navigator

answers liaison’s

ongoing

questions related

to patient’s health

or care plan

Liaison continues

care support as

needed, informs

navigator if there

are health-related

concerns

Liaison recruits

volunteers to

provide inpatient

and post-

discharge support

Liaison visits

patient to assess

need for

volunteer

services and

social support

• Relationship between MCHI, the health system, and each

congregation is grounded in a signed MOU

• All parties required to sign document before official

admittance into network



CASEEXAMPLE

Maryland Faith Health Network at LifeBridge Health

Three hospitals in Maryland’s LifeBridge Health system (Sinai

Hospital of Baltimore, Northwest Hospital and Carroll Hospital) that

operate in urban, suburban and rural settings joined 68 faith-based

congregations under the leadership of Maryland Citizens’ Health

Initiative Fund to form the Maryland Faith Health Network

► Hospital navigators initiate community post-discharge

support upon patient admission and offer health education

to faith-based liaisons; liaisons identify potential program

participants and provide them with spiritual and social

support post-discharge

► Network requires formal entry into the network by signing a

memorandum of understanding among MCHI, the

hospitals, and each congregation, outlining specific

responsibilities

► To date, 121 liaisons serve more than 1,600 community

members

Source: Population Health Advisor interviews

and analysis.



45

Non-clinical

intervention

Strength of

evidence

Reduces

cost

Right-sizes

utilization

Improves

quality

Improves

access

Improves

satisfaction1

Food

security services

Supportive

housing services

Transportation

services

Employment/

income support

Health

literacy support

Language-

concordant care

Social cohesion

interventions

Demonstrate the value of investments to leadership

Source: Population Health Advisor, “Care Delivery Innovation Reference Guide,” Advisory Board Research; Population Health Advisor interviews and analysis.

Documented impact of implementing non-clinical interventions

1) Includes staff and patient satisfaction.

Low

High

Medium

Low

Medium

Medium

Low



46

A few lessons from experienced peers

Source: Health Care Advisory Board interviews and analysis.

Three key principles to maximize impact and avoid missteps

Drive

community

development

through your

business

Commit to

long-term

involvement in

the community

Sporadic and short-

term efforts are

unlikely to produce

meaningful results

and could do more

harm than good

Maximize your

impact by hiring and

sourcing within the

local community

when possible

Work with members of the

community to ensure that efforts

address issues most important to

them and are embraced rather

than viewed as patronizing

Use a grassroots to

grass tips approach

Not all investments in social determinants are created equal



47

Missed our last webconference?

Surface disparities in outcomes and care delivery


Review

Health Equity 101

Review the webconference recording here.

Learn best practices to design a data-driven

framework to identify and prioritize equity

efforts across the system and incorporate them

into patient care.




49

Appendix



50

Sources cited, page 10


Housing

“Health Care and Homelessness,” National Coalition for the Homeless, http://www.nationalhomeless.org/factsheets/health.html;

Feigal L, et al., “Homelessness and Discharge Delays from an Urban Safety Net Hospital,” Public Health, 128, no. 11 (2014):

1033-1035, https://www.sciencedirect.com/science/article/pii/S0033350614001292.

Food

“What are the Connections Between Food Insecurity and Health?,” Hunger + Health,

https://hungerandhealth.feedingamerica.org/understand-food-insecurity/hunger-health-101/; Estimating the Health-Related

Costs of Food Insecurity and Hunger,” Bread for the World,

https://www.bread.org/sites/default/files/downloads/cost_of_hunger_study.pdf.

Economics

Robert Wood Johnson Foundation, “How Does Employment—or Unemployment— Affect Health?” Health Policy Snapshot

Issue Brief, 2013, http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf403360; “Social Risk Factors and

Performance Under Medicare’s Value-Based Purchasing Programs,” United States Department of Health and Human Services,

2016, https://aspe.hhs.gov/system/files/pdf/253971/ASPESESRTCfull.pdf.

Interpersonal

“Threat to Health,” Campaign to End Loneliness, https://www.campaigntoendloneliness.org/threat-to-health/; Njeru J, et al.,

“Inpatient Health Care Utilization Among Patients Who Require Interpreter Services,” BioMed Central, 15, no. 214 (2015),

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4448538/.

Education

“Population Health: Behavioral and Social Science Insights,” Agency for Healthcare Research and Quality,

https://www.ahrq.gov/professionals/education/curriculum-tools/population-health/zimmerman.html; Haun J, “Association

Between Health Literacy and Medical Care Costs in an Integrated Healthcare System: A Regional Population Based Study,”

BMC Health Services Research, 15, no. 249 (2015), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4482196/.


http://www.nationalhomeless.org/factsheets/health.html

https://www.sciencedirect.com/science/article/pii/S0033350614001292

https://hungerandhealth.feedingamerica.org/understand-food-insecurity/hunger-health-101/

https://www.bread.org/sites/default/files/downloads/cost_of_hunger_study.pdf

http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf403360

https://aspe.hhs.gov/system/files/pdf/253971/ASPESESRTCfull.pdf

https://www.campaigntoendloneliness.org/threat-to-health/


https://www.ahrq.gov/professionals/education/curriculum-tools/population-health/zimmerman.html



51

Sources cited, page 18


Lack of housing

“Health Problems of Homeless People,” NCBI, (1988), https://www.ncbi.nlm.nih.gov/books/NBK218236/; “Health Care and

Homelessness,” National Coalition for the Homeless, http://www.nationalhomeless.org/factsheets/health.html; “The Cost of

Homelessness Facts,” Green Doors, http://www.greendoors.org/facts/cost.php.

Food insecurity

Aungst, “Food Insecurity and Health Impacts,” Michigan State University Extension,

http://msue.anr.msu.edu/news/food_insecurity_and_health_impacts; “What are the Connections Between Food Insecurity and

Health?,” Hunger + Health, https://hungerandhealth.feedingamerica.org/understand-food-insecurity/hunger-health-101/; Cook,

J et al., “Estimating the Health-Related Costs of Food Insecurity and Hunger,” Bread for the World Institute,

http://www.childrenshealthwatch.org/wp-content/uploads/JohnCook_cost_of_hunger_study.pdf.

Economic insecurity

Robert Wood Johnson Foundation, “How Does Employment—or Unemployment— Affect Health?” Health Policy Snapshot

Issue Brief, 2013, http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf403360; “Social Risk Factors and

Performance Under Medicare’s Value-Based Purchasing Programs,” United States Department of Health and Human Services,

2016, https://aspe.hhs.gov/system/files/pdf/253971/ASPESESRTCfull.pdf.

Social isolation

Seegert, “Social Isolation, Loneliness Negatively Affect Health for Seniors,” Association of Health Care Journalists,

https://healthjournalism.org/blog/2017/03/social-isolation-loneliness-negatively-affect-health-for-seniors/; “Threat to Health,”

Campaign to End Loneliness, https://www.campaigntoendloneliness.org/threat-to-health/; Gerst-Emerson, “Loneliness as a

Public Health Issue: The Impact of Loneliness on Health Care Utilization Among Older Adults,” American Journal of Public

Health, 105, no. 5 (2015): 1012-1019, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4386514/.


https://www.ncbi.nlm.nih.gov/books/NBK218236/

http://www.nationalhomeless.org/factsheets/health.html

http://www.greendoors.org/facts/cost.php

http://msue.anr.msu.edu/news/food_insecurity_and_health_impacts

https://hungerandhealth.feedingamerica.org/understand-food-insecurity/hunger-health-101/

http://www.childrenshealthwatch.org/wp-content/uploads/JohnCook_cost_of_hunger_study.pdf

http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf403360

https://aspe.hhs.gov/system/files/pdf/253971/ASPESESRTCfull.pdf

https://healthjournalism.org/blog/2017/03/social-isolation-loneliness-negatively-affect-health-for-seniors/

https://www.campaigntoendloneliness.org/threat-to-health/


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