Caring for the Vulnerable

Confronting Social Determinants of Health Improves Outcomes

Health systems—large, small and in between—across the country are proactively addressing societal issues that affect the health of their communities and patient populations. Access to housing, healthy food and mental healthcare are increasingly seen as crucial to improving health. And, as healthcare shifts to a value-based model, these initiatives, which top leadership drives, have the added benefit of potentially improving the organizations’ bottom lines.

The following are five examples of hospitals and health systems who have invested in community health and are making a measurable impact on the wellness and stability of their patients.

Kaiser Permanente
“The interesting part of focusing on housing and homelessness is that there is no silver bullet,” says John Vu, vice president of strategy for Kaiser Permanente, Oakland, Calif. The largest managed care organization in the United States, Kaiser Permanente sees the challenges and disruptions of those issues from the front lines, in particular with the housing crisis in the Bay Area. Kaiser has launched several initiatives, across the country and at home, to address the needs of the homeless and lack of housing.

In partnership with Enterprise Community Partners, Columbia, Md., a nonprofit organization that works with partners nationwide to finance, build and advocate for affordable housing for low- and moderate-income families, Kaiser has established two major funds. 

RxHome is a national low-interest loan fund available within Kaiser’s markets to developers of affordable housing. Housing for Health Funds matches investments from other healthcare systems, nonprofits and organizations committed to affordable housing. 

RxHome’s focus in the Bay Area is on preserving existing affordable housing by protecting housing units and buildings in neighborhoods on the verge of gentrification. “Could we work with affordable housing developers to acquire those buildings and protect them and maintain the affordability for generations to come?” asks Vu. The effort to do so is certainly under way.

Currently, there are up to six deals across the Bay Area to purchase and preserve housing. Those include an 85-unit building, senior housing and a long-term goal to build 2,000 units over the next few years. Other industries headquartered in areas facing severe housing issues, including Microsoft in Seattle, have taken notice of RxHome’s initiative. “We are seeing some momentum building as others are jumping into this in big ways,” says Vu.

Northwell Health
Northwell Health is New York State’s largest healthcare provider and 
routinely calculates a clinical risk score for patients. Those with chest pain, for example, are categorized as being at higher risk for a heart attack if they also have high blood pressure, and measures are taken to address those factors. “Now,” says Ram Raju, MD, FACHE, senior vice president and community health officer for Northwell, “we are creating risk scores based on social determinants of health because we know that outcomes are determined approximately 20% by clinical care and 80% by nonclinical factors, such as socioeconomic and environmental issues.”

"The interesting part of focusing on housing and homelessness is that there is no silver bullet."

- John Vu, Kaiser Permanente

Patients are asked 15 questions, and the answers are processed through an algorithm that creates a social vulnerability index, which indicates social risks that may be relevant to them. That information is then processed through NowPow, a platform that connects patients to social service or community-based organizations addressing their particular social issues, such as transportation, food, public safety, mental health, based on patients’ ZIP codes.

Food insecurity is an issue in many of the communities that Northwell serves, and a pilot program has begun in which patients are given a food prescription—in addition to their medication—that corresponds with their condition. Patients stop at Northwell’s Food Farmacy in the lobby of the hospital, and their food prescription is filled with free, fresh food. They also receive nutritional counseling. Patients unable to carry the food home themselves receive their filled food prescription through a community-based organization, Long Island Cares, which delivers the food to their homes.

Northwell’s efforts around food extend to inpatients and employees, as well. A Michelin Star chef was engaged to revamp the hospital’s food. Healthy food is now attractive and tasty food, too, and the same menu is used in the hospitals’ cafeterias. “That was a big hit,” says Raju. “And our patient satisfaction scores went up, too.”

AMITA Health
AMITA Health, Lisle, Ill., is part of the Chicago HEAL (Hospital Engagement, Action and Leadership) Initiative, a consortium of almost 30 hospitals and public health departments throughout the Chicagoland area.

The collaboration has enabled organizations to specialize in various areas, and AMITA, as the largest behavioral health provider in Illinois and among the top 10 nationwide, was well poised to address that issue innovatively, and effectively.

“We recognized that a lot of folks in our communities didn’t have a full understanding of what behavioral health conditions look like, how they manifest and how to help a person experiencing a behavioral health crisis,” says Will Snyder, senior vice president and chief advocacy officer for AMITA, and an ACHE Member. AMITA adopted an eight-hour certificate training program called Mental Help First Aid, which offers training on identifying and understanding different mental health conditions, how to identify and engage sufferers and connect them with appropriate resources. “There’s a big difference between somebody who is depressed and somebody who suffered from schizophrenia,” says Snyder. “Knowing the difference in how those symptoms present is really important.”

AMITA recognized that as many community partners as possible needed to be engaged, and it created partnerships with the Chicago public library system, the YMCA and others. To-date, more than 2,000 people have received the training.

Referring those with less obvious, though equally debilitating issues, such as depression, to available and nearby resources, is also a crucial component of effectively caring for behavioral health patients. “I think that in the past health systems have not made it clear how you access behavioral health services,” says Snyder. “Over the last three or four years we have really seen that change, and I think the solution, and potential, in a community-based setting is that people don’t have to leave their neighborhoods. They can go to a library, a church or a community center to get the resources and services they need.”

"We are creating risk scores based on social determinants of health . . . because we know that outcomes are determined approximately 20% clinical care and 80% by nonclinical factors, such as socioeconomic and environmental issues."

- Ram Raju, MD, FACHE, Northwell Health

Now, numerous hospital systems in the HEAL Initiative have implemented Mental Help First Aid or are investigating it as a curriculum to offer themselves.

University of Illinois Hospital & Health Sciences System
In 2015 the University of Illinois Hospital & Health Sciences System, which is also part of the Chicago HEAL Initiative, launched its Better Health Through Housing program, which identifies the ED and behavioral health patients who are chronically homeless and helps them find supportive housing. The program uses the Housing First model, which places no preconditions, such as being on medication or in treatment, on potential participants.

“The magic of the whole thing is that once you put somebody into housing, they stabilize and get to a place where they can manage their own lives,” says Stephen Brown, director of preventative emergency medicine. And retention rates prove his point. Under previous guidelines retention was around 20 percent, but now it has flipped and is steady at 80 percent.

Another factor in the program’s success is that patients are offered a choice in where they live. In partnership with the Center for Housing in Help and the AIDS Foundation of Chicago, patients are directed to approximately 4,000 units scattered throughout Chicago. 

The University of Illinois Hospital & Health Sciences System experienced an almost 60 percent drop in IP utilization, and an almost 70 percent drop in ED utilization, and those rates have remained consistent. 

“We acknowledged our health equity mission here as one of two public hospitals in the city of Chicago,” says Brown. “Our CEO (Michael B. Zenn, an ACHE Member) said, ‘This is the right thing to do.’ This initiative has given us an opportunity to examine a very vulnerable population, patients who are most at risk for early death, bad outcomes and who suffer as the result of chronic homelessness and associated illnesses.”

Arnot Health
Smaller health systems have launched ambitious initiatives, too. Arnot Health, Elmira, N.Y., a three-hospital system, participates in a New York State initiative for Medicaid patients that identifies “high-utilizers,” patients with four or more inpatient visits within a 12-month period. Its IT department developed an automated alert that uses data analytics to identify these patients and intervene when they visited the ED or are admitted to one of the hospitals.

“We identified that when patients are discharged, they’re often on their own to figure out how to get thier meds, how to get transportation to their primary care provider and set up appointments,” says Pallavi Kamjula, MD, medical director of care coordination. “We felt that if we identified these patients in the hospital and helped keep them in their homes before we connected them to a primary care physician, you might make an impact.”

Rose Barnes, RN, visits with patients in their homes to assess the environment as part of Arnot’s Transition to Home program. Along with a hospital resident, “We go over their discharge medications to make sure that they match with what they have in their home,” she says. “We also educate them on appropriate food choices if they are diabetic, for instance, and also, for patients with chronic obstructive pulmonary disease, that they know how to use their inhalers, including which ones are for immediate needs and which ones are for daily use.”

Arnot has impacted the community on a micro level, as well. Another team member, Sue McCabe, RN, is a congestive heart failure educator. She visited local grocery stores to shop for low-salt foods and found that they were unmarked, inaccessible and seldom at eye level. She contacted nearly every grocery store manager in the area and received a reply from only one. She met with the manager, and now that grocery store is in the process of rearranging its aisles, 
with one dedicated to low-sodium food items.

The Future of Social Programming on Population Health
Increasingly, hospitals, health systems and other major healthcare organizations are realizing the impact of social and societal factors on overall population health, and are taking action to address and mitigate these ill effects. This key shift comes as the result of extensive population health research, as well as a corporate demand for more efficient and cost-effective initiatives to address the growing need for preventive health offerings. 

Investment in community health, even on a smaller, ad hoc level, can have a measurable impact on the wellness and stability of the patients it serves. Education, opportunity and accessibility are hugely important factors in the overall health of local communities, and as these programs work to address the unfilled needs of their populations, their success could help encourage the development of similar initiatives, and therefore improved population health, in additional communities across the country. 

Brian Justice is a freelance writer based in Chicago.