The growing movement to include the patient voice in medicine through
Motivational Interviewing, patient-reported outcomes, social determinants of health
and shared decision-making
One day in 2011, as a part of my research on ways to improve patient-provider communication about health behaviors, I was shadowing Dr. G., a talented young internist with a cheerleader demeanor. He marched through 12 afternoon patient appointments with confidence and purpose. But when he saw the name of the last patient on his schedule, he turned pale, faced me and said, “I apologize for what you are about to see.”
I must have looked confused. He repeated, “I
apologize for what you are about to see.”
We walked into the exam room. I’m not sure either
one of us knew what to expect. The patient, a white, obese man, was seated,
doubled over. He had a wad of paper towels jammed in his mouth. He threatened
to pull out his own, presumably abscessed, tooth. He refused to see a dentist
because he had no dental coverage, no money and no one to borrow money from. He
said he would use pliers to pull his tooth, but stayed put, rocking in his
seat. At the computer, the young doctor’s white-knuckled hand gripped his
mouse. Click. Click. Click. He searched the patient’s chart aimlessly for help.
Alerts kept popping up about the patient’s missing A1C results. It took two
minutes, but it felt like 20.
Dr. G. left the room and came back a few minutes
later. He gave the patient the name of a dentist who would see him at no cost.
I suspected Dr. G. had called the dentist and said he would pay for the
appointment out of his own pocket. The patient hugged Dr. G. He only wanted
help, and Dr. G. wanted to help. The tension was resolved for the moment.
Health disparities domestically and globally can often be attributed to social determinants of health (SDoH). According to Healthy People 2020, SDoH are conditions and resources in the environments in which “people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” Examples of these include: resources to meet daily needs (e.g. access to and quality of housing and food markets), educational opportunities, employment opportunities, and transportation. Despite well-established literature on the importance of SDoH, these factors are often overlooked and excluded in health care frameworks.
Concurrently, health services provided in
traditional settings such as hospitals and clinics can be expensive and
inaccessible. There are a large number of communities, from rural areas to
major cities, that are in need of high-quality care. Innovative technologies
can mitigate these challenges. Home and community-based care models coupled
with digital tools provide the opportunity to serve patients where they feel
most comfortable in a cost-effective manner.
For the SDoH Challenge, innovators were asked to
develop novel digital solutions that can help providers and/or patients connect
to health services related to SDoH. Over 110 applications were submitted to the
SDoH Challenge. For the Home and Community Based Care Challenge, applicants
were asked to create technologies that support the advancement of at-home or
community-based health care. Nearly 100 applications for Home and Community
Based Care Challenge were received.
Slide into Health in 2 Point 00 (or rather, Health 2.0 HIMSS Europe) with Jess and I today! On Episode 84, Jess asks me about the big news that CVS has now made it possible for employees to get reimbursed for Big Health’s Sleepio, an insomnia digital therapeutic, and about Atrium Health’s $10 million investment in an affordable housing plan, addressing the social determinants of health. Hear some of my key takeaways from the conference so far, too. –Matthew Holt
Nearly a decade has passed since Healthy People 2020positioned social determinants of health (SDoH) at the forefront of healthcare reform. As defined by the report, SDoH are the “conditions in the environment in which people are born, live, learn, work, play, worship, and age, that affect a wide range of health, functioning, and quality of life outcomes.” Examples of social determinants include:
Resources to meet daily needs (e.g., safe housing and local food markets)
Educational, economic, and job opportunities
Community-based resources in support of community living and opportunities for recreational and leisure-time activities
The ability to influence
social determinants largely falls outside of the health care system’s reach.
Therefore, a key to address opportunities for health involves collaboration between
health care and different industries such as education, housing, and
transportation. Both the public and private sectors have made significant
efforts to bridge the gap between physical, mental, and social care by
experimenting with non-traditional partnerships.
The Center for Disease Control and Prevention (CDC) has spearheaded multiple programs with government agencies and community partners to achieve the goals outlined in Healthy People 2020. One of the most notable successes is the Childhood Lead Poisoning Prevention Program, an initiative by the CDC with the Department of Housing & Urban Development and the U.S. Environmental Protection Agency. Through housing rehabilitation, enforcement of housing and health codes, and partnerships with healthcare experts, the program helped Healthy People 2020 exceed their target of reducing blood lead level in children.
Other programs such as the “National Program to Eliminate Diabetes Related Disparities in Vulnerable Populations,” leveraged community partners and resources to increase food security, health literacy, and physical spaces for active living. In one of their projects, the program partnered with community health workers (promotoras) who spoke Spanish to engage with Hispanic/Latino communities where participation to Diabetes Self-Management Education (DSME) was low. The community health workers provided linguistically and culturally-sensitive materials that effectively increased participation in DSME among the targeted population. The outcomes from such initiatives have inspired more health and community organizations to work together to reduce health disparities.
Today on Health in 2 Point 00, Jess is in Italy…and has me up far too early in the morning for this episode. On Episode 79, Jess asks me for an update on uBiome after their raid by the FBI. We also talk about nutrition startup Noom’s $58 million raise and clinician house-call platform DispatchHealth’s $33 million raise. In other news, Kaiser Permanente is launching a network to integrate the social determinants of health with their EHR. –Matthew Holt
By SAMYUKTA MULLANGI MD, MBA, DANIEL W. BERLAND MD, and SUSAN DORR GOOLD MD, MHSA, MA
Jenny, a woman in her twenties with morbid obesity (not her real name), had already been through multiple visits with specialists, primary care physicians (PCPs), and the emergency department (ED) for unexplained abdominal pain. A plethora of tests could not explain her suffering. Monthly visits with a consistent primary care physician also had little impact on her ED visits or her pain. Some clinicians had broached the diagnosis of functional abdominal pain related to her central adiposity, and recommended weight loss. This suggestion inevitably led her to become defensive and angry.
our standard screen for safety at home had been completed long ago, I wanted to
probe further, knowing that many patients with obesity, chronic pain and other
chronic conditions have suffered an adverse childhood – or adulthood –
experience (ACE). Yet, I hesitated. Would a busy primary care setting offer enough
latitude for me to ask about a history of trauma when it can occur in so many
forms, in so many ways and at different times of life? Furthermore, suppose she
did report a history of trauma or adverse experience. What then? Would I be
able to help her?
I began: “Jenny, many patients with symptoms like yours have been abused,
either emotionally, physically, or sexually, or neglected in their past.
Sometimes they have suffered loss of a loved one, or experienced or witnessed
violence. Has anything like this ever happened to you?”
yielded our first breakthrough. Yes, she had experienced neglect, with parents
who were separated for much of her childhood, and then later divorced. She had
seen her father physically abuse her mother. With little parental oversight,
she had engaged in drug and alcohol use throughout her teenage years. But, she
wanted to be sure we understood that this was all behind her. She had gotten an
education, was in a committed relationship, and had a stable job as a teacher.
That part of her life was thankfully now closed.
The Robert Wood Johnson Foundation (RWJF) has partnered with Catalyst @ Health 2.0 to launch two innovation challenges on Social Determinants of Health (SDoH) and Home & Community Based Care. As a national leader in building a culture of health, RWJF is inspiring and identifying novel digital solutions to tackle health through an unconventional lens.
Health starts with where we live. As noted in Healthy People 2020 social determinants
of health are, “conditions in the environments in which people are born, live,
learn, work, play, worship, and age… [that] affect a wide range of health
functioning, and quality-of-life outcomes and risks.” For example, children who
live in an unsafe area cannot play outside making it more difficult for them to
have adequate exercise. Differences in SDoH heavily influences communities’
well-being and results in very different opportunities for people to be
Despite our knowledge on SDoH, the current healthcare system utilizes care models that often fail to take into account the social and economic landscape of communities– neglecting factors such as housing, education, food security, income, community resources, transportation and discrimination. Little progress has been made on incorporating SDoH into established health care frameworks. Healthcare providers and patients alike either have limited understanding of SDoH or have limited opportunities to utilize SDoH knowledge. RWJF established the “Social Determinants of Health Innovation Challenge” to find novel digital solutions that can help providers and/or patients connect to health services related to SDoH.
Home and community-based care is also important to enable Americans to live the healthiest lives possible. In-patient and long-term institutional care can be uncomfortable, costly, and inefficient. Digital health solutions in the home and community offer opportunities for care that better suit the patient and their loved ones. For example, innovations such as remote patient monitoring (RPM) have created new care models that allow the providers, caregivers, and patients to manage care where a person is most comfortable. RPM serves as a reminder that technologies in the home and community offer alternatives methods to engage the patient, increase access to care, and receive ongoing care. Therefore, RWJF is launching the “Home & Community-Based Care Challenge,” to encourage developers to create solutions that support the advancement of at-home or community-based health care.
As U.S. providers continue their slow but steady march away from fee-for-service reimbursement and toward value-based payments, they’re increasingly seeking means of addressing patients’ health-related social needs. That’s because social determinants of health—life circumstances including socioeconomic status, housing, education, and employment—are estimated to have at least twice the impact on risk of premature death than health care. So addressing them is an important part of value-based strategies aiming to improve health while reducing health care costs.
Hennepin Health, a safety-net Accountable Care Organization (ACO) serving Medicaid patients in Minneapolis, Minnesota, is an encouraging example of the trend. Hennepin Health’s ACO is a partnership between the county’s local Human Services and Public Health Department, a local teaching hospital, a Medicaid managed care health plan, and a Federally Qualified Health Center. Its innovative care model is designed to meet the unique needs of the partners’ shared, “high-risk” members, whose complex combination of issues—such as mental illness, addiction, homelessness and/or other hallmarks of social deprivation—often prevent them from accessing or receiving appropriate care through the traditional health system.
The ACO is staffed by an integrated care team comprised of
physicians, nurses, pharmacists, social workers and community health workers.
Unlike traditional care processes, which often only involve medical assessment,
Hennepin Health’s begins with an assessment of members’ social needs, like
housing and food insecurity, or lack of transportation and unemployment, so
that its care team can tackle those barriers to health in conjunction with
members’ medical problems. And throughout members’ care, the team strives to
develop and maintain a trusting relationship with members, many of whom have
been let down by traditional health care, so that they can continue to identify
and assist with more health and social needs over time.
Results thus far has been impressive—according to a Commonwealth Fund case study, the ACO’s medical costs fell an average of 11% per year between 2012 and 2016. And, between 2012 and 2013, its members’ emergency room visits decreased by approximately 9%, with hospital admissions remaining flat and outpatient visits increased by 3.3%. Assuming its results have continued on the same trajectory (we could not find more recent figures), Hennepin Health’s innovative care model shows significant promise.
But does it have the potential to disrupt America’s traditional, episodic, acute care delivery model? We put it to the test with six questions for identifying a Disruptive Innovation.
How can understanding the underlying social risks impacting patient populations improve health outcomes AND save health plans some serious per-member-per-month costs? You’re probably familiar with the concept of ‘Social Determinants of Health’ (SDOH) but Dr. Trenor Williams and his team at health startup Socially Determined are building a business around it.
By looking at data around what Trenor calls ‘the Significant 7’ social determinants (social isolation, food insecurity, housing, transportation, health literacy, and crime & violence) he and his team are working to help health plans intervene with their most vulnerable populations and bring down costs.
What kind of data is Socially Determined looking at? Everything from publicly available data on housing prices and air quality, to commercial datasets on buying preferences and more. Plus, with help from their health plan partners, they’re using clinical and claims data to create a complete picture of health care spend, utilization, and outcomes.
Trenor walks through some very specific examples in this interview to help illustrate his point. In one, Socially Determined was able to identify how Medicaid could better help asthmatics manage their asthma AND save a thousand dollars per affected member each month. Another project in Ohio identified that a mother with a history of housing eviction was 40% more likely to give birth to a baby requiring NICU care – opening up myriad opportunities for early intervention and the potential to positively impact the lifetime health of both mother and child.
As healthcare continues to realize its ‘data play’ – and look beyond the typical data sets available to healthcare companies – the opportunities for real and meaningful impact are tremendous. Listen in to hear more about what Trenor sees as the new opportunity for Social Determinants of Health.
Filmed at AHIP’s Consumer Experience & Digital Health Forum in December 2018.
Get a glimpse of the future of healthcare by meeting the people who are going to change it. Find more WTF Health interviews here or check out www.wtf.health.
Historically, the Centers for Medicare & Medicaid Services’ (CMS) stance on the influence that social determinants of health (SDOH) have on health outcomes has been equal parts signal and noise. In April 2016, the agency announced it would begin adjusting the Medicare Advantage star ratings for dual-eligibility and other social factors. This was amid calls for increased equity in the performance determinations from the managed care industry. At the same time, CMS continued to refuse risk-adjustment for SDOH in the Hospital Readmissions Reduction Program (HRRP) despite the research supporting the influence of these factors on the HRRP.
It wasn’t until Congress interceded with the 21st Century Cures Act that CMS conceded to adjusting for dual-eligibility under the new stratified approach to determining HRRP penalties beginning in fiscal year 2019. The new methodology compares hospital readmission performance to peers within the same quintile of dual-eligible payer mix. The debate surrounding the adjustment of incentive-based performance metrics for SDOH likely is to continue, as many feel stratification is a step in the right direction, albeit a small one. And importantly, the Cures Act includes the option of direct risk-adjustment for SDOH, as deemed necessary by the Secretary of Health and Humans Services.
SDOH are defined as “the conditions in which people are born, grow, live, work and age.” The multidimensional nature of SDOH reach far beyond poverty, requiring a systemic approach to effectively moderate their effects on health outcomes. The criteria used to identify SDOH include factors that have a defined association with health, exist before the delivery of care, are not determined by the quality of care received and are not readily modifiable by health care providers.
The question of modifiability is central to the debate. In the absence of reimbursement for treating SDOH, providers lack the resources to modify health outcomes attributable to social complexities. Therefore, statistical adjustments are needed to account for differences in these complexities to ensure risk-adjusted performance comparisons of hospitals are accurate.