Social Determinants of Health

Addressing Social Determinants of Health

February 23, 2018 9:34 am

Payers may eventually require providers in value-based contracts to screen for and address hunger and other social challenges, says ProMedica’s Lee Hammerling, MD.

ProMedica, a 13-hospital system serving northwest Ohio and southern Michigan, thinks about the social determinants of health—hunger, housing instability, and financial worries—the same way it thinks about an uncontrolled chronic condition: Without proper diagnosis and treatment, the condition gets worse and more expensive.

“If you have poorly controlled or undiagnosed hypertension, it will lead to health complications and emergency department visits that may result in admission,” says Lee Hammerling, MD, chief physician executive and chief medical officer for the Toledo-based system.

ProMedica started addressing food insecurity among its patients in 2009, and it has found the same logic applies. When patients with diabetes, for example, suffer from food insecurity, they are likely to end up in the hospital, with poor outcomes and high costs.

“We are addressing the social determinants like a true health issue because that is where our research is starting to take us,” he says.

It is a daunting task for a health system to tackle huge social problems like hunger and homelessness that government agencies and social service providers struggle to solve. But as health systems begin to accept responsibility for population health, they are seeing an opportunity to make a difference in their patients’ lives.

Sidebar: Learn how ProMedica screens 1 million patients every year for social determinants of health

“Healthcare is in a really unique spot because we are often the trusted providers,” Hammerling says. “Sometimes our patients who might not be comfortable reaching out for services or might not know where to turn have a relationship with their doctor that can become an entry point to services and programs in the community.”

That is why ProMedica plans to invest at least $50 million over the next decade to implement a three-pronged strategy—community outreach, clinical integration, and research—to address social determinants across its 27-county service area.

“Our thinking—and our strategies—have evolved to address the social determinants through interventions,” says Kate Sommerfeld, president of social determinants of health at ProMedica.

Getting to Here

ProMedica began its social determinants of health journey in 2009 when it established its Hunger is a Health Issue initiative and established an advocacy fund to support community agencies that provide food, clothing, and shelter. Since then, the health system has become ever more “hands on” in its approach to understanding and addressing social determinants of health.

Its initiatives include the following activities:

  • Opening a healthy-foods grocery store in a “food desert”
  • Collaborating with a casino and other food sites to collect prepared-but-unserved food, repackage it, and deliver it to soup kitchens and other food-service programs
  • Creating a “food clinic” that offers primary care patients food for their entire household that will last two to three days, along with nutrition services and referrals to community resources
  • Opening a Financial Opportunity Center to help community members improve their financial situation as well as receive job training and life skills training

Meanwhile, the health system has taken a lead on the national scene by participating in these activities:

  • Partnering with the Alliance to End Hunger and the U.S. Department of Agriculture to host multistakeholder conferences called “hunger summits” around the country
  • Collaborating with the AARP Foundation to create the Root Cause Coalition, a national not-for-profit organization focusing on policy initiatives and best practices to address hunger and other social determinants of health

The health system began screening patients for food insecurity in 2015 and more recently expanded the screening to include 10 social determinants of health. Most recently, ProMedica announced a $50 million initiative—$28.5 million from a private donor; $11.5 million from the health system; and a commitment to raise $10 million—to push more aggressively into social determinants of health.

The Ebeid Promise Initiative, named after the late philanthropist Russell J. Ebeid, will initially focus on a single high-poverty neighborhood—called UpTown—in Toledo, where ProMedica began working on social determinants of health in 2014. Doubling down on its previous efforts, the health system will expand the Financial Opportunity Center; hire more financial coaches; recruit and train healthcare workers, particularly certified nursing assistants and other hard-to-fill positions; and ensure children have access to high-quality preschool education.

Thinking About ROI

The big picture is this: More than 25 percent of the adults living in UpTown did not graduate from high school, and more than half make less than $20,000 a year. Research shows that strong early childhood education programs can break the chain of poverty, and poverty is strongly associated with poor health status and high health costs.

ProMedica has already proven to itself the benefit of addressing patients’ poverty-related issues. When its patient food insecurity screening reveals a need, it refers patients to its own food clinic and connects them to community resources.

A preliminary analysis of 4,000 Medicaid patients who were screened for food insecurity found that the initiative delivered the following results:

  • 3 percent reduction in emergency department usage
  • 53 percent reduction in hospital readmission rate
  • 4 percent increase in primary care visit rate

Moreover, ProMedica and its integrated insurance company, Paramount, found a 32 percent reduction in per member per month medical costs for Medicare patients who participated in the ProMedica Food Clinic program.

Hammerling believes the connection between social determinants of health and healthcare utilization is so strong that payers will eventually require providers in value-based contracts to screen for and address hunger and other social challenges.

“Because there are some very clear linkages between health outcomes and the cost of care and the social determinants, I would not be a bit surprised to see those built into value-based systems,” he says. “Just like we screen for heart failure or hemoglobin A1C or cholesterol, we will all be screening for food insecurity, financial insecurity, transportation issues, social isolation, and these other things as well.”

Making Long-Term Commitments

In addition to its intervention strategies, ProMedica wants to understand more clearly how social determinants of health affect individuals’ health and the communities in which they live. It plans to create a social determinants of health research center in cooperation with The University of Toledo College of Medicine and Life Sciences.

ProMedica physicians will work with faculty members to aggregate and analyze ProMedica’s clinical data along with community data to study how social determinants of health interventions affect health outcomes and healthcare costs.

The center’s scientific advisory board has identified more than 30 studies it intends to launch in the next few years, Hammerling says. The research center’s goal is to identify and disseminate best practices that can be used to improve quality of care and inform medical education and healthcare payment reform.

For example, when ProMedica finds shelter for a patient who screened positive for homelessness, the information is entered into the patient’s electronic health record. “Over time, we’ll be able to say, ‘What was the impact of homelessness on the patient’s outcomes and cost of care?’” Sommerfield says.

Interviewed for this article:

Lee Hammerling, MD, is chief physician executive and chief medical officer, ProMedica, Toledo.

Kate Sommerfeld is president of social determinants of health, ProMedica, Toledo.


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