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Extending Health Care Beyond the Medical Campus: Addressing Social Determinants of Health

Editor’s Note: Christina Bucciere, Sg2 Implementation Analyst, and Lauren Seno, Sg2 alumna, contributed to this post. 

It’s a well-documented connection: the more money spent on social services, the better the health outcomes. People who feel unsafe in their communities, lack adequate housing or food, need access to legal aid, or are without other basic human necessities will more likely suffer from poor health outcomes. How can someone with diabetes be expected to keep her blood pressure under control if she doesn’t have a safe place to live? Immediate needs take priority over a distant and intangible health threat, often compounding the health issue and resulting in a more acute or otherwise preventable condition.

So, what role should health care providers play in addressing these immediate needs? Especially considering they may already be stretched thin to manage margins in a quickly changing health care environment? Does the shift to value-based care affect this equation? What’s the ROI on investing in social service support, and more importantly, how can it be operationalized?

Read on to learn from 2 Sg2 members who serve as safety net providers. Not only is ensuring access to social services a key part of their mission, it’s also foundational to the health of their populations.

AHS Health Advocates Meet Community’s Social Needs, Free Clinicians to Focus on Clinical Care

AHS is a 3-hospital health system dedicated to serving the region’s most vulnerable population. Highland Hospital, a safety net provider within AHS and Alameda County, has championed innovative social programming for years. And while providers recognized patients’ many social needs, they lacked resources to address them, resulting in poor health outcomes. In 2012, based on the Health Leads model discussed in a previous post, Health Advocates was born.

Health Advocates uses volunteers to connect patients to social services, including housing, legal aid, healthy foods and more. The underlying premise is simple: minimize barriers to a healthy, high-quality life by creating a single gateway that connects vulnerable patients to social resources. One hundred twenty volunteers, primarily college students with aspirations to work in health care, provide referrals to community resources, help patients navigate the systems and follow up as needed. Since its inception, Health Advocates has grown to 3 sites and 3 FTEs: a social work supervisor, a program coordinator and a community health worker.

Although proving causation between social service access and health outcomes is tricky, findings from a Bright Research Group report point in the right direction. From 2016 to 2017, Health Advocates served more than 2,600 patients at any one 1 of their 3 locations. One quarter of patients’ social needs, primarily housing, were resolved. At the same time, the model helps train future health care professionals on the important link between social and health care needs.

TMC Partnered to Improve Community Health From Outside Its 4 Walls

While AHS found a way to bring social service access on-site, TMC ventured out into the community it serves but cannot always reach. Last March, TMC opened a 7,000-square-foot clinic in the Linwood neighborhood YMCA. The clinic, paid for and operated by TMC, cements the link between health care and community resources. There are 12 exam rooms, a procedure room and a consult/telemedicine room, all in the same building as the community YMCA.

The clinic provides primary care and behavioral health services staffed by 3 TMC-employed internal medicine physicians and 1 pediatric internal medicine physician. Other specialties are available through residents and rotating specialists. The relationship with the Y is mutually beneficial. Physicians refer patients to the Y’s fitness and nutrition programs, supporting chronic disease management, and the Y sends patients with clinical needs back to the clinic.

Regular Communication Is Essential for an Effective Partnership

Key to the partnership is communication, and the Truman and Y staff communicate seamlessly. They were trained together and huddle regularly to discuss issues and partnership opportunities. Y staff are even trained to screen for high blood pressure and send patients to the clinic for evaluation and primary care management.

These partnerships create an opportunity to build a community health record fed by data from Truman, the Y and a participating Federally Qualified Health Center, something the clinic’s medical director, Daphne Bascom, MD, PhD, is passionate about. This repository of data would finally establish a central hub of information about patients’ clinical and social needs.

Before the clinic opened, a community needs assessment identified leading causes of death in the Linwood neighborhood. Chronic conditions like diabetes and hypertension were the expected culprits. Much to the surprise of clinic leadership, however, colon cancer and homicide topped the list. Truman and the Y staff are exploring how to address the high incidence of colon cancer, such as a partnership with University of Kansas Medical Center, as well as making screenings more attractive to African American males who disproportionately die from the disease.

Addressing the second leading cause of death, homicide, is more difficult, but Truman and the Y have already held 2 joint meetings with community members, including police, school staff, business owners and churches, to discuss ways to curb violence.

Similar to the Health Advocates at AHS, workforce education also plays a role: engaging residents at the Y clinic expands their education beyond the exam room, better preparing them to work with underserved communities as physicians.

Take a Measured Approach to Improve Your Community’s SDH

As you consider either partnering like TMC did or building out internal resources to better serve your population’s social determinants of health, consider the lessons learned from these leaders in the field. If you are interested in partnering with community organizations to address SDH, take a measured approach that includes a needs assessment, a thoughtful launch, and an emphasis on ongoing operations and maintenance.

Sources: Bradley EH et al. Health Aff (Millwood). 2016;35:760–768; Alameda Health System. Health Advocates Program Final Evaluation Report. Bright Research Group. 2017; Sg2 Interview With Health Advocates, Alameda Health System, April and May 2018; Sg2 Interview With Truman Medical Centers. April 2018; Sg2 Analysis, 2018.

Sg2 Member Resources:

Not an Sg2 member yet? Contact us to talk about what role your organization can play in addressing social needs to better the health outcomes for your population.

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