Melinda Henderson, MD, CMD, FAAHPM

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What do 79-year-old Carl who has diabetes and dementia, 83-year-old Lucille who is wheelchair bound and suffers from CHF, and 92-year-old Marisol, a non-English immigrant who is terminally ill have in common? While all three are elderly and have serious chronic health diagnoses, managing their care is made much more complicated and costly because of the impact of social determinants of health (SDoH) in their lives.

Specifically, Carl lives in a rundown trailer with his wife with no electricity, running water and lacks access to healthy food. Lucille has no access to affordable transportation to doctor appointments and social activities. Marrisol’s family does not understand what hospice does and feels like they would be abandoning her if they didn’t provide her care personally.

Their circumstances offer insights into some of the most common SDoH: lack of adequate housing, access to healthy food, and transportation, as well as healthcare illiteracy.

Health plans recognize the impact of addressing SDoH

While most healthcare executives have long recognized the impact that SDoH play in the health of members, until recently most of them didn’t fully embrace the integration of SDoH in their overall approach to member care.

A number of state Medicaid programs now include a requirement that Medicaid managed care plans address these critical needs for their members. A 

 determined that SDoH had an 80% impact on a person’s health outcome vs. only 20% for clinical care.

And, while addressing the SDoH in members’ lives can result in a significant improvement in health outcomes, it also has a dramatic impact on their cost-of-care.

What should a successful approach for a health plan managing SDoH include? The basics include tools for collecting key member information, identifying resources that would address SDoH, merging SDoH, member HRAs and clinical records, and the capability to identify the highest risk members in the plan.

4 Ways Health Plans and Communities Can Address SDOH

But most importantly, a plan should have feet on the ground to engage with the member in person. These community health workers can provide the “secret sauce” for a health plan to integrate traditional care management with contemporary approaches to addressing SDoH.

Community health workers make a difference

Community health workers are trained and certified lay staff with specialized skills who work and live in the communities where the health plan members live.

It was a community health worker who visited Carl and his wife numerous times to convince them to move to a place that could provide proper care and a healthy diet for him.

It was a community health worker who was able to help Lucille learn how to use her health plan transportation benefit, which allowed her to more easily make doctor visits and have much more freedom in her life.

And, it was a community health worker who understood the cultural concerns that Marrisol’s family had about hospice care would violate their personal involvement with her care.

For Carl, Lucille, and Marisol, their health plan’s understanding of the role that SDoH played in their care helped them more than any clinical intervention could have. As difficult as each of their circumstances were, they were all improved by the services provided by their community health worker as part of their health plan’s approach to the SDoH impacting their lives.

Melinda Henderson, MD, CMD, FAAHPM, is chief medical officer at PopHealthCare.

Articles

Tackling SDoH issues requires efforts beyond traditional healthcare roles.

Why Community Health Workers Are Vital to Addressing SDoH

Preventable hospital readmissions, an objective measure of quality, have long been a concern for health plans. Each unnecessary readmission costs on average $14,000 and there are more than 2,000,000 each year. In addition to increased costs, preventable readmissions are also associated with increased morbidity and mortality and, as an important Medicare quality measure, a reduction in STAR ratings. Beginning in 2013, the ACA included disincentives in the form of reduced Medicare reimbursement to hospitals with readmissions above specific levels for a targeted group of diagnoses. Initially, readmissions began to decline slightly but more recently they’re trending higher. What can a health plan do to respond?

The simple answer is preventable readmissions are the result of a failure in the transition of care from an inpatient facility to another setting. These readmissions are often the result of not identifying those patients who are at a high risk because of age, comorbidities, socioeconomic status, social determinants of health, social supports and a history of behavioral health diagnoses. Other contributing factors, at the point of discharge from a hospital, include a lack of out-patient work-up, incomplete test results, or a discharge summary either not readily available or lacking key components. In addition, failure to provide adequate post-discharge information to the patient and their family or the lack of follow-up can lead to avoidable readmissions.

Impacting unnecessary readmissions requires that health plans take a greater role in the oversight of the hospital discharge process, beginning as soon as a patient is admitted. This includes requiring network hospitals to focus on patient risk assessment, patient/family education about therapies, education on medications and treatment side effects, as well as a clear commitment to post-discharge services including follow-up with the patient. Employing evidence-based programs such as Eric Coleman’s Care Transition Program, the Transitional Care Model, Project RED or Project BOOST increases the opportunities for successful discharges. Finally, it is critical to use a validated readmission tool such as LACE or HOSPITAL to assess the potential for a patient’s likelihood of readmission. 

Once discharged, an effective transition of care program should assure the provision of appropriate care for at least 30 days following post-hospital discharge. This should include patient outreach and in-person follow up within 72 hours of discharge, care coordination, provision of care including closing care gaps, and support coordination with all members of the patient’s care team.  Increased direction, beyond a traditional in hospital discharge is critical to ensure common causes of readmission are avoided, including ensuring prescriptions are filled and DME is delivered. More recent research has demonstrated social supports like personal care aides and meal delivery can also reduce readmissions.   

Addressing the issue of preventable hospital readmissions requires the commitment of a health plan’s provider network and clinical teams to be involved in the oversight of a patient’s care from hospital admission through their successful transition to a home or other setting. Because of the significant investment in specialized tools and staff required for preventing unnecessary readmissions, many health plans partner with organizations who have developed this expertise to achieve greater success in this area. No matter how a health plan approaches this issue, the importance of reducing unnecessary expense and poor member outcomes cannot be overstated.

Melinda Henderson, MD, chief medical officer of PopHealthCare, is a board-certified internal medicine, geriatric and hospice & palliative medicine physician. She is experienced in Medicaid and Medicare managed care and is a fellow of the American Academy of Hospice and Palliative Medicine and a Certified Medical Director with the Society for Post-Acute and Long-Term Care Medicine. PopHealthCare provides physician led teams to support individuals with complex conditions with in-home care, including post-acute care

Preventable hospital readmissions, an objective measure of quality, have long been a concern for health plans. Here’s a care plan that could be the solution.

Author | Melinda Henderson, MD, CMD, FAAHPM

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Why Community Health Workers Are Vital to Addressing SDoH

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