- Asthma to Primary Care
The Sinai Urban Health Institute (SUHI), located in Chicago, started multiple SDOH programs over the years, based on where it sees community needs. That includes programs focused on diseases like diabetes, breast health, and asthma. They reduced asthma-related ED visits by 73% and hospitalizations by 75% during the program’s first year, sending community health workers into patient homes for one-on-one education and assistance.
SUHI recently did two large door-to-door surveys in different Chicago communities to pinpoint current needs and analyzed Chicago Department of Public Health data as well. As a result, the latest program is also using community health workers, often starting in the ED. SUHI trains them in core skills for motivational interviewing, home visits, and cultural competence.
“Utilizing healthcare workers can be a cost-effective way to reduce utilization,” says Stacy Ignoffo, SUHI’s director of community health innovations. “Our own research shows if we do some interventions, they can decrease healthcare utilization in expensive hospital and emergency room usage,” while increasing the less expensive outpatient care.
Like the OhioHealth Hilltop program, SUHI community health workers identify patients in the ED without primary care physicians, screening them for SDoH. After identifying needs, they provide referrals and follow up with patients in the home setting if possible, to ensure they’re connecting with the agencies, as well as with primary care providers. “We’re finding that primary care and food insecurity are up there in needs, as well as housing,” she says.
- Cultivating Health for Success
Housing is an important issue in Pittsburgh as well, and Medicaid plan UPMC for You took this issue on for some of its patients in the Cultivating Health for Success (CHFS) program. “When looking into how to make an impact up to a decade ago, housing was number one,” says Dan LaValle, director of government programs, UPMC Health Plans. Until recently, the program targeted those who met the strict U.S. Department of Housing and Urban Development (HUD) definition of homelessness, with a goal of finding and placing up to 25 individuals in housing that year. Some stay with the housing program permanently, some move on, and UPMC is fine with either—it doesn’t place conditions on the patients.
Using a team and partnership model, UPMC community health workers, clinicians, and its partner, the local HUD vendor Community Human Services, work together to ensure the patients in the program get needed housing, medical care, transportation, food, and any other needs met. “The vast majority of individuals we serve have a significant number of chronic conditions and co-occurring behavioral health diagnoses,” LaValle says.
UPMC found it took 10 months of consecutive stable housing to get to the changes it wanted to see: better primary care trends and less ED utilization. “We now know that if we can get someone housed for 10 months, that will change their trajectory,” he says. With the program, those enrolled saved about $6,000 per member per year on expenses, which UPMC put back into the program.
It is starting to expand the program to those who don’t meet the HUD definition of homelessness but qualify for Section 8 housing vouchers. This population also has high needs, is not getting recommended medical screenings, and goes to the ED frequently. UPMC is using the same agency and model for partnership and case management, with some funding differences. One change is incentivizing providers with shared savings in a pay-for-performance model.
While 72% of hospitals are not investing in SDoH programs, according to a 2017 Deloitte Center for Health Solutions survey of 300 hospitals and health system, most that do limit their investments to a targeted small patient population, which may include high healthcare utilizers, or those who may be frequent ED visitors. Healthcare organizations don’t have to do it all by themselves, as UPMC showed. Partnering with other organizations can make a big difference.