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Patients who lack resources likely won’t have improved health outcomes even with interventions. Some plans are exploring how to address the problem.
Patients who can’t buy food are not going to buy medications. Patients who don’t drive or have a car often can’t get to doctor’s appointments. Mental health problems can cause a host of issues when it comes to adhering to a care plan. These are just some of the nonmedical issues facing patients, and they keep patients from achieving the improved health outcomes that providers need them to reach to secure reimbursements and avoid penalties.
Melinda K. Abrams, vice president of delivery system reform for The Commonwealth Fund, says the literature linking social and economic factors to health outcomes is clear.
“These studies uniformly suggest that nonmedical factors play a substantial role, in fact a larger role, than other aspects of healthcare,” Abrams says. “When we really examine the needs of patients with clinically complex needs, a lot of what contributes to that complexity is not just their medical conditions, but their social health conditions and needs.”
Karin VanZant, executive director of life sciences at CareSource managed care company, started her career as a social worker and community developer. “I look at these issues through a completely difference lens,” says VanZant. “Constantly, I’m looking at my colleagues with MDs and PhDs wondering how they think people can be compliant when they don’t have resources.”
At CareSource, she’s working on a care model that values social stability in a way that historically has been reserved for physical health. This includes making sure an individual has stable housing, education and training, and support structures. The organization is exploring ties with housing and education groups, chambers of commerce and others to develop more community support.
“We’re starting to prove there’s lots of resources that our members are taking advantage of and there are a lot of resources they aren’t taking advantage of because they didn’t know they existed,” VanZant says.
In some cases, patients have a medical diagnosis compounded by mental health problems and social factors. The question, VanZant says, is how to best identify these issues and triage that patient. Many times, however, this process stalls in the physician’s office.
“I think the hesitancy, especially when we talk to health partners, is how to make that connection. The reason that sometimes the questions aren’t being asked around behavioral health and social stability is that many clinicians have been trained not to ask a question they don’t have the answer for.”
In one internal study, CareSource found that assigning Medicaid members life coaches to address social factors reduced emergency department utilization and hospital stays and improved compliance.
Programs for low-income patients and their families may be the most effective, Abrams says. This can include housing support for high need, complex individual and nutritional assistance for low-income children and seniors, and people with disabilities. Case management and community outreach programs also provide a lot of assistance for low-income families and older adults who have difficulty managing the planning, resources, and logistics required to improve their health outcomes.
Sometimes, solutions are fairly simple but not traditionally medical, such as providing an air conditioner for a patient with asthma or stable housing with electricity for someone with diabetes, Abrams says.
The Commonwealth report identifies a number of examples of models that have worked, and Abrams says there are more than 20 with decent evidence. Some of the programs Abrams mentions by name include Independence at Home, Care Management Plus, and Programs of All-Inclusive Care for the Elderly (PACE).
Thomas H. Ebert, MD, executive vice president and chief medical officer of Fallon Health, a plan based in Worcester, Massachusetts, says the whole issue of mental health parity is very serious, but finding a way to integrate services is a problem.
“The coordination of behavioral and physical health is the issue,” says Ebert. Fallon Health’s Summit ElderCare program is the fifth largest PACE program in the nation.
It offers home support, including house calls by pharmacists to answer questions and offer training after a patient is discharged. Medication issues are responsible for many readmissions, so the service aims to prevent problems. The pharmacists also use their time to check safety and coordinate other home services patients might need.
The Affordable Care Act and initiatives like the Triple Aim have led to shifts in previous standards, and payment models are increasingly holding providers financially accountable for patient outcomes and costs, giving providers new incentives to look beyond a medical diagnosis when creating a patient’s care plan.
Patient-Centered Medical Home Programs, adopted by more than 40 states, provide new payment and care models that wrap social supports into the model and usually result in higher reimbursement rates.
“The critical element to enable this to happen is the payment model,” Abrams says. “In a payment environment where it’s about outcomes and value, and avoiding unnecessary and expensive care, the perspective and priorities shift.”
Rachael Zimlich is a writer in Columbia Station, Ohio.