Non-clinical risk factors, also known as the social determinants of health, have a larger impact on a patients' health outcomes than the clinical care they receive—double the impact, in fact. Yet few providers (only 20%) feel comfortable addressing these social needs, which include socioeconomic status, housing, transportation, literacy, hunger, safety, and social support.
With the shift towards value-based care, organizations need to be equipped to address these determinants that exacerbate health disparities, or else face tremendous costs. It's estimated that health disparities directly cost the U.S. health care system $77 billion annually.
To address the major social determinants of health while conserving limited organizational resources, turn to best-in-class local community partners who can help inflect change on a patient and community level.
Forge ongoing ties with disengaged, high-risk patients
Even the best-funded health equity interventions won't be successful if the provider organization is disconnected from its most at-risk patient populations. To overcome trust and access gaps, upskill community partners to perform outreach and reroute patients to wraparound care.
MedStar Health in Columbia, Maryland, was having trouble reaching and treating African American males in their community with hypertension. Instead of receiving preventive primary care to manage their chronic illness, patients showed up at the ED in critical condition. In response, MedStar created the "Hair, Heart, and Health" program based in local barbershops, trusted and frequently-used establishments in the community.
Barbers were trained to promote the program and provide basic health education to customers, while on-site health navigators provided blood pressure and blood glucose screenings. Over half of participants were diagnosed for the first time as having or being at-risk for hypertension, and one-fifth of these participants were connected with follow-up care.
By screening in the community, providers can activate non-users of primary care, surface high-risk needs before they lead to an admission, and direct patients to the right site for ongoing care. To do this effectively, prioritize screening in community hotspots of risk.
Leverage community-based expertise to advance system-wide, health equity aims
Building trusted relationships in the community is the first step to mitigating the effects of social determinants of health. Next, provider organizations must leverage the expertise, resources, and connections of community partners to combat ingrained, structural issues that contribute to health disparities (e.g., lack of affordable housing, food deserts).
ProMedica, a health system across Ohio and Michigan, identified food insecurity and obesity as a major health issue in their community. Population health leaders formed a partnership with local food banks to create a food pharmacy program.
Primary care staff across outpatient clinics screen and refer in-need patients to the food pharmacy. Staff frame food insecurity as a health issue, writing food prescriptions, to reduce shame and stigma. Then, patients receive condition-specific healthy food provided by partner food banks for up to six months before returning to their PCP for another referral. Since 2015, ProMedica has served over 3,000 households.
By allocating resources to community partners who are addressing the critical social determinants of health, providers can begin to move the needle on health disparities in their communities. Not only does this approach improve health outcomes for the most vulnerable, but it reduces costly ED and inpatient utilization.
Mobile Health Clinics: Improving Access to Care for the Underserved
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