The continued acceleration of value-based payment incentives has almost all providers investing energy into addressing the social determinants of health to some extent, often relying on community-based organizations via partnerships.
However, providers can hit a variety of roadblocks while establishing these partnerships—such as minimal funding, few operational resources, inadequate leadership buy-in, mistrust in the community, lack of goal alignment with partners, and the inability to adapt or be flexible.
Over the last several years, the University of Vermont (UVM) Medical Center has overcome these barriers to sustain collaboration across multiple community-based organizations that address the costly health care and housing needs of patients experiencing homeless. And to date, this partnership has saved over $1.7 million. During a recent webconference, we chatted with UVM Medical Center and its community partners to understand the central components that drive the partnership's continued success. Here are seven lessons to help you forge your own community partnerships to address the social determinants of health.
1. Don't wait for someone else to launch a request for proposal before you start thinking about a proposed solution.
Before the partnership was in place, the state implemented a motel voucher program—but it was costly and ineffective. Vermont spent $2.2M for 38,000 hotel stays in 2012. Simultaneously, the number of Vermonters experiencing homelessness increased 9% and shelter use increased 62%.
With 10-15 housing insecure patients ready for discharge at any time costing $500-1,000 per bed night, UVM Medical Center could not wait for the state to propose a solution. Instead, it sought partners with the expertise to close this housing gap given the impact of this challenge on the hospital.
2. Start with trackable projects to engage finance leaders early on.
UVM was strategic in where it focused first on the social determinants of health. Starting with non-clinical needs that have a trackable impact is essential to achieving buy-in from finance leaders. More specifically, trackable measures are those that link to cost savings (measured by ED use for un- or under-funded populations, hospital length of stay, readmissions, and primary care no-show rates). Point to other organizations' case studies, randomized controlled trials, and other information in the literature to support your claims.
UVM Medical Center used seed money from its Community Health Investment Committee (a philanthropic arm) to fund a pilot program. The early results demonstrated clear ROI, including a 42% decrease in ED visits and a 68% decrease in hospitalizations among the first 95 patients in short-term housing. As a result, finance leaders had the evidence they needed to pull the program into the core operating budget.
3. Plan to outreach in waves to impacted community groups, as buy-in will be required for success, but not necessarily from all community stakeholders at the same time.
You can think about your community-based stakeholders in two groups: implementation and influencer partners. In any partnership, you'll need to create a bilateral outreach strategy for implementation and influencer partners, especially when targeting stigmatized populations.
Implementer partners help your organization get the initiative done by donating resources, staff, and time (e.g., community health centers, non-profits, social services). Influencer partners are stakeholders who will be impacted by a community initiative, and thus can derail any good implementation plan if they're not engaged.
For example, think about the impact that providing housing in a community for complex, homeless patients can have on local law enforcement or even local residents. When local law enforcement and community residents understand the drivers and goal of an initiative, the likelihood that there will be roadblocks down the line decreases. In fact, their buy-in can accelerate execution as well.
4. A leader across your organization needs to own these community-based initiatives. Empower your already motivated organizational change agents, and modify their responsibilities to take accountability for addressing social determinants.
UVM Medical Center executive leadership identified Dr. Stephen Leffler (at that time a Chief Medical Officer) as a change agent. Having witnessed the implications of homelessness on patients' health and utilization working in the ED, Dr. Leffler was an early advocate of investing in housing for patients. In fact, he introduced the game-changing mantra "housing is health care" to the region. This principle aligned stakeholders around a mission of improving the community and impacting their patients' lives.
With a new title of Chief Population Health and Quality Officer, Dr. Leffler now dedicates 10% of his time to forming community partnerships, which he had limited ability to do in his previous role as a Chief Medical Officer.
5. Local FQHCs are likely best positioned to the serve needs of vulnerable populations. Identify opportunities to further enhance their capabilities to provide primary care and wrap-around services for your target population.
Investing in already strong FQHCs, free clinics, and FQHC look-alikes is necessary for providing a regular source of care to vulnerable populations and avoiding unnecessary high-cost utilization. Given their mission and reimbursement structure from federal and state payers, they typically have several relationships targeted at providing the significant level of social wrap-around support that vulnerable populations need. With some extra funding, they can scale the scope of their existing responsibilities to provide tailored support for your target patients.
In Burlington, Vermont, the Community Health Centers of Burlington already had devoted an entire clinic to serving this population. So, UVM Medical Center contributes over $300K each year to support their wrap-around services, which pays for onsite case management at the housing sites.
6. Hold regular bi-directional leadership meetings between the provider and the CBOs, even if there's no set agenda.
True collaboration means asking uncomfortable questions, which requires all partners to establish open communication channels that systematically break down silos.
Leadership from UVM Medical Center and Community Health Centers of Burlington meet quarterly—sometimes with a set agenda, and sometimes without one. When issues come up, they use this as a foundation to help each other problem solve, no matter how small or big the issue is.
7. Be a partner who is open to creative and flexible problem-solving.
No matter the amount of planning and effort consumed by this work, things are not going to be perfect. So when you hit barriers, be sure to assume positive intent in your partner, communicate, be flexible, and get creative.
For instance, when the partnership's short-term housing sites' zoning classification came into question, Dr. Leffler—an atypical representative of a housing location—presented to a zoning review board. It was a success and that housing location continues to operate today.
Make your patients healthy and your ED happy with community paramedicine
For organizations assuming population health risk, top priorities include reducing the rates of avoidable ED visits, avoidable admissions, and readmissions. But most organizations don't have all the staff they need to engage patients and support robust care management.
Our infographic explains how community paramedics can help extend the care team to achieve these system goals.
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