Hospitals and the Social Determinants of Health

Recently, the American Hospital Association (AHA) released a one-page strategic document for its members to use in understanding and addressing the social determinants of health (SDOH). The document – Emerging Strategies to Ensure Health Care Services: Addressing Social Determinants of Health — provides three general strategies hospitals can use, briefly defines the SDOH, and discusses policy options that could assist hospitals in making a difference in community health.

The new guide was developed as one of several resources outlining various SDOH and how hospitals can respond. Currently, the series includes Housing and Food Insecurity with others planned for development.

Learn more about Community Health Initiatives from the AHA.

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Why Medicaid Is The Platform Best Suited For Addressing Both Health Care And Social Needs

The following excerpt comes from the article by Katharine Witgert published September 7, 2017 on the Health Affairs Blog.


...The Medicaid program provides a plausible platform upon which to build a health infrastructure that incorporates the social determinants of health. Medicaid could provide a common entry point that links individuals and families not just to health care services, but also to social services that affect their health. Indeed, state Medicaid leaders have long embraced this concept and are experienced in building bridges that link health and social programs to meet the comprehensive needs of their citizens.

Where Medicaid Leads In Addressing Social Determinants

Medicaid programs have long been leaders in addressing social determinants of health. A range of innovations for incorporating social determinants of health have been tested in Medicaid programs across the country. State Medicaid programs make referrals to social services, directly connect individuals to needed services, align systems to share goals, and invest future savings to the health care system into social services programs. For example:

  • In Pennsylvania, the online health and human services programs eligibility system known as COMPASS allows individuals and families to simultaneously apply for Medicaid, the Children’s Health Insurance Program (CHIP), and the health insurance marketplace, together with programs that administer food stamps, school lunches, child care assistance, and other benefits. There is evidence from a range of social programs that transaction costs—the difficulty of applying—significantly influence take-up rates. Single applications can facilitate access.
  • Colorado’s Medicaid program divides the state into seven Regional Care Collaborative Organizations, each of which connects beneficiaries to health care providers as well as social and community services. The goal is to link every beneficiary with a primary care provider who not only serves as a central point of contact for medical care, but also assesses a person’s nonmedical needs.
  • Louisiana, meanwhile, has embedded permanent supportive housing into Medicaid home- and community-based services, allowing for better integrated care for individuals who are homeless or at risk of homelessness.
  • Recognizing the mutually reinforcing roles of health and education—health status influences a child’s ability to learn, for instance—Oregon began aligning its health care and early education systems around 2011. The Medicaid program and early learning systems share goals, staffing, and funding.

Additionally, Massachusetts, New York, Oregon, Utah, and Vermont are all testing strategies not only to link Medicaid and social services, but also to use Medicaid funds to actually deliver supportive services that affect social determinants of health. These value-based delivery system reforms include the creation of accountable care organizations, health homes, community health teams, and accountable communities for health.

Most recently, the Centers for Medicare and Medicaid Services (CMS) launched an initiative called Accountable Health Communities to better manage the health-related social needs of Medicare and Medicaid enrollees. The initiative will test whether systematically identifying and addressing the social determinants of health through screening, referral, and community navigation services will impact health care costs and reduce health care utilization. Over the next five years, the model will provide support to community organizations that link enrollees to services that address housing instability, food insecurity, utility needs, interpersonal violence, and transportation needs. As CMS begins to test this model, there is reason for optimism, given Medicaid’s track record of integrating health care and social services.

Read the full article.

Reducing Racial and Ethnic Disparities in Access to Care: Has the Affordable Care Act Made a Difference?

The following excerpt comes from the Issue Brief written by Susan L. Hayes, Pamela Riley, David Radley, and Douglas McCarthy.  It was originally posted to the Commonwealth Fund website on August 24, 2017.


Historically, in the United States, there has been a wide gulf between whites and members of minority groups in terms of health insurance coverage and access. Proponents of the Affordable Care Act (ACA) hoped that law’s major insurance coverage expansions and reforms would begin to bridge those gaps.

Evidence suggests that uninsured rates have declined among blacks and Hispanics under the ACA, but have these coverage gains reduced disparities between whites and ethnic and racial minorities? This brief seeks to answer that question and to examine if disparities in access to coverage and care are different in states that expanded Medicaid and states that did not.

We compared national averages between 2013 and 2015 for white, black, and Hispanic adults on three key measures of health care access to determine the effect of the ACA’s major coverage expansions on disparities:

  • the share of uninsured working-age adults ages 19 to 64
  • the share of adults age 18 and older who went without care because of costs in the past year
  • the share of adults age 18 and older without a usual source of care.

These measures align with those reported in the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition.

Additionally, we sought to determine if there were differences in disparities in states that chose to expand their Medicaid programs under the ACA and states that did not. For each indicator, we calculated the average rate for white, black, and Hispanic individuals in 2013 and in 2015 in two groups of states: the group of 27 states that, along with the District of Columbia, expanded their Medicaid programs under the ACA between January 1, 2014, and January 1, 2015, and the group of 23 states that had not expanded Medicaid as of that time.

As the current administration and Congress weigh how to move forward after the recent failed attempt to repeal and replace the ACA, it is useful to examine how successful the law has been in making health care available to racial and ethnic groups that have historically been left out.

Findings include:

  • Racial and Ethnic Disparities in Adult Uninsured Rates Narrowed After the ACA’s Major Coverage Expansions
  • Racial and Ethnic Disparities in Rates of Adults Who Went Without Care Because of Costs Narrowed After the ACA’s Major Coverage Expansions
  • Racial and Ethnic Disparities in Rates of Adults Without a Usual Source of Care Narrowed After the ACA’s Major Coverage Expansions
  • Disparities Between Hispanic and White Adult Uninsured Rates in Medicaid Expansion States vs. Nonexpansion States, 2013–2015
  • Disparities Between Black and White Adult Uninsured Rates in Medicaid Expansion States vs. Nonexpansion States, 2013–2015
  • Disparities Between Hispanic and White Adults Who Went Without Care Because of Costs in Expansion States vs. Nonexpansion States, 2013–2015
  • Disparities Between Black and White Adults Who Went Without Care Because of Costs in Expansion States vs. Nonexpansion States, 2013–2015
  • Disparities Between Hispanic and White Adults Without a Usual Source of Care in Medicaid Expansion States vs. Nonexpansion States, 2013–2015

Download the full issue brief.

2017 CHA Led Projects: Reaching the Community to Improve Health

This June, five Community Health Advocates(CHAs), submitted applications to the Center for Healthy Communities to implement short term, limited scope community projects addressing nutrition, health literacy, family health, and mental health. These projects are:

Nutrition through Gardening: CHA Lead, Sheena Billingsley
Starting in July, Sheena and her partners planned four health and nutrition awareness events at community gardens in the area. These events focused on educating community members on healthy eating and healthy living. Each consisted of

  • Hands on gardening activities
  • Healthy cooking demonstrations
  • Sustainable gardening techniques
  • Conversations with volunteer health professionals

As an incentive for participation, participants received personal growing space in the community garden located in their zip code.

Community Garden at Ridge Manor: CHA Lead, Frewin Osteen
The goal of this project is to increase and enhance home-based and community centered gardening though the construction of a Hoop House to demonstrate the feasibility of a new gardening method suited to small, protected areas.

Smart Grocery Shopping Workshop: CHA Lead, Barbara Hodnett
Through this workshop which was held in June, Ms. Hodnett offered an educational program designed to help participants develop shopping skills to save money while buying healthy foods. The workshop topics included:

  • Learning the typical layout of a grocery store
  • Arranging your pantry and food storage areas to maximize healthy choices
  • Reading labels to determine whether a product is a sound nutritional choice
  • Creating a healthy weekly meal plan

Workshop participants also participated in a walking field trip to practice applying the information they had learned.

Hearts to HEAL (Health Education and Literacy): CHA Lead, Porsche Blount
This five-day summer enrichment program aims to improve the health knowledge and literacy, reduce associated stigmas, improve self-self esteem, and help to create a positive self-image among adolescent girls aged 12 to 18. The topics addressed in the program are

  • Health literacy
  • Nutrition
  • Family Health
  • Mental Health

A pre/post test design will be used to measure the knowledge gained by participants in the program. Also, the final day of the enrichment experience will be an opportunity for the girls to give presentations about what they have learned.

Black Mental Health Matters: CHA Lead,  Zionne Williams
Through this two part project, Zionne and her partners hope to “break the stigma associated with mental health in minority communities and to bring much-needed awareness to the issues associated with mental health.” Part one of the project consists of a family-friendly community event to raise awareness of the importance of recognizing when someone may need help and how to connect those in need with the correct resource. The event included fun kid’s activities, food and entertainment, and presentations from mental health professionals.

The second part of the project is the development of a mental health awareness campaign through an online platform to promote health literacy, create an open dialogue with the community, and encourage potentially affected individuals to seek and complete treatment. To accomplish the goal, individuals will be invited to share their personal stories through visual, written and audio documentation that will be shared online.

These CHA led projects provide an important mechanism for the Center for Healthy Communities to support the CHAs in applying the knowledge they gain through CHC supported trainings to target health issues that are of greatest concern to them.  Through these projects they provide information in culturally relevant formats to improve the health of their neighbors.

Learn more about the CHA program.

I Had to ‘Unlearn’ Medicine to Treat Vulnerable Patients

The following excerpt comes from an August 14, 2017, posting written by Anita Ravi in the Fresh Perspectives: New Docs in Practice section of the AAFP website.


Two years ago, I started the PurpLE (Purpose: Listen & Engage) Clinic at the Institute for Family Health, a federally qualified health center in New York, N.Y. We offer a health home for people who have been victims of human trafficking and other trauma, and I meet patients of all genders, ages, documentation statuses and backgrounds who are encountering a range of medical issues.   

…. When I prescribed medications such as ibuprofen, reminding people to “avoid taking these on an empty stomach” was reflexive — until last year. A PurpLE Clinic patient seeking asylum after being tortured while living in his native country had an appointment to address ongoing pain related to his injuries. As I was prescribing him an anti-inflammatory medication, I didn’t think twice about saying, “Make sure you take this with food,” until I noticed his blank stare.

Ten minutes earlier, he had told me he had no income and relied on a friend who worked in a restaurant to bring leftovers to eat; sometimes there were none. I realized that what I was actually telling him with my prescription instructions was that I had been hearing but not listening. I needed to unlearn the idea that common medical advice has universal applicability, and instead learn that some prescriptions need their own treatment — such as assisting with food access — to help a patient.  

My assumptions regarding food have been tested in other ways, too. One patient called to let me know she was running late because she had a chance to get food and hadn’t eaten in three days. This was not an uncommon reason for patients to be delayed, so I said I completely understood, envisioning a very specific scenario.

When she arrived that evening, I asked what she had eaten, and she responded, “Nothing,” because she had only “collected $3.83 worth.” This patient was paying for food by collecting cans and bottles to recycle, and she had come up short.

Hunger is frequently addressed during PurpLE Clinic appointments because they are typically on weekends, when there is limited access to assistance such as food pantries.

“When was the last time you ate?” is something physicians ask when we order labs that require fasting. I’ve unlearned the purpose of this question. Having implemented a way to provide point-of-care access to food, I now ask “When was the last time you ate?” to ensure no one leaves the clinic hungry.

As I mentioned, patients at our clinic often come in later than scheduled for many reasons. Life is unpredictable. Some undocumented patients rely on informal networks for jobs and may find out the night before that a hair-braiding, construction or housekeeping job has become available. Some patients, however, always make it on time and never miss an appointment.

Other patients said they had to decide between eating a meal or paying subway fare — making appointment days particularly difficult. In New York City, where issues such as turnstile-hopping were resulting in arrest,(gothamist.com) it was troubling that attending appointments could be a link in the cycle of poverty and incarceration. To address this, I needed to unlearn that on-time appointments were a measure of success in health care delivery, and our team implemented a system that made subway cards available to patients.

Read the full post.

The Interplay of Community Trauma, Diet, and Physical Activity

The following excerpt comes from the Discussion Paper by Howard Pinderhughes* posted August 7. 2017 on the National Academy of Medicine website.


Diet- and activity-related illnesses—such as heart disease, stroke, cancer, and type 2 diabetes—can shorten life spans and adversely impact quality of life. Over the past 15 years, the public health field has made important progress in addressing these illnesses by shifting the focus from individual behavior to the broader social and economic forces that shape health. There is now widespread agreement among experts in the field that in order to improve health outcomes and reduce the impact of these illnesses, we must pursue strategies, practices, and policies that are multifaceted, comprehensive, and focused on community- and institutional-level change.

There is a growing understanding that community conditions—the places where we live, work, and play—have a significant impact on our health and that adverse community experiences (community trauma) affect our food and activity behaviors. Advances in understanding the connection between adverse childhood experiences and health have revolutionized the field of trauma-informed care, which has now become an important standard practice in communities across the country. But we must also seek to illuminate how adverse community experiences impact healthy eating and activity, and to develop integrated solutions. Adverse community experiences are destructive factors—such as racial, residential, and economic segregation; violence; structural racism and discrimination; intergenerational poverty; and public and private disinvestment—that traumatize entire communities. For example, experiencing and witnessing community violence can negatively impact the ability to eat healthfully and be active. Violence and fear of violence reduce social interactions that would otherwise contribute to community cohesion, thus reducing support for healthy eating and active living. The pervasive presence of community trauma can become a significant barrier to efforts to improve population health and health equity, including those that address eating- and activity-related diseases. When people don’t feel safe in their communities, they are less likely to walk to the grocery store, use local parks, access public transportation, and let their children play outside. Healthy food retailers and recreation businesses are less likely to invest in communities perceived as unsafe.

An analysis of the production of health inequities across multiple determinants of health revealed that adverse community factors—which decrease opportunities for healthy eating and activity—are rooted in structural violence in the form of government policies and business practices. These policies and practices have led, for example, to the over concentration of unhealthy food outlets in communities of color and communities with low to average household incomes. In the case of food retail, public policies such as those of the Federal Housing Administration incentivized suburban home ownership, which resulted in white middle-class flight to the suburbs and a concentration of poverty in the inner cities. Supermarkets, grocery stores, and many other businesses followed the white middle-class population in migrating to the suburbs. This flight (along with financial policies and practices, including redlining) left a void for unhealthful food outlets to fill. The high cost and scarce availability of land in dense urban areas contributed to the migration of businesses out of the cities and resulted in loss of jobs and tax revenues, and has influenced decisions about the siting of grocery stores and supermarkets. Additionally, there has been limited availability of loans for local residents in underserved neighborhoods so that they might open businesses that sell and promote healthy food options. These adverse community experiences have resulted in limited economic opportunities for residents and a poor food system in which chain restaurants and stores fill the gap with less healthy or unhealthful food options.

Read the full Discussion Paper.

*References have been removed from the excerpt. Please visit the full paper for more details.

The Affordable Care Act and Women

In August, the Commonwealth Fund released the issue brief How the Affordable Care Act Has Helped Women Gain Insurance and Improved Their Ability to Get Health Care Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2016. The brief explores how the Affordable Care Act (ACA) reforms on women’s insurance coverage and access to care. Prior to the law’s consumer protections implemented in 2010, women faced obstacles to buying health insurance in the individual market:

  • Being turned down
  • Charged a higher premium because of their health
  • Had specific health problems excluded from their plans.

To understand how the ACA’s consumer protections, researchers analyzed data from the Commonwealth Fund Biennial Health Insurance Surveys covering 2001 to 2016. Findings include:

  • After rising steadily through 2010, the number of uninsured women in the U.S. had fallen by nearly half in 2016.
  • Women with low incomes have made gains in coverage across race and ethnic groups
  • Young women have made the greatest coverage gains of any age group since 2010.
  • More women have coverage through Medicaid and the individual market since the ACA’s passage.
  • Women in Texas and Florida are more likely to report being uninsured compared to women in California and New York
  • The ACA’s individual-market reforms and subsidies have made it easier for women to buy health plans on their own.
  • Fewer women say they are not getting needed care because of cost.
  • There has been a modest reduction in reports of medical bill problems by women.
  • Insured women were more likely to receive cancer screenings than uninsured women in 2016.
  • Insured women are more likely to have a regular source of care and receive preventive services.

Download the full issue brief.

What are the Top Common Social Determinants of Health?

The following excerpt comes from an August 9, 2017, article by Sara Heath on Patient Engagement HIT.


The social determinants of health are the factors that affect health outside of the four walls of the hospital. Housing, social services, geographical location, and education are some of the most common social determinants of health.

These factors have a significant impact on the current healthcare landscape. As more healthcare organizations deliver value-based healthcare, they are developing strategies to drive wellness care.

Organizations are catering to patient needs outside of the hospital with the goal of keeping patients healthy in the long-run. Patients who have better health support in their daily lives may be less likely to fall ill and require an expensive medical intervention.

But what are the specific social determinants of health? Which examples are most common? And how can healthcare organizations and community partners act on these determinants?

Socioeconomic factors can encompass several different social determinants of health. Poverty can limit access to healthy food, safe neighborhoods, and good schools, among other things. Most prominently, poverty affects housing.

Although individuals can lose reliable housing for a number of reasons – trauma, violence, mental illness, addiction, or another chronic health issue – poverty remains a notable factor driving homelessness.

Hospitals treating a large homeless patient population can forge partnerships with housing departments to help drive housing in the community. Housing development partners can help place individuals who are homeless in houses and offer support that will help individuals maintain that housing.

“Access to safe, quality, affordable housing – and the supports necessary to maintain that housing – constitute one of the most basic and powerful social determinants of health,” wrote the Corporation for Supportive Housing (CSH) in a 2014 white paper.

“Supportive Housing, an evidence-based practice that combines permanent affordable housing with comprehensive and flexible support services, is increasingly recognized as a cost-effective health intervention for homeless and other extremely vulnerable populations,” CSH wrote.

Expanding housing development can also help ensure that living conditions are safe, free of asbestos, lead paint, or other environmental factors that can impair health.

Housing support can also account for other poverty-driven determinants of health, CSH said.

“Furthermore, supportive housing developments often attract or directly bring critical services to resource-barren neighborhoods,” wrote CSH. “Many supportive housing developments are increasingly featuring on-site or direct linkages to gym facilities, after-school programs, recreational spaces, food pantries, recovery support groups and full-service health clinics that benefit the larger community.”

There are countless different social support and public service gaps that are significant social determinants of health, according to Healthy People 2020, a public health organization developed as a part of the Affordable Care Act.

Issues such as race disparities, lack of social support groups, weak culture of health equity, and limited public services are all drivers of adverse health events.

Populations rely on community partners that will advocate for health equity. Examples of partners include the housing department working with homeless patients or health navigators helping a population’s surplus of single mothers.

Social support also includes efforts toward desegregation, which in turn may ensure certain races are not targeted disproportionately for the social determinants of health. One example is black patients living in poverty-ridden areas at a higher rate than their white patient counterparts.

Support for the public good means ensuring public services meet all patient needs. For instance, neighborhoods that are filled with trash need more support from public sanitation departments.

Public safety is also integral and requires the partnership of safety officers, such as fire departments and police. Police specifically can work to reduce drug issues, crime, and incidents of violence. Public safety officers can also help funnel patients out of negative lifestyles by reducing safety issues.
To learn more, read the full article.

Working with Communities to Improve Health

The following excerpt comes from an article that first appeared May 1, 2017, on the NIMHD website under NIMHD Community Health and Population Sciences Feature Articles


Improving health is not always a matter of prescribing the right medicine. Sometimes the environment needs to change. Many Americans live in neighborhoods that lack safe walking routes, grocery stores, and health facilities.

“Are there places for kids to play? Are there good farmers markets or grocery stores?” asks Irene Dankwa-Mullan, M.D., M.P.H., formerly of NIMHD and now deputy chief health officer of IBM Watson Health. Such features help people in a neighborhood live healthier lives. Along with NIMHD director Eliseo Pérez-Stable, Dr. Dankwa-Mullan wrote an editorial in the April 2016 issue of the American Journal of Public Health, “Addressing Health Disparities Is a Place-Based Issue.”

Efforts to address these problems in particular communities are called “place-based interventions.” Ideally, these interventions come from a collaboration among community members, businesses, and other stakeholders, working together with police, urban planners, and other groups to improve their neighborhood. Community members are involved to make sure the interventions are based on their values.

Examples of place-based interventions include an effort to bring a farmers market to a neighborhood without a grocery store or promoting public safety so that residents feel safe walking on the street. Walking is a simple way to improve health, but there can be many barriers to walking, a fact highlighted in the Surgeon General’s Call to Action on walking.

Place-based interventions have been used successfully in rural areas, disadvantaged urban neighborhoods, and Indian reservations. People who live in such places tend to have particular health problems, such as diabetes and heart disease, and working to change the place-based conditions may help address health disparities.

Communities are complicated, and figuring out the best way to improve the health of all residents in a particular place can be a daunting task. “Part of the issue is that we do not have a best practices model for place-based interventions,” Dr. Dankwa-Mullan says. The editorial in the American Journal of Public Health was part of a new series on best practices for place-based interventions. Through this series, public health professionals will be able to learn how to develop place-based interventions.

One key to success of place-based interventions is involving the community. This is similar to community-based participatory research, a way of doing research in which the community sets priorities, ensuring that communities that are asked to participate in research get answers to the questions that are most important to them.

Read the full article.

 

Talking about Health Equity

Recently, the Health Policy Research Consortium create a YouTube Series, Conversations on Health Equity,  exploring health equity with leading experts. Available videos include