A newly launched program to integrate social determinants of health into clinical care is putting into practice what many health policymakers, plans, and providers are increasingly trying to get their heads around—how to more fully and effectively address all the social factors increasingly recognized as contributing to ill health to improve health outcomes by better disease management and ultimately disease prevention.
In October, RWJBarnabas Health (RWJBH), the largest, most comprehensive academic health care system in New Jersey covering nine counties and 5 million people, launched a pilot program that will screen all participating patients for social determinants of health and connect them to resources as needed. The program initially includes 100,000 patients in three to four locations. Unlike programs that target only low-income patients or the chronically ill, this program screens all patients for social factors such as food security, access to housing, access to transportation, educational opportunities, substance abuse, and other social and behavioral factors.
Called Health Beyond the Hospital, the program was developed to respond to barriers that make it difficult to accurately identify the social needs of specific patients and the challenge for providers to integrate these social needs into clinical care. A dominant barrier for accurately identifying social needs of patients, particularly minority patients, is the lack of trust they often have in confiding with health care providers and systems about the social conditions and needs affecting their health.
Without trust and transparency between patients and health care providers, the first and essential step of accurately identifying a patient’s social needs is not met. For providers, a main challenge to addressing social factors in clinical care is the lack of time, resources, and expertise to manage a dimension of health care for which they are not trained.
To overcome these barriers, RWJBH partnered with a diverse group of stakeholders to implement best practices and draw on lessons learned from across the country.
“We’ve known for decades that health and social services agencies needed to work together, but now we have the technology to move that forward,” said DeAnna L Minus-Vincent, MPA, senior vice president, chief social integration and health equity strategist for RWJBH, adding that building evidence on how to integrate social determinants into clinical care will require the use of multiple strategies and modalities.
To help achieve the critical first step of accurately identifying the social needs of patients, ConsejoSano, a patient engagement and patient navigation company, will use its well-developed platform to identify the social needs of the 100,000 patients in the pilot program.
Once identified, NowPow, a personalized digital community referral platform, imputed the information into their digital platform to connect patient needs to the appropriate community-based organizations.
Identifying Social Needs
With years of experience connecting underserved patient populations—people across multiple cultures, those with low health literacy, the undocumented, and those with low income—to Medicaid programs in 15 states, ConsejoSano has developed a deep understanding of patient populations for whom addressing social determinants are particularly critical. Through their work in connecting these patients to Medicaid programs, the organization recognized the initially unelicited information patients were giving them regarding things like food insecurity or lack of transportation and realized the value of the information to help providers and health care systems address these social determinants.
“The entities best able to address social determinants in my opinion are health plans and health systems, but these are the institutional stakeholders that patients are least likely to share their social needs with,” said Abner Mason, founder and CEO of CansejoSano, underscoring that the US health care system is still engaging with patients much the same way it did since 1970 despite the growing and expanding multicultural demographics of the country.
For example, educational materials and clinical information for patients are still predominantly designed for an English speaker by an English speaker and then translated into another language, which, said Mr Mason, is not adequate to truly understand the full context in which a person lives (ie, the cultural, ethnic, geographic, and socioeconomic factors of their lives).
Mr Mason underscores what is well recognized but difficult to achieve—the need to build trust with patients to engage them in the health care system and in their own health. “We were brought in to help RWJBH do a better job of understanding what the social determinants are in the lives of their patients,” said Mr Mason.
To do this, ConsejoSano first gathers data on each patient through what they call “community detailing” and “resource analysis” in which they collect public and private data, as well as claims data when available, to form a comprehensive picture of where the patient lives and their potential needs (eg, is the patient likely to own a car or have access to public transportation). Data collected is imputed into a technology platform built around a broad understanding of how different communities in the United States consume and engage health care.
The information is then used to develop culturally appropriate messaging for specific cohorts of patients. Mr Mason called this cultural cohorting, in which a large patient population is divided into much smaller groups based on culture and specific messaging developed for each cohort.
In working with RWJBH, ConsejoSano is reaching out to all 100,000 patients using the process described above. Essentially, they are responsible for the first step in correctly identifying the social needs of these patients to ensure patients are set up to receive what they need.
To ensure that patients receive what they need, RWJBH contracted with NowPow to use their digital platform to connect patients with resources.
Connecting Patients to Resources
“Once patients are assessed for social risks, Health Beyond the Hospital care providers use NowPow’s personalized digital community referral platform to refer and connect them to the right community services and supports,” said Stacy Lindau, MD, MAPP, founder and chief innovation officer, NowPow.
To do this, NowPow creates a resource list tailored to each patient’s specific needs that takes into account both the health and social needs of the patient as well as key demographic information (ie, age, gender, eligibility, location, preferred language, and insurance type). “Think of it as an e-prescription for patients that connects them directly to services and supports, such as places to help access the federal Supplemental Nutrition Assistance Program and stress management programs,” said Dr Lindau, adding that NowPow will be fully integrated into the systems electronic health platform to provide seamless utilization in all areas of patient care.
Dr Lindau emphasized the value of digitizing human and social service referrals to help advance the quality and quality improvement culture in these vital sectors. “When used at scale, this digital technology generates critical data insights about the geospatial distribution of demand for these resources relative to supply and about the quality and capacity of the resource providers,” she said.
This is important given the long-standing difficulty for providers and health systems to efficiently and effectively address the recognized social and economic factors affecting patients’ health. Moving the personalized referral system from analog to digital makes it easier for providers and health systems to link patients to the vital community resources they need, and makes the process easier for patients as well to actually access these resources.
One essential boon to patients, suggests Dr Lindau, is their ability to more fully take charge of their own health. “Most of us want to care for ourselves most of the time, without going to the doctor or hospital. NowPow’s technologies give everyone access to information about all the vital resources of the community that are there to ensure people’s independence and well-being.”
Ms Minus-Vincent stressed, however, that Health Beyond the Hospital recognizes that some people need a little help along the way so the patient-centered program is designed to help people in a way that meets their needs and lifestyle. Once enrolled in needed programs, patients can choose to connect with NowPow and receive reminders via text messaging or opt for phone-based coaching and support. For patients who need a more intensive level of care management, RWJBH will coordinate their right level of care with internal and community-based resources.
Dr Lindau also emphasized that patients who use NowPow’s referral platform can share the community resource information with their family and friends, further highlighting the utility of a digitized platform to benefit not only the first user, so to speak, but that user’s network of family and friends. “Enabling spread from individuals who receive the intervention to others works like a force multiplier for health-promoting information in communities.”
This last feature may be particularly important during the current pandemic with more individuals in need of services and less resources to go around, said Ms Minus-Vincent. By linking social services with one another and the health care system, she underscored that Health Beyond the Hospital offers a critical component to providing comprehensive and integrated care.
Currently, the pilot is funded by the Walmart Foundation and the Robert Wood Johnson Foundation. Going forward, Ms Minus-Vincent said that a critical aspect of the pilot will include tracking outcomes to provide evidence of the role of social factors in health outcomes. They also will be documenting and collecting data on ICD-10 diagnosis codes to document the prevalence of social factors, which will be useful as payers move more toward value-based care.
“As we move beyond reimbursement models, and social issues such as hunger are seen as underlying factors for chronic diseases such as diabetes and stroke, it is less expensive for payers to support prevention than support the more costly effects of intervention or treatment,” said Ms Minus-Vincent.
Dr Lindau also emphasized that NowPow will be helping RWJBH collect data to inform reimbursement strategies and ultimately shift financial models in health care. “Value-based care must be linked to community-based care if it’s going to succeed.