Managing the health of a community takes more than building good hospitals; it requires recognizing and addressing the social determinants of health, experts say.
A large part of the mission of the Affordable Care Act was to drive down the nation’s overall health care costs by keeping people healthy and out of hospitals and emergency departments, where the most expensive care is typically administered. This approach toward managing population health has directed many hospitals, health systems, insurers and other community health institutions to address not only the physical and mental components of health, but also the underlying social determinants that affect well-being, such as housing and food security, economic opportunity, and access to care and transportation, to name just a few.
It’s also the reason why Optum, a health care company that is part of UnitedHealth Group, says it has invested millions of dollars in affordable housing in the markets it serves. “From our perspective, it’s really about getting down to the root cause of what’s driving problems and health conditions in our communities,” said Norman Wright, chief marketing and customer experience officer at Optum, during a webinar hosted by U.S. News & World Report. This was the fourth event in the Community Health Leadership Forum, a virtual event series from U.S. News.
Without addressing foundational social determinants like housing, “our populations will be in and out of the ERs, they’ll be seeing a doctor far more frequently, they’ll be absolutely using the health care system pretty excessively, and that’s by a factor of multiples in terms of what that cost would be,” Wright said.
That attitude prevails at many hospitals and health systems across the country, too. At Providence, a nonprofit health system that includes more than 50 hospitals across several western U.S. states, executives can see, through rigorous metrics, how investments in population health lead to reduced ER use, shorter lengths of stay in clinics and increased trust among patients, which helps increase adherence to plans of care, said Dr. Rhonda Medows, president of population health management at Providence.
“If we only wait for people to become acutely ill, if we only wait for them to come into the emergency room, to be admitted, we have missed our opportunity and we have done them a disservice,” Medows said. “If we come upstream and meet them where they live, where they work, where they play, where they learn, we do so much better.”
Kinneil Coltman, senior vice president and chief community and external affairs officer for North Carolina-based Atrium Health, concurred. Coltman noted that studies show that when people can “graduate out of” homelessness into stable, affordable housing, they use the ER less often. Thus, these kinds of “social impact investments” in housing and other areas provide both a financial and a societal return on investment. Atrium has also worked with community partners to improve food access in the areas it serves. “These are worthy and noble investments,” she said.
They are widely needed, as well. In a survey conducted by Kaiser Permanente before the COVID-19 pandemic, 68% of respondents reported at least one unmet social need – food, housing, transportation, social isolation, financial stability – in the previous year, said Dr. Bechara Choucair, senior vice president and chief health officer at Kaiser Permanente.
Choucair added that about 1 in 4 respondents to the survey said they had to choose between buying food or paying rent and covering a medical copay or health insurance deductible. “And we all know … which needs get met first,” he said. Addressing social health issues is “a no-brainer for us,” he added, and it requires doing so with the same rigor as treating physical and mental health conditions.
Kaiser Permanente has invested some $200 million in affordable housing efforts, particularly in California. If you “carve out a portion of these dollars and invest them in projects that not only would give you a financial return on investment, but will actually give you social return on investment,” Choucair said.
The pandemic, of course, has highlighted socioeconomic disparities in health, and health systems have had to adapt on the fly to help communities in need. For many institutions, in the early days of the pandemic, “It wasn’t about precision at that moment, it was about: What can we do right now, in this moment, to do everything we can to save as many people in our community?” Coltman said.
Since then, Atrium Health has implemented numerous strategies, including a multicultural communications task force to fight misinformation, a COVID-19 dashboard to identify hot spots, roving testing to eliminate social barriers to care and a virtual hospital, with one “floor” to monitor patients and another to send paramedics if needed. As a result, the racial disparities in outcomes in the rest of the country “didn’t happen in our community,” Coltman said.
For many, COVID-19 “jarred people awake” to health disparities, Medows said, so health organizations “had to basically up our game,” and provide direct health care in the neighborhoods that needed it most. The most effective way to make a difference, the panelists agreed, was by partnering with community-based organizations that know their populations and have fostered their trust.
For example, when Optum’s data showed three specific ZIP codes – in Louisiana, Los Angeles and near Philadelphia – that were suffering disproportionately early in the pandemic, the company wanted to “get in there and try to drive some impact,” Wright said. “It was amazing to discover that the most effective way to reach the people was through partnerships with community organizations that are already there, already on the ground, have established trust, credibility.”
Indeed, building trust will be especially important moving forward, when a coronavirus vaccine or vaccines become available and distributed. “Without that trust,” Medows said, “no one is going to take that vaccine.”