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The Social Determinants of Health: Case Management's Next Frontier
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Two recent studies indicate more can be done by providers and payers.
The healthcare industry continues to devote ample attention to the social determinants of health (SDoH). A minimum of two studies on the topic appear weekly, each yielding the same compelling arguments:
- Healthcare organizations, providers, and stakeholders could do more to address social needs; and
- If the SDoH are not addressed, care costs will spiral out of control. It’s hard to imagine a price point beyond the current annual national health expenditures of $3.5 trillion.
The loud industry gasp some may have heard last week involved a survey conducted by the Urban Institute and Robert Wood Johnson Foundation. The survey was based on interviews with the five major Medicare Advantage (MA) insurers, which cover approximately 35 percent of the total.
While the Centers for Medicare & Medicaid Services (CMS) released new policies last April allowing the MA plans to expand coverage of non-clinical services (e.g., meals, transportation, home cleaning services, etc.) that could enhance health conditions, few plans did so. The bottom line is clear: far more is expected of the MA plans to address the SDoH.
The gasp continued in response to Dartmouth University Study, and a story that quickly hit a number of news outlets: a majority of healthcare providers and physician practices are not adequately screening for the SDoH. According to researchers at Dartmouth University, 2,333 physician practices and 757 hospitals were surveyed from June 2017 to August 2018, and the following was found:
- The good news: most U.S. physician practices and hospitals screen for at least one social need.
- The concerning news: only 24 percent of hospitals and 16 percent of physician practices screened for all five social needs prioritized by CMS under its accountable health communities’ model. These include:
- Food insecurity;
- Housing instability;
- Utility needs;
- Transportation needs; and
- Interpersonal violence (also the most commonly screened need identified)
With just about every entity across the industry investing extensive human and physical capital to address the SDoH, the Dartmouth research was a reminder that more could be done. The results put many healthcare organizations and providers on the defense.
The sites with the highest screening rates included those that traditionally screen populations viewed as more disadvantaged and at risk of the social determinants:
- Federally qualified health centers;
- Academic health centers;
- Bundled payment participants;
- Primary care improvement programs;
- Medicaid accountable care organizations; and
- Physician practices in those states with Medicaid expansion.
The reasons identified for limited screening varied, though lack of assessment tools should not have been one. While there is no consistent tool used across the industry, a number are in operation:
- The PRAPARE model developed by the National Association of Community Health Centers;
- The Health Related Social Needs Screening Tool developed for CMS’s Accountable Health Communities Model; and
- The Screening for Social Needs Tool developed by the American Hospital Association.
Other evolving models account for a “whole person” or more comprehensive view of a patient’s health. Contra Costa Health Services worked with EPIC and QLIK to develop an assessment, screening tools, and dashboards for social needs. The tools have been incorporated into an interactive care plan used by their case managers, who screen over 14,400 patients monthly. NCCare360 is the first statewide coordinated care network to electronically connect persons at risk of (or dealing with) the SDoH to community resources. The network is partnering with community providers, plus health and behavioral health organizations, to ensure that clients receive the care they need. Programs of this nature serve as models for other healthcare organizations and providers of creative wholistic programming in response to assessing and addressing all five domains of the SDoH.
The barriers identified for screening patients sounded familiar: lack of financial resources, time, or other factors. Proactive efforts beat reactive responses every time, and that extends to the social determinants. Appropriate assessment of patients’ social needs will take more investment of human and financial capital on the front end, yet these efforts consistently yield significant savings, not to mention organizational sustainability, on the back end.
This week’s Monitor Mondays Listeners Survey provided its own affirmation for the industry to make sure the SDoH are on their radar. The survey question asked:
Of the 5 social needs posed by CMS, how many does your organization routinely screen patients for (e.g., food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence)?
- 1 social need3.03%
- 2-4 social needs21.21%
- all 5 social needs29.29%
- I'm unsure46.46%
As you can see, option D received the most votes, which was unfortunately not surprising. Like many hot topics in healthcare, the SDoH may be on everyone’s to-do list, but exactly to what degree remains the pivotal question. The SDoH should be on everyone’s radar in every organization, independent of their role. Each person, professional, provider, and practice setting has a unique part to play in appropriately assessing and addressing the social needs of their patients and populations.
Follow this continuing story weekly on Monitor Mondays, 10-10:30 a.m. EST, for the State of the Social Determinants report.