More than a decade ago, family physician Jeffrey Brenner, inspired by police department strategies to map crime data to identify “hot spots,” began to use ambulance records and emergency department (ED) data to predict and aim to address health care hot spots. Health care hot spots are areas where many people with complex problems frequently come to the ED. They often have conditions that could be better managed by primary care clinicians, social workers, and behavioral health professionals. This population makes up only about 5 percent of patients, but accounts for 50 percent of health care spending. As the FFS system continues to shift toward one based on value, many health systems are aligning financial incentives to keeping patients healthier. This means a growing number of hospitals are focusing on factors outside of the health care system or clinical models of care that influence health, such our environment, access to nutritious food, stable housing, and other related factors.
Brenner’s work began in Camden, New Jersey and lives on today through the Camden Coalition. Now, he and his team are trying to disseminate their learnings and leading practices around the country. The Patient Care Intervention Center in Texas is trying out these strategies on its sickest and most isolated patients. Its program is built around collaboration between city and county agencies, hospitals, and nonprofits. Many of the hospitals in Houston and the fire department and paramedics combine their data in one database so that health IT professionals can find the super users of health care. Staff from the program help the super users make and get to doctor appointments, get visits by home health aides, and get their homes cleaned and utility bills paid. The program has been in place for two years; costs for the target population have decreased 83 percent, and hospital visits have declined by 70 percent.
A key question is what role each stakeholder should play in addressing the social determinants of health. Many experiments and efforts to advance care delivery and payment reforms that reduce costs and improve health outcomes are still focused on quality and cost measures that reflect traditional health care services. This uncertainty is not stopping many innovative health systems, health plans, and nonprofits from piloting programs and sharing what they learn. For example, Trinity Health has introduced an annual pay incentive for executives based on improving certain population health metrics, such as reduced rates of obesity, tobacco use, and hospital readmissions. These interventions often require addressing social determinants of health, such as helping patients access healthy foods and getting counseling through community health workers. Financial targets have less weight in the incentive programs than the total health metrics. Mercy Health and Henry Ford Health System have similar incentive programs that align with population health metrics.
Some health care facilities in Southeast Michigan are working with local farmer’s markets and government agencies to encourage low-income patients and families to use the federal Supplemental Nutrition Assistance Program (SNAP). The program provides a $20 incentive match when people use SNAP benefits to purchase fruits and vegetables. Since many SNAP participants are not aware of this program, having clinicians in health care facilities screen patients and provide information about the program led to an increase in use and consumption of fruits and vegetables. The program is one example of the change that can happen when sometimes siloed parts of the health care and public assistance programs collaborate.
Analysis: According to the Gallup Well-Being Index, 80 percent of health outcomes are determined by environmental and social factors. Socioeconomic status, family support, location, and even availability of transportation are factoring into health plan and health systems’ policies and programs for vulnerable populations. A recent paper from Deloitte, Social determinants and collaborative health care: Improved outcomes, reduced costs, reviews some of the individual and collective impacts that physical health, behavioral health, and social determinants have on individuals and the US health system. The paper examines how collaborative care models can help improve outcomes and lower costs and discusses challenges to implementing integrated care.
(Source: The Kaiser Family Foundation, Health Care Costs: A Primer, March 02, 2012)
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