As America rethinks the care delivery system yet again, there is a growing recognition that health happens in neighborhoods and on playgrounds ... through vending machines and water pipes ... and at bus stops and in classrooms all across the nation.
Experts focused on population health recognize access to healthcare providers is only one driver of outcomes, albeit an important one. Yet, they believe moving the needle on health in the United States will require addressing socioeconomic and environmental factors outside of what has traditionally been considered the healthcare system.
"What we've seen is that under the Affordable Care Act there have been large gains in coverage," said Samantha Artiga, director of the Disparities Project for the Kaiser Family Foundation (KFF). However, she continued, "There's a growing recognition that health coverage is one key component, but there are a variety of other components, too. Health is influenced by a broader array of factors. To really improve health, you have to address the social determinants."
Artiga coauthored the KFF issue brief, 'Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity,' with Harry Heiman to explore both the problem and potential solutions. In the brief, the authors wrote, "Based on a meta-analysis of nearly 50 studies, researchers found that social factors, including education, racial segregation, social supports, and poverty accounted for over a third of total deaths in the United States in a year."
To address this issue, communities are utilizing innovative measures including 'health in all policies' and 'place-based' approaches. The former has been gaining traction over the last two decades and encourages policymakers and decision-makers to consider health consequences in non-health sectors. Much like an environmental impact study, a health assessment evaluation might engage education leaders to consider the consequences of vending machine contents or a developer to consider the health impact of installing sidewalks.
An example of a place-based approach is the Philadelphia Healthy Corner Store Initiative, which has brought healthier foods to more than 600 corner stores and resulted in a 60 percent increase in the sales of fresh produce.
"As we documented in the brief, we've seen initiatives in a number of sectors," Artiga noted. "We've also seen how to better integrate social determinants within health."
Rebecca Tyrell, a senior consultant for Advisory Board with deep expertise in population health, agreed social determinants are increasingly becoming part of the health equation. "Providers who have typically not been in the business of talking to patients regularly about non-clinical needs are now asking how to screen for issues and then how to access resources," she said. "The issue at hand is how do we connect the dots?"
Yet, she said, effective community partnerships make sense on multiple levels. She recently penned 'Building the Business Case for Community Partnership: Lessons from the BUILD Health Challenge' to explore steps to extend care, engage patients, and improve cost and quality.
With limited time and a heavy clinical burden, Tyrell said a number of hospitals and practices are turning to non-clinical staff members to create an inventory of resources and link patients to needed services. "In many cases, they are high school-educated individuals who are well connected in the community and have a familiarity with the community resources," she noted.
An innovative program by ProMedica in Ohio looks to destigmatize hunger. Tyrell said the system has partnered with community agencies to bring food pantries onsite to the hospital campus. Every primary care visit includes two simple questions to screen for food insecurities. Those identified as being at risk are given a food prescription. "They are trying to medicalize the issue and connect patients directly to food rather than referring them to an outside entity," explained Tyrell. "It also plays a big role in reducing the stigma."
Tyrell counsels clinical clients to assess needs and start with one project. Transportation, she noted, is a relatively low-lift barrier to address through ride share services or community transportation resources. "Start with whatever seems feasible with whatever resources you have available," she noted. "You can always scale your efforts from there." She added, "Don't be overwhelmed by the range of possibilities or options. There will always be more needs in your community than you'll be able to address right away."
While more individuals, including policymakers, now recognize health happens in a broader context than the narrow constructs of the delivery system, Artiga said that piece should not be underestimated. "When looking at what's at stake in the current environment, the potential coverage losses under the American Health Care Act could make it more challenging to address social determinants of health because the health coverage piece provides a connection point to assess needs and to connect individuals to broader services in the community."
Even if there are more hurdles to clear in the future, Tyrell said she believes efforts to integrate health would continue to gain momentum. "Regardless of your political affiliation, we're all focused on how to lower the cost of care while improving quality, and addressing the social determinants of health is a key lever to doing that because it allows us to go further upstream."