Systems Practices for the Care of Socially At-Risk Populations (2016) / Chapter Skim
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, contracted with the National Academies of Sciences, Engineering, and Medicine to convene an ad hoc committee to identify best practices of high-performing hospitals, health plans, and other providers that serve disproportionately higher shares of socioeconomically disadvantaged populations and compare those best practices to practices of low-performing providers serving similar patient populations. The committee comprises expertise in health care quality, clinical medicine, health services research, health disparities, social determinants of health, risk 1 Health equity means that every person has the opportunity to attain his or her full health potential and no one is disadvantaged from achieving this potential because of social position or other socially determined circumstances.
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, socially at-risk populations include individuals with social risk factors for poor health outcomes such as low socioeconomic position, social isolation, residing in a disadvantaged neighborhood, identifying as a racial or an ethnic minority, having a non-normative gender or sexual orientation, and having limited health literacy. Although these populations receive care from a wide range of providers, they are disproportionately represented among the patients treated by a small subset of providers, including safety-net hospitals, minority-serving institutions, critical access hospitals, and community health centers (Bach et al., 2004; Jha et al., 2007, 2008)
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The committee reviewed both the peer-reviewed and grey literature in order to identify innovations, interventions, and other strategies providers disproportionately serving socially atrisk populations have implemented to improve care and outcomes for their patients. The committee reached out to organizations known to conduct research or represent providers disproportionately serving socially at-risk populations (Alliance of Community Health Plans, America's Essential Hospitals, America's Health Insurance Plans, and The Commonwealth Fund)
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The common themes describe a set of practices delivered within a system of collaborating partners, not to specific health care interventions, and are consonant with research findings from the quality improvement literature and related clinical interventions designed to decrease disparities. Note that "system" as used here is not limited to a single health care organization, but refers more generally to a set of interconnected actors who work together to accomplish a common purpose -- in this case to improve health equity and outcomes for socially at-risk populations.
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F Finally, the h hard work of providing h f highquality ca is never done; this sy are ystems approoach provide a continuo process for es ous improvem ment. FIGURE S-1 Promisin systems pr ng ractices to imp prove care fo socially at-r populatio or risk ons.
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. Because most of the efforts described in this report involve fixed costs and potentially shared benefits across multiple payers, their economic feasibility depends not only on Medicare's payment system but also that of other payers.
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2012. Federally qualified health centers and private practice performance on ambulatory care measures.
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2011. Medicaid patients seen at federally qualified health centers use hospital services less than those seen by private providers.
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2014. Readmission penalties for chronic obstructive pulmonary disease will further stress hospitals caring for vulnerable patient populations.
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