Integrating Social Care into the Delivery of Health Care Moving Upstream to Improve the Nation's Health (2019) / Chapter Skim
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2 Five Health Care Sector Activities to Better Integrate Social Care
2 Five Health Care Sector Activities to Better Integrate Social Care
Pages 33-58
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From page 33... ...
focus on improving care delivery provided specifically to individual patients based on information about their social risks and protective factors (conditions or attributes that may mitigate or eliminate risk)
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From page 34... ...
HEALTH CARE ACTIVITIES TO STRENGTHEN SOCIAL CARE AND HEALTH CARE INTEGRATION The five complementary types of integration activities correspond to different roles that health systems can play to strengthen the delivery of social care in health care settings. These activities build on the community-informed and patient-centered care1 recommendations from a previous National Academies of Sciences, Engineering, and Medicine (the National Academies)
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From page 35... ...
Near-upstream activities are targeted toward interactions that individuals have with health care clinical providers or clinical systems, whether for primary prevention or treatment of acute and chronic illness. They include ensuring that health care providers adjust traditional medical care decision making based on social risk and assets data and that patients with social risk factors then receive assistance connecting with and securing available government and community resources related to identified social needs.
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From page 36... ...
Awareness: Strategies to Increase the Health Care Sector's Awareness of Social Risks Both national and local health sector activities seeking to increase social and health care integration frequently begin with elevating and sustaining awareness about the influence of social risk and protective factors TABLE 2-1 Transportation-Related Examples Highlighting Different Categories of Social and Health Care Integration Activities Awareness Ask people about their access to transportation. Adjustment Assistance Alignment Advocacy Reduce the need Provide Invest in community Work to promote for in-person health transportation ride-sharing or time- policies that care appointments vouchers so that bank programs.
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The Kaiser Permanente Social Needs Network for Evaluation and Translation (SONNET) has highlighted five different pathways through which information about social risks and assets can be brought to the attention of health care systems (see FIGURE 2-3 PubMed search results for "social determinants of health" overall and in the context of health care, 2000–2018.
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On the clinical side, patients visiting health care organizations are increasingly being asked to answer social risk screening questions in the context of their care and care planning. In some places, screening is incentivized by payers.
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These and other uses of PHATE are summarized in Box 2-1. Some nonprofit hospitals, federally qualified health centers, and local public health departments also use the community-level social risk data in community health needs assessments, which are required by the Internal Revenue Service and are intended to influence community-level investments (Alberti et al., 2014)
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In reviewing different strategies to increase the health care sector's awareness of patient and population social risk and protective factors, the committee went on to ask whether increasing the health care sector's recognition of social risks alone could contribute to changes in health outcomes in the absence of dedicated social care interventions. Specifically, does asking equate to an intervention?
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From page 41... ...
Adjustment: Activities Where Social Risk Information Is Used to Inform Clinical Care Decision Making There are many different ways in which an awareness of social risks (collected through any of the awareness strategies described above) can subsequently influence health care sector activities, leading to such things as providing social care coordination and services and augmenting the availability of social care resources (see assistance, alignment, and advocacy sections below)
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From page 42... ...
. Other examples of ways that providers can adjust care based on known social risks involve changing insulin dosages at the end of the month when food benefits are more likely to run out (Seligman et al., 2014)
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For example, though many expert care guidelines on diabetes, hypertension, and obesity recognize the influence of social context, sparse information is provided in those social guidelines about how providers should alter their care based on specific social risks (American Diabetes Association, 2017; Armstrong and Joint National Committee, 2014; Eckel et al., 2014; Jensen et al., 2014; Stone et al., 2014)
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From page 44... ...
. More intensive assistance activities are often directed to medically and socially complex patients, and they typically include processes such as relationship building, comprehensive biopsychosocial needs assessments, care planning, interventions (e.g., resource connections, ongoing case management, and behavioral activation interventions, such as motivational interviewing)
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Goal: Provide high-risk, low-income individuals with tailored social support, navi gation of complex health systems, and advocacy to help them achieve their health goals. Approach: Community health workers are hired from the local community to work with patients.
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Alignment and Advocacy: Activities Where Health Care Organizations Partner and Collaborate with Other Sectors Increasingly, health care delivery organizations, health plans, and other health care stakeholders play roles in aligning health care assets with existing social care assets in communities and advocating for more social resources to improve community health and well-being. The committee defined alignment activities to include those undertaken by health care systems to understand existing social care assets in the community,
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From page 47... ...
While providers, patients, and caregivers also can advocate to improve social resources for individual patients, the committee defined health care sector advocacy as activities that are aimed more broadly at increasing the availability of community resources for groups of patients. The net effect of both of these types of activities (alignment and advocacy)
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From page 48... ...
. One study demonstrating effectiveness found significantly lower death rates from potentially preventable conditions among communities with multi-sector networks supporting population health activities with alignment and advocacy strategies extending well beyond the boundaries of the traditional health care system to include policy changes supporting improved health outcomes (e.g., smoking bans and increasing access to healthy food)
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From page 49... ...
A growing number of health care initiatives explore roles that the health care sector can play in improving the social, economic, and political landscape of local economies. In these cases, health care organizations adopt place based, health-equity-focused strategies that recognize that social and economic determinants are largely responsible for health outcomes.
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These strategies alone or in combination may be funded by health care organizations via community benefit programs -- the required contributions that nonprofit health care delivery systems must make to earn their tax-exempt status. The committee recognizes that health care organizations can bring funds, data, and political and other forms of capital to catalyze community activities -- including through the various strategies described in this chapter.
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From page 51... ...
The exception involves awareness activities, which typically are foundational to the others. • Some health care systems have had success with using these strategies to strengthen social care services and, subsequently, to link social care activities with improved health outcomes.
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2018. Association of a care coordination model with health care costs and utilization: The Johns Hopkins Community Health Partnership (J-CHiP)
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2018. Addressing social determinants of health through Medicaid accountable care organizations.
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2015. Social work participation in account able care organizations under the Patient Protection and Affordable Care Act.
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2016. Community health center pro vider ability to identify, treat, and account for the social determinants of health: A card study.
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2018. Hospital readmission and social risk factors identified from physician notes.
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From page 57... ...
. Kaiser Permanente SONNET and Kaiser Permanente Community Health, September 2018.
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From page 58... ...
Presentation to the Committee on Integrating Social Needs Care into the Delivery of Health Care to I mprove the Nation's Health, September 24, 2018, Washington, DC. Wasserman, M., M
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