Models for Population Health Improvement by Health Care Systems and Partners Tensions and Promise on the Path Upstream: Proceedings of a Workshop (2022) / Chapter Skim
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2 Overview of the Landscape: Tensions and Promise
2 Overview of the Landscape: Tensions and Promise
Pages 5-18
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effort, and to assume a more supportive, collaborative role in an upstream effort, which may be better led by a social service agency. Gourevitch explained that one of the workshop's tasks was to showcase examples of interventions from across the spectrum that feature dif 5
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(Gottlieb) • North Carolina's Healthy Opportunities initiative pilots will allow the state to ex amine how contributions to social services may improve health care outcomes.
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* WORKING DRAFT – prepared by Marc Gourevitch with assistance from Alina Baciu to inform discussion at the September 19 workshop Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream FIGURE 2-2 Diagram displaying up/mid/downstream paradigms in advancing population health and health equity.
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She suggested that the recent emphasis on addressing SDOH and social risks within the health care delivery system is only one part of a comprehensive strategy necessary to achieve population health and health equity. Categories of Health Care Activities Related to Social Conditions Gottlieb explained that the National Academies of Sciences, Engineering, and Medicine's Committee on Integrating Social Needs Care into the Delivery of Health Care to Improve the Nation's Health, of which she was a member, articulated five categories of health-sector activities related to providing social care or improving social conditions -- the five As (awareness, adjustment, assistance, alignment, and advocacy; NASEM, 2019a)
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the adjustment of medical care or treatment decisions based on information about social risk, and (2) inter ventions by health care systems to assist patients in improving social conditions by providing social services onsite or connecting patients to social services offsite.
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Examples include helping patients obtain a refrigerator to be able to refrigerate medications, connecting patients to food programs, and helping patients obtain jobs paying a living wage. In addition to the patient-directed adjustment and assistance strategies, Gottlieb noted that the National Academies committee also considered ways that the health care system can affect social conditions at the community level.
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G ottlieb also wondered "could the health care sector's sudden enthusiasm around SDOH actually end up exacerbating our underfunding crisis in the third sector? "3 She suggested that academics, patients, providers, community members, public health practitioners, and social services representatives work together to increase awareness of potential unintended consequences and invest in effectiveness and implementation research to understand how health care sector activities affect patients from different demographic groups, as well as caregivers, and the social sector.
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Money noted that most of the current work builds on successful past initiatives. Background on North Carolina and Its Approach to Addressing Social Drivers of Health Money provided background on the state of North Carolina, noting that it is the 10th most populous state in the United States and 37th in overall health status.
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Medicaid Transformation Money explained that Medicaid transformation is a key driver of the state's work to address social factors that influence health. He noted that Medicaid transformation was originally scheduled to launch in February 2020, but political disagreements around Medicaid expansion between the governor and legislature are likely to delay that timeline.4 The state is intending to move toward a "whole-person care system" with Medicaid managed care organizations, also called prepaid health plans.
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The program is also focused on aligning payments and incentives. Money pointed out that value-based payments for health and the delivery of social services create incentives for prepaid health plans to invest in those services, particularly in communities involved in the pilots.
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The prepaid health plans would provide this funding through lead pilot entities, which are organizations that bridge the relationship between health care organizations and housing, food, and transportation service providers in the community. Money noted that it will be important to ensure that the pilot pays for nonhealth care interventions that will improve the health of the most vulnerable patients, and that the services are used.
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AUDIENCE DISCUSSION Gourevitch opened the audience discussion by asking Gottlieb if her research has found effective approaches based on the five As of care informed by social risk. Gottlieb responded that research has been primarily focused on awareness and assistance activities.
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He explained that the health care systems at that time indicated an interest in addressing factors outside their usual focus that improve health, as such factors influence health plans' abilities to improve health outcomes, which is central to a capitated payment model. When the current governor began his administration, the model shifted to emphasize SDOH and the Healthy Opportunities pilot was developed.
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and cost-effectiveness of these different types of interventions should be evaluated. She noted that the National Academies report on integrating social care into health care delivery includes content regarding financing strategies and how to scale up pilot projects (NASEM, 2019a)
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