Health systems are evolving and advancing their strategies to address social determinants of health

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.

Read the full article here:  http://blogs.deloitte.com/centerforhealthsolutions/health-systems-are-evolving-and-advancing-their-strategies-to-address-social-determinants-of-health/