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Social Determinants of Health
by Peter Shea, MD

One of the underlying themes of population On another front the hospital has recently committed to a statewide
health is the profound impact of the project on SDoH sponsored by the Connecticut Hospital Association
Social Determinants of Health (SDoH) (CHA). The concept behind the project is to understand and address
on clinical outcomes. The literature cites social determinants in a proactive, preemptive way. The project
that clinical care only has a 15-30% requires the participating hospitals in conjunction with community
impact on a patient’s ultimate outcomes. partners (ECHC in the East Region for us) to screen all the patients
Socioeconomic, environmental, behavioral of one particular clinical unit for SDoH. This pilot unit may range
and cultural factors have been found to from an inpatient area to an outpatient clinic. To start, the CHA
be far more influential. Whatever the project team has selected food insecurity, housing instability, and
actual percentage is, we must face reality transportation as initial domains. The plan is then to correlate
and recognize this emerging era of value-based payment where the social data with clinical and demographic findings to localize
providers, hospitals and physicians are paid on the basis of health opportunities around such issues as food or housing availability.
outcomes. We must acknowledge that conditions such as poverty,
malnutrition, and drug addiction have a greater impact than many This all sounds good, but who’s going to pay? Does paying a
clinical risk factors. Clearly there is now a pressing incentive for patient’s rent represent healthcare dollars? We need to break the
physicians to understand and help reconcile social drivers with cycle of unaddressed social needs leading to preventable medical
patient care. care and then recycle the savings in overall cost back into the
system. One approach is to have hospitals and providers take on
Here at the William W. Backus Hospital work has begun to total global risk, a commitment to a specific revenue for a year
incorporate SDoH in a more holistic approach to support the regardless of the ultimate volumes. This has already been tested in
healthcare we all provide. As reported in the winter 2018 issue of states such a Maryland where it was rolled out in rural, suburban
The Open Journal, the hospital and members of the medical staff and urban hospitals. A recent review in JAMA noted that the first
have connected with community partners to prioritize the health three years of the program demonstrated a yearly 1.53% increase
needs of the population through the Eastern Connecticut Health in per-capita hospital spending compared to a 3.58% increase
Collaborative (ECHC). The group is now beginning to work on modeled on the expected rate of growth of the Maryland economy.
healthy eating and opioid addiction. Commercial and government programs are also beginning plans
for payment for non-medical services. Earlier this year Congress
A second new project at Backus Hospital is the Preventive passed the CHRONIC Care Act which allows Medicare Advantage
Medicine Team (PMT). The team consists of an APRN and an LCSW plans to pay for non-medical supplementary benefits starting in
who focus on patients at risk for frequent admissions. The aim 2020.
is to reduce emergency room visits and hospitalizations, thereby
improving the quality of life and driving down the total cost of their Where this all ends up is still unclear, but it appears that this train
care. These patients go through careful screening of their SDoH as is a good way out of the station. What is absolutely true is that
well as their clinical profile. A detailed plan of care formulated, and addressing social issues is the only real proposed model to date
each patient is followed closely by the team both in the hospital and that has the potential to drive true improvements in quality and cost,
post discharge at home. To date the team has reported significant and that success will demand greater integration of the medical
improvement in self-reported quality of health and marked staff, hospital, and community. Most essentially, all of this will
reduction in readmissions. The last two month’s data demonstrates require physician leadership. n
improvements of 52% and 68% for Health Care Quality of Life
ratings, a 76% and 75% reduction for Inpatient/Observation
admissions, and 8% and 24% reduction in ED use. This serves as
an excellent example of value-based care targeting social needs
and lowering cost.

FALL 2018 21