By Emma Opthof, Center for Health Care Strategies
Health care has largely embraced the realization that it is near impossible to fully address most health issues without first responding to an individual’s social needs such as homelessness, food insecurity, and economic instability. However, what is the health care system’s role in addressing these social needs? The National Academies of Sciences, Engineering, and Medicine (NASEM) recently examined this critical question with the help of an expert committee. The resulting report, Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health, explores two key opportunities: (1) how can services to address social needs be integrated into medical care; and (2) what kind of infrastructure is needed for this integrated model to be successful?
To learn about the recommendations and challenges outlined in the report, the Better Care Playbook recently spoke with Kedar Mate, MD, Chief Innovation and Education Officer at the Institute for Healthcare Improvement, who served on the NASEM expert committee.
Q. What inspired this report? Why now in terms of what's going on in the health care field?
A: Almost every day, there's a new finding further confirming the impact of social determinants on health outcomes. Yet, for many years, we really questioned whether social factors directly influenced health status. Today, the notion that social factors influence health outcomes is no longer controversial. So that's actually an important switch in mindset that partially inspired the report, because it's not about figuring out whether these factors have an influence — but rather, how do we as health care delivery systems, as health plans, as an industry — work on these factors in a fundamentally different way?
The other thing that inspired the report is the need to understand what workforce is well-equipped to meet this need. If you recognize that social needs are influential on health outcomes and that health care has a role to play, then the next question is — who in those systems might play a key role in addressing social needs?
Q. How did the committee get to consensus on the five key activities that were laid out, and what are the practical applications of those in the field?
A: At our first committee meeting, we found that there were many activities that health care organizations were already undertaking in addressing unmet social needs — including population-specific and place-based approaches — but there wasn't an organized approach to frame opportunities. From our analysis of the available literature and through our conversations, we organized these interventions into the Five A’s — five buckets that largely categorized the current activities of health care:
- Awareness covers activities related to identifying the social risks of patients and populations.
- Adjustment includes activities to modify care to meet the individual's needs, such as developing language sensitive services or extending office hours.
- Assistance can include everything from providing connections to local housing agencies or closed loop referrals through an e-referral platform, all the way to meeting the social need itself, such as a health system providing transitional housing or food from a food pharmacy.
- Alignment is about bringing existing health care resources into alignment with addressing social determinants or social needs of patients and families in the system. For example, alignment could be how the system invests its own resources in ride sharing or another transportation program.
- Advocacy covers working together with local agencies to go beyond the existing resources of the health system to a wider array of actors that might be necessary to solve the problem, such as working with local government to fix transportation problems.
While these five A’s are not the only way of thinking about this issue, they offer a useful organizing framework to help health care organizations build their approach to addressing their patient’s social needs. It helped us to organize the report, because then we could think about questions like: where does the workforce need to be developed in order to address these five areas? How do we align data assets and technology to support integration along these five areas? How do we organize the money so that we can support these five areas?
Q. Through this national exploration, what if any, aha moments, did the research present for you?
A: Right from the start, I recall thinking that the tagline of this report should be: “all of us have social needs.” It’s actually a pretty profound point. Many people may think of the “social needs population” as being permanently destitute, downtrodden, and at-risk. But literally every single human on the planet has social needs. For many people, social needs actually enhance your health. We are all a product of our social environments and for some, because of social circumstances, those needs go unmet and can contribute detrimentally to health outcomes. The health system is where the consequences of unmet social need or social factors that are detrimental play out, so what is the role of the health system in helping us meet those needs? Much of the report is consumed with trying to answer this question and identify strategies to build our social fabric to ensure better outcomes for everyone.
Q. What are some ways that cross-sector teams can successfully collaborate to address social and health care needs to improve health outcomes?
A: The most successful things that I've seen are multi-stakeholder coalitions working to achieve collective impact. For example, in Detroit, there are multi-stakeholder initiatives involving all of the health systems as well as many community-based actors to try to reduce infant and maternal mortality in the city. These are big goals that require interdisciplinary actions. For these cross-sector teams, it is important to develop a common purpose and identify specific roles to help each organization reach that common goal.
Q. What are some challenges faced by cross-sector teams that hinder their ability to integrate social and health care?
A: One of the classic challenges within broad partnerships is something called the “wrong pockets” problem. You work on something upstream in education and it benefits health care, or you work on something in health care and it benefits criminal justice. Yet there isn't really a wrong pockets problem. It comes out of one pocket, which is our pockets — all of us collectively. But it's filtered through these agency/sector pockets that can declare victories while showing losses elsewhere. It is a problem requiring solutions that involve some type of collective financing. If we're going to solve this, we ultimately need to create common asset pools that multiple sectors contribute to and essentially get back to a community pot, which is more representative of where the money is actually coming from. There are a lot of intermediate steps that you could take that don't involve this more radical solution, and the mechanisms for building this system are not straightforward. But if we want to truly have cross-sector teams that are working together to solve community problems, it’s going to take a pooled financing model where everybody shares in the responsibility for resources.
Q. What does it mean to “medicalize” social care, and what are the considerations for health system leaders looking to avoid medicalizing this care?
A: When we referenced the medicalization of social care, we meant that health systems would essentially try to take over and execute the social care service itself. There may be situations in which that's necessary, like when the social care systems are really not available, efficient, or effective. But that's relatively rare. In most cases, there are well-developed networks of community-based actors that have been working in communities for quite some time and really understand these issues well. In those cases, health care should utilize those existing channels and learn from these organizations. The health care system should partner with and strengthen their relationships with these organizations rather than trying to conduct these activities themselves.
Q. What are the most important takeaways and how can we practically apply this information to further the field?
A: The first thing is that we're slowly but surely redefining what a health care service really is. Something we discuss in the financing section of the report is the need to consider social care factors as part of the equation. It's not just being added to the numerator of the medical loss ratio — it's redefining what is or isn't a health care service and including social needs care as a part of what contributes to health outcomes. The second takeaway is the expansion of the scope of practice. I think we've been pretty provincial about who can actually provide these kinds of social care services inside or outside of health care. The report calls for an expanded workforce that can actually address the social care needs of our patients and population. Finally, we need to enhance cross-sector relationships through shared financing to create better mechanisms of addressing social care. Ultimately, we would expect to see longer term ROI for these pooled assets.
Q. How does this fit within the larger scale of complex care?
A: Complexity is sometimes defined by not just clinical complexity but social complexity. I think this report comes at an important moment where the field of complex care is growing and gaining momentum. A Blueprint exists. The Playbook is organizing the knowledge assets. And now you've got this report that's saying it is time for health care to get more involved in this space. Hopefully, it will serve as a stimulant to the growing field of complex care.