Archive for the ‘Social Determinants of health’ Category

From Last Place, Bronx Communities Now Prize Culture of Health

December 7th, 2017 by Patricia Donovan

Barely eight years ago, the Bronx landed at the very bottom of the first county health rankings issued by the Robert Wood Johnson Foundation (RWJF) —the least healthy of 62 New York counties, to be exact.

It didn’t help that as a borough, the Bronx topped a few other lists compiled by New York officials, including the highest prevalence of obesity and diabetes and the top consumers of sugary drinks.

Rather than discourage this diverse borough, however, these rankings galvanized residents and a number of Bronx organizations, including the Bronx Institute of Health, to partner and examine facets of community life to see where health might be improved. Under the hash tag and rallying cry of #Not62, the coalition’s reach has extended into Bronx schools, housing and even local food stores known as bodegas as it attempts to reimagine and enhance community health.

During Innovative Community-Clinical Partnerships: Reducing Racial and Ethnic Health Disparities through Community Transformation, a November 2017 webcast now available for rebroadcast, Charmaine Ruddock, project director, Bronx Health REACH, charted the path to some of the innovative community health partnerships forged by her organization.

Formed in 1999 with a grant from the Centers for Disease Control and Prevention (CDC), Bronx Health REACH (shorthand for “racial and ethnic approaches to community health”) is charged with eliminating racial and ethnic disparities in health outcomes, particularly those related to diabetes and heart disease, in Bronx populations. Since its inception, Bronx Health REACH has grown from five to more than 70 community-based organizations, schools, healthcare providers, faith-based institutions, housing, social service agencies and others.

“Those founding partners were particularly concerned that Bronx Health REACH not be seen as a program per se, but as a catalyst for creating a movement around health and well-being in the community,” explained Ms. Ruddock.

From early focus groups, Bronx Health REACH determined that community members not only felt disrespected by the healthcare system, but also powerless to advocate on their own behalf for better services. Those findings helped to shape the Bronx Health REACH mission and subsequent efforts.

Outreach began at the organizational level, such as examining the way a local church provided meals at church events. The coalition brainstormed ways to prepare those meals in a healthier manner, supplementing the church’s work with nutrition training that quickly spread throughout the faith community. From there, the program applied that approach to the food offered during school meals and via vending machines, and eventually within the local food retail environment, which consists principally of bodegas.

Today, the scope of Bronx Health REACH is broad, encompassing street safety, physical activity and overall wellness, among other areas. Its early work with bodegas has grown from demonstrations and tastings of healthy foods to the formation of a Bronx bodega work group and a new Healthy Bodegas marketing initiative. It has engaged farmers’ markets in its objective of increasing healthier food options. To that end, healthcare providers now issue “prescriptions” for fruits and vegetables that are accompanied by ten-dollar coupons.

The transformation is visible in the community, Ms. Ruddock notes. Today, some previously padlocked playgrounds are open; murals by visiting artists that adorn the walls of local housing are left alone for all to enjoy.

However, a great deal of work remains. “We have given ourselves as a goal that by 2020, we will establish a multi-sector infrastructure working with housing groups, economic development groups, and others as the first step in addressing many of the health-related factors and issues,” explained Ms. Ruddock.

But for now, the enthusiasm and contributions of Bronx residents have not gone unrewarded. In 2015, just five years after receiving its disappointing health ranking, the Bronx was one of eight recipients of the RWJF’s Culture of Health prize. The prize is awarded to communities that work to ensure residents have the opportunity to live longer, healthier and more productive lives.

Listen to Charmaine Ruddock explain how early findings from focus groups helped to shape Bronx Health REACH initiatives.

Community Health Partnerships Can Change the Culture of Poverty: 2017 Benchmarks

November 28th, 2017 by Patricia Donovan

Community health partnerships address unmet needs, providing services related to transportation, housing, nutrition and behavioral health.

For residents of some locales, community health partnerships (CHP) —alliances between healthcare providers and local organizations to address unmet needs—can mean the difference between surviving and thriving, according to new CHP metrics from the Healthcare Intelligence Network (HIN).

“We could not survive without community partnerships. Our patients thrive because of them. They are critical to help change the culture of poverty that remains in our community,” noted a respondent to HIN’s 2017 survey on Community Health Partnerships.

Partnerships can also mean the difference between housing and homelessness. According to the survey, more than a quarter of community health partnerships (26 percent) address environmental and social determinants of health (SDOH) like housing and transportation that can have a deleterious effect on population health.

“To date, we have housed 49 families/individuals who were formally homeless or near homelessness,” added another respondent.

“Social health determinants are more important than ever to managing care,” said another. “Community health partnerships make a big impact when it comes to rounding out care.”

Motivated to improve population health, healthcare providers are joining forces with community groups such food banks, schools and faith-based organizations to bridge care gaps and deliver needed services. The majority of community health partnerships are designed to improve access to healthcare, say 70 percent of survey respondents.

Eighty-one organizations shared details on community health partnerships, which range from collaborating with a local food bank to educate food pantries on diabetes to the planting of community gardens to launching an asthma population health management program for students.

Seventy-one percent conduct a community health needs assessment (CHNA) to identify potential areas for local health partnerships. Priority candidates for 36 percent of these partnerships are high-risk populations, defined as those having two or more chronic medical conditions.

Overall, the survey found that 95 percent of respondents have initiated community health partnerships, with half of those remaining preparing to launch partnerships in the coming year.

Other community health partnership metrics identified by the 2017 survey include the following:

  • Local organizations such as food banks top the list of community health partners, say 79 percent.
  • The population health manager typically has primary responsibility for community health partnerships forged by 30 percent of respondents.
  • Foundations are the chief funding source for services offered through community health partnerships, say 23 percent. However, funding remains the chief barrier to community health partnerships, say 41 percent.
  • Forty-five percent have forged community health partnerships to enhance behavioral health services.
  • Two-thirds attributed increases in clinical outcomes and quality of care to community health partnerships.
  • Forty-four percent reported a drop in hospital ER visits after launching community health partnerships.

Download an executive summary of results from the 2017 Community Health Partnerships survey.

HINfographic: Patient Engagement: Educate to Overcome Social Determinants of Health and Low Health Literacy

October 30th, 2017 by Melanie Matthews

Social determinants of health (SDOH), conditions in which individuals are born, grow, live, work and age, and low health literacy pose the greatest barriers to engaging patients in self-care, say respondents to the 2017 Patient Engagement Survey by the Healthcare Intelligence Network.

A new infographic by HIN examines the top components of patient engagement programs, the most challenging patients to engage and the return on investment from patient engagement programs.

Beyond hoped-for improvements in clinical outcomes from actively engaged patients, patient engagement metrics now factor heavily into the equations of risk- and value-based reimbursement models.

2017 Healthcare Benchmarks: Patient Engagement documents tactics, targeted populations and clinical conditions, program components, technology use, success measures, challenges and many other patient engagement metrics reported by 75 healthcare organizations responding to the 2017 Patient Engagement survey by the Healthcare Intelligence Network.

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Healthcare Hotwire: Social Determinants of Health

October 25th, 2017 by Melanie Matthews

Healthcare risk sharing requires a new focus on the whole patient…addressing all of the factors that could impact the health of accountable populations.

Evidence is mounting that social determinants of health—social, economic and environmental factors that impact quality of life—significantly influence population health.

Initiatives such as CMS’ Accountable Health Communities Model and other population health platforms encourage healthcare organizations to tackle the broad range of social, economic and environmental factors that shape an individual’s health. Mission Health recently attributed its success in CMS’ Medicare Shared Savings Program to its care coordination model that addresses the whole person.

And 2015 research by Brigham Young University found that the social determinants of loneliness and social isolation are just as much a threat to longevity as obesity.

In the new edition of Healthcare Hotwire, you’ll get details on how social health determinants impact patient populations and what healthcare organizations are doing to address these factors.

HIN’s newly launched Healthcare Hotwire tracks trending topics in the industry for strategic planning. Subscribe today.

Cityblock Health to Open First ‘Neighborhood Health Hub’ for Underserved Urban Populations in NYC

October 6th, 2017 by Patricia Donovan

Cityblock Health neighborhood health hubs for underserved urban populations: “Where health and community converge.”

Cityblock Health expects to open its first community-based clinic for underserved urban populations, known as a neighborhood health hub, in New York City in 2018, according to a Medium post this week by Cityblock Health Co-Founder and CEO Iyah Romm.

Cityblock Health is a spinout of Sidewalk Labs focused on the root causes of health for underserved urban populations. Sidewalk Labs is an Alphabet company focused on accelerating urban innovation.

The neighborhood health hub, where members can connect with care teams and access services, is one of several key member benefits outlined on the Cityblock Health web site. Other advantages include a personalized care team available 24/7, a personalized technology-supported Member Action Plan (MAP), and a designated Community Health Partner to help members navigate all aspects of their care.

According to Romm, who brings a decade of healthcare experience to the initiative, the neighborhood hubs will be designed as visible, physical meeting spaces where health and community converge. Caregivers, members, and local organizations will use the hubs to engage with each other and address the many factors that affect health at the local level, Romm said.

For example, Cityblock Health states it will offer members rides to the hub if needed. Transportation, care access, and finances are among multiple social determinants of health that drive health outcomes, particularly for populations in urban areas.

Where possible, the hubs will be built within existing, trusted spaces operated by its partners and staffed with local hires, he added. Cityblock envisions offering a range health, educational, and social events, including support groups and fitness classes.

The hubs are part of Cityblock Health’s larger vision to provide Medicaid and lower-income Medicare beneficiaries access to high-value, readily available personalized health services in a collaborative, team-based model, Romm explained in his post. The organization will partner with community-based organizations, health plans, and provider organizations to reconfigure the delivery of health and social services and apply “leading-edge care models that fully integrate primary care, behavioral health, and social services.”

Three key health inequities related to underserved urban populations motivated the formation of Cityblock Health: disproportionately poor health outcomes, interventions coming much later in the care continuum, and the significantly higher cost of interventions in urban areas as compared to other populations.

Cityblock Health will use its custom-built technology to enhance strong relationships between members and care teams, while simultaneously empowering and incentivizing the health system to do better, he added.

Data Analytics, SDOH Screenings Flag Disengaged and 12 More Patient Engagement Trends

October 5th, 2017 by Patricia Donovan

More than 70 percent of healthcare organizations have created formal patient engagement initiatives, according to 2017 benchmarks from the Healthcare Intelligence Network.


To identify individuals that are poorly engaged in their health, nearly two-thirds (63 percent) of healthcare organizations mine clinical data analytics, according to the 2017 Patient Engagement Survey by the Healthcare Intelligence Network, while 37 percent screen patients for social determinants of health related to housing, care access, transportation, nutrition and finances.

Patients who screen positive for social determinants of health (SDOH) and individuals with diabetes are typically the most difficult populations to engage, according to 2017 survey benchmarks.

Thirty-five percent of respondents to the September 2017 survey said the presence of SDOHs, which the World Health Organization defines as “conditions in which people are born, grow, live, work and age,” pose the greatest challenge to health engagement, while 26 percent said a diabetes diagnosis presents the top clinical challenge to engagement interventions.

One-quarter report some resolution of SDOH factors resulting from engagement efforts.

To improve engagement, 75 percent of respondents rely on education of patients, family and caregivers, supported with telephonic outreach (13 percent) and home visits (13 percent).

Efforts by 71 percent of respondents to create a formal patient engagement program underscore the critical role of engagement in healthcare’s value-based care and reimbursement models, particularly in regards to chronic illness.

In other survey findings:

  • Patient experience rankings are the most reliable measure of engagement program success, say 43 percent.
  • For one quarter of respondents, patient engagement is the primary domain of case managers.
  • Eighty-three percent saw quality metrics improve as a result of patient engagement efforts.
  • Half attributed a drop in hospital emergency room visits to their patient engagement interventions.

Download an executive summary of the 2017 Patient Engagement Survey.

Infographic: Food Insecurity Among Medicaid Seniors

October 2nd, 2017 by Melanie Matthews

There’s an estimated 5.2 million seniors who are eligible for the Supplemental Nutrition Assistance Program (SNAP) but are not enrolled, according to a new infographic by Benefits Data Trust.

The infographic examines the impact of food insecurity on seniors’ health and healthcare costs and quality.

2017 Healthcare Benchmarks: Social Determinants of HealthInitiatives such as CMS’ Accountable Health Communities Model and other population health platforms encourage healthcare organizations to tackle the broad range of social, economic and environmental factors that shape an individual’s health. To underscore the need to address social determinants of health, Healthy People 2020 included “Create social and physical environments that promote good health for all” among its four overarching goals for the decade.

In one measure of their impact, 2015 research by Brigham Young University found that the social determinants of loneliness and social isolation are just as much a threat to longevity as obesity.

2017 Healthcare Benchmarks: Social Determinants of Health documents the efforts of more than 140 healthcare organizations to assess social, economic and environmental factors in patients and to begin to redesign care management to account for these factors.

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Have an infographic you’d like featured on our site? Click here for submission guidelines.

Chronic Care Plus for the Chronically Homeless: ‘Recuperative Care on Steroids’

September 28th, 2017 by Patricia Donovan

Chronic Care Plus is designed for ‘Joe,’ a prototypical vulnerable client and frequent hospital user who for some reason has not connected to either his community or healthcare system.

Illumination Foundation’s joint venture pilot, which began as an ER diversion project, now offers community-based stabilization following a hospital stay for medically vulnerable chronically homeless patients. Here, Illumination Foundation CEO Paul Leon describes the origins of Chronic Care Plus (CCP), which has been associated with a $7 million annual medical cost avoidance at all hospitals visited by the 38 CCP clients.

Back in 2008 when we first started, we began to realize that housing was healthcare. With many of the patients we were seeing, although we experienced great success, we ended up discharging them many times back into a shelter or into an assisted living or sober living situation. And although these options were better than being in the hospital or being discharged to the street, we knew we could improve on this.

So, in 2013, we implemented the Chronic Care Plus (CCP) program. Basically, CCP was recuperative care on steroids. It was recuperative care with more tightly wrapped social services and a longer length of stay. At that time, we began a pilot program in conjunction with UniHealth and St. Joseph’s Hospital in which we took the 28 most frequent users and kept them in housing for two years. We also brought these individuals through recuperative care, and wrapped them tightly with social services.

These efforts would eventually lead us to create our ‘Street2Home’ program, which we’re working on now. It implements more bridge housing and permanent supportive housing that is supplied not only by us but by collaboratives in the community. We are able to link to these collaboratives to take our individual, our ‘Joe,’ from a street to eventual permanent housing.

Source: Homelessness and Healthcare: Creating a Safety Net for Super Utilizers with Medical Bridge Housing

home visits

Homelessness and Healthcare: Creating a Safety Net for Super Utilizers with Medical Bridge Housing spotlights a California partnership that provides medical ‘bridge’ housing to homeless patients following hospitalization. This recuperative care initiative reduced avoidable hospital readmissions and ER visits and significantly lowered costs for the collaborating organizations.

Empathy Interviewing Elicits Patient’s ‘Story,’ Uncovers Social Determinants of Health

September 26th, 2017 by Patricia Donovan

social determinants of health

Healthcare must mitigate patient risk factors outside of the hospital, referred to as social determinants of health (SDOH).

If healthcare hopes to move the needle on runaway expenses and improve the health of its communities, it must first focus on patients’ social and environmental circumstances, also known as social determinants of health (SDOH).

That’s the advice of Cindy Buckels, director of population health for TAV Health, which helps healthcare organizations navigate the challenges of SDOHs.

“When we don’t address these issues as we’re addressing someone’s health, we get high readmissions, negative outcomes and dissatisfaction. There’s also increased cost and increased risk,” noted Ms. Buckels during Social Determinants of Health: Using Empathy Interviewing To Help Care Teams Understand Factors Impacting Patient Health, a September 2017 webinar now available for rebroadcast.

To encourage individuals to open up about economic, educational, nutritional, or community deficits they face that drive 60 percent of their health outcomes, TAV Health recommends care teams employ empathy interviewing, also known as motivational interviewing (MI).

“With motivational interviewing, you’re entering into a relationship with a person, not as the expert, but as a partner coming alongside to help them find their own strengths, and affirming them as a person in order to affect positive change,” said Ms. Buckels. Her presentation included a review of the four core skills of motivational interviewing (“Listen for that positive nugget,” she urges), as well as ‘back pocket’ questions to ask when the conversation stalls.

Finally, she outlined traps for care teams to avoid during an MI session, such as the urge to give advice. “Always ask permission to give information or advice. Don’t just assume that’s something that you can do, because you’ve picked up the phone and called them.”

It may take time to master, but ultimately, motivational interviewing is more effective than healthcare’s typical “Chunk-Check-Change” education approach in transforming patient ambivalence and effecting positive behavior change, she said.

Information gleaned from motivational interviewing, even minor details like a patient’s nickname or the presence of a cherished pet, should become part of the patient’s record so that every person along the care continuum who ‘touches’ that patient can access it.

“For example, if a patient’s legal name is Charlene, but she goes by Michelle, if you really want to build a relationship with her and gain her trust, you start by calling her what she goes by, which is Michelle.”

In closing, Ms. Buckels outlined a patient-centric workflow connecting all supportive organizations, healthcare providers, community organizations and family and friends within the patient’s circle of care, which places more eyes and ears on the individual. With communal oversight to report anything worrisome, the likelihood is much less that a socially supported patient will visit the ER or be admitted to the hospital.

Listen to Cindy Buckels explain the advantages of motivational interviewing over the “Chunk-Check-Change” educational approach.

SDOH Video: Tackling the Social, Economic and Environmental Factors That Shape Health

September 7th, 2017 by Patricia Donovan

Initiatives such as CMS’ Accountable Health Communities Model and other population health platforms encourage healthcare organizations to tackle the broad range of social, economic and environmental factors known as social determinants of health (SDOH) that shape an individual’s health.

This video from the Healthcare Intelligence Network highlights how healthcare organizations address SDOH factors, based on benchmarks from HIN’s 2017 Social Determinants of Health Survey.

 

 

Source: 2017 Healthcare Benchmarks: Social Determinants of Health

SDOH benchmarks

2017 Healthcare Benchmarks: Social Determinants of Health documents the efforts of more than 140 healthcare organizations to assess social, economic and environmental factors in patients and to begin to redesign care management to account for these factors. These metrics are compiled from responses to the February 2017 Social Determinants of Health survey by the Healthcare Intelligence Network.