Sentara Healthcare Boosts Efforts to Address Social Determinants of Health

The health system has created a community care program that includes mobile units and neighborhood-based Community Care Centers.

Sentara Healthcare has launched a community care program to provide neighborhood-level access to services for people who are on Medicaid or are uninsured or underinsured.

A primary focus of Sentara Community Care is to help patients address social determinants of health such as housing, food security, and transportation, which have a pivotal impact on the physical and mental health of patients.

So far, Sentara Community Care has launched a mobile unit and two facilities:

• Sentara Mobile Care: This bus is serving the Hampton Roads, Virginia, area to work with individuals who struggle with lack of transportation and time constraints. The mobile unit sets up at community events and offers scheduled services at multiple locations, including Queen Street Baptist Church in Norfolk, Ivy Baptist Church in Newport News, and the Center for Global Diplomacy in Virginia Beach.
   
• Sentara Community Care Center—Union Mission: Sentara has opened a Community Care Center at Union Mission, which is a homeless residential program in Norfolk. The care center offers both on-site and virtual care services as well as care navigation and health improvement programs.
   
• Sentara Community Care Center—Berkley/South Norfolk: This care center is located at an affordable housing apartment complex, and it serves one of Norfolk's most medically underserved neighborhoods. The care center provides traditional medical services such as primary care as well as on-site social services and wellness resources.

Sentara Community Care is designed to meet basic medical care needs as well as social service support, says Jordan Asher, MD, executive vice president and chief physician executive of the Norfolk-based health system. "Our integrated healthcare delivery model will provide comprehensive primary care, behavioral health, and social support services. Specific services vary by location and are designed to meet the individual needs of the community."

A range of services are available through Sentara Community Care, including the following:

• Food and nutrition security assistance
   
• Cooking and health education services
   
• Healthcare navigation
   
• Substance use resources
   
• Education and career training
   
• Transportation assistance
   
• Housing assistance
   
• Domestic and community violence assistance
   
• Financial literacy services

The health system plans to launch another mobile unit in Harrisonburg, Virginia by the end of the year, Asher says. "Then we have eight different Community Care Center locations on the drawing board slated through 2023 and as many as eight more sites in 2024," he says.

Addressing 'dis-eases of life'

Asher says it is critical to address social determinants of health, which he calls "dis-eases of life."

"We believe that by being out in the communities where the needs are greatest and helping to address social determinants of health—or the dis-eases of life—we can medically care for individuals even better. To truly drive measurable change and advance health equity in the communities we serve, we must focus on addressing the root factors that greatly influence a person's health and well-being beyond the care that we deliver inside of our medical facilities," he says.

Sentara Community Care is based on the belief that dealing with social determinants of health is essential to achieving positive clinical care outcomes, Asher says.

"Sentara Community Care builds on our existing efforts and commitment to address social determinants of health, especially in those who are most vulnerable and have the greatest need. Social determinants of health, such as housing, financial literacy, food insecurity, and transportation needs, directly impact 80% of a person's health and well-being—factors that occur outside the walls of medical offices and facilities. We are focused on treating these dis-eases of life before treating medical diseases."

Targeting community care

Sentara is using data to target neighborhoods for community care services, Asher says. "We spent a lot of time over the past year engaging our communities. We got data points from the grassroots level, including community leaders and faith-based ministers and pastors. So, we came at this from a voice-of-the-customer perspective. We also came at it from a market perspective, meaning, what does the market need by the definition of what data shows us such as geographic information system data, gaps in care for Medicaid lives, and gaps in care for the uninsured?"

Sentara combined geographic information system and insurance data with data collected from communities, he says. "We married that data with qualitative and quantitative data that we got from the communities. That has made a huge difference in where we go and what services we bring to those areas, which might be different from place to place. Most importantly, we are building trust and community commitment because they were part of the data collection to begin with."

Financing community care

Sentara is financing the health system's community care program itself, Asher says. "We are financing the community care program because we believe that a healthier community is better for the overall community. As a not-for-profit, we are a community asset, and the community care program is part of how we are going to fulfill our community role."

Serving the uninsured is part of the financing challenge, he says. "We are an integrated delivery network, so we have an insurance arm. When people come in and they are uninsured, we are working on getting them insurance, and we can do that because we have an insurance arm. That's one of the big social determinants—not having insurance or a way to fund your healthcare needs when you need to fund them."

Community Care Center staff offer uninsured patients affordable options, Asher says. "A lot of these people qualify for services that they don't know they qualify for, and they need someone to help them through the process. So, we can sign up people for Medicaid, and we are able to work with them from an Affordable Care Act standpoint on the individual insurance market depending on their income level. Virginia is a Medicaid expansion state, so enrolling people in Medicaid is one of our major focal points. At our Community Care Centers, we have staff there to help patients get what they qualify for."

Related: Social Determinants of Health: Lead or Partner