Social Determinants of Health: Lead or Partner

To tackle social determinants of health effectively, health systems must set clear priorities and know their role.

This article appears in the May/June 2020 edition of HealthLeaders magazine.

When nonprofit hospitals conduct their community health needs assessments every three years as required, there's generally no shortage of needs for them to identify.

Food insecurity, housing instability, and hurdles to education and employment are just a few of the social determinants of health (SDOH) that hospitals can and do address as part of their charitable duty to their communities. The opportunities to meet community needs in a meaningful way are seemingly infinite—which is why hospitals must develop and reinforce a clear sense of purpose and self-awareness about the concrete roles they play in the communities they serve.

Samuel Ross, MD, chief community health officer for Bon Secours Mercy Health, says the health system's role will vary from one SDOH project to the next. In some cases, it makes sense for a provider organization to be the primary funder of a given project. "But in other cases, we may be the convener, or we may be the facilitator, or we may have staff or resources that provide certain expertise to a particular activity that's going on," Ross says.

Whether your team spearheads a given initiative, offers support from the sidelines, or takes on a public advocacy role really depends on what else is happening in the community, he says. That's the case from the very beginning of the community health needs assessment; it's the case when stakeholders and potential partners prioritize which SDOH they will tackle; and it's the case as communities continually refine their priorities moving forward.

The effectiveness of this iterative process hinges on true community engagement, Ross says. Stakeholders don't just want to answer survey questions or speak up at a town hall. They want to be active participants at the table when decisions are made, he says.

"We sometimes give more lip service to that phrase of 'community engagement,' " he says. "But if you look at the most successful relationships, it's because those individuals don't just show up sometimes; they're present at pretty much all times when critical decisions are being made and are truly seen as a value partner in initiatives that impact communities as a whole."

As healthcare leaders continue to adapt to the widespread disruption caused by the COVID-19 pandemic, their SDOH priorities should adapt, too, following the needs community members are expressing, Ross says. The rapid rise in unemployment, for example, which can quickly add to SDOH complications, has prompted health systems to rework their community health priorities, he says.

The temptation to try and solve every systemic problem that plagues your community may be strong. But even as you respond and adapt to evolving stakeholder needs, it's important that you also keep tabs on what potential partners are doing and able to do. Other organizations may be well aligned to make shared investments toward shared goals, as outlined more below.

The business benefits of effectively tackling SDOH are not limited to the risks and rewards of managed care contracts, Ross says. For example, most health systems are members of large purchasing organizations that could explore more local supply chain options, which might offer reasonable contract opportunities and strengthen the local community, he says.

"It's not always that it's some huge windfall, but establishing sustainable relationships that bring goods and services to your organization can have just as valuable a return as a relationship with some large national vendor," he says.

"And it's even more important because you are being a good citizen within your community," he adds. "You are looking to improve social and economic conditions in your community, and that return tied to mission and values can be as significant as any other big rebate or something that we tend to look for in some of these other relationships."

When to partner

For healthcare organizations, there are specific circumstances when forming partnerships is preferred over making direct investments to meet SDOH needs, says Adam Myers, MD, chief of population health and director of Cleveland Clinic Community Care at Cleveland Clinic in Ohio.

"Partnerships are effective anytime when there is work already being started or when work that hasn't been started would best be done collaboratively," he says.

Health systems and hospitals should resist the temptation to create a "de novo project" aimed at any SDOH, Myers says. "Rather than creating our own program, we often need to be learning, listening, and standing beside existing community organizations to determine what we can do to support them and create synergy."

Trust is the indispensable ingredient for a successful SDOH partnership, he says. "It has to be built on trust, and trust is only possible through true listening, seeking to understand each other's felt needs, and partnering in ways that strengthen community-based organizations and help meet community needs."

Humility is also an essential factor when working with community-based organizations (CBO), says Annette Fetchko, director of strategy at the Allegheny Health Network (AHN) Center for Inclusion Health in Pittsburgh. "Health systems have always felt that we have the answer. However, we are learning that we need to understand what is needed from the community's perspective and the CBO's perspective. That has been essential in forging relationships with CBOs."

Barbara Gray, MBA, senior vice president for social determinants of health at AHN's corporate parent, Pittsburgh-based Highmark Health, offers several pieces of advice to healthcare organizations seeking to forge SDOH partnerships.

"Take the time to invest in the relationship. Understand each other's goals and objectives. Articulate the guiding principles under which you are going to operate as a partnership. Be flexible. Recognize what each other brings to the table. And be open to learn from each other and transform—not only the program but also the way you see your role in serving your population," Gray says.

Food security partnerships

The opening of two Healthy Food Centers on AHN hospital campuses is a prime example of effective SDOH partnerships, Fetchko says.

The first step was identifying the need and recognizing the benefits of establishing partnerships, she says.

"When we began to screen at the system level for food insecurity and evaluated the data, we clearly recognized that there was a significant social gap in access to nutritious food. As a health system, we also recognized that we were not the experts in identifying access to nutritious food and distribution of those foods. Organizations in our communities were far better experts."

AHN opened the health system's first Healthy Food Center in April 2018 at the West Penn Hospital campus in Bloomfield, Pennsylvania. The second Healthy Food Center opened in January at Allegheny General Hospital in the North Side neighborhood of Pittsburgh.

Each Healthy Food Center is managed by a registered dietitian and stocked with nutritious dried, refrigerated, and frozen foods. AHN clinicians can make patient referrals to the Healthy Food Centers through the health system's electronic medical record (EMR), Epic. CBOs can make referrals to the Healthy Food Centers via a scanned document or fax.

Referring through Epic helps ensure that referred patients don't fall through the cracks, Fetchko says. "If a referred individual has not engaged with the Healthy Food Center, we have a process where we will do outreach to that individual." Fetchko says they explain the Healthy Food Center's services to the patient, encourage the patient to make an appointment, and assist with transportation as needed.

As of mid-April, there had been 2,200 referrals to the Healthy Food Centers, providing meals to more than 6,700 people, she says.

The cost of operating one of the Healthy Food Centers, which is funded by AHN, ranges from $175,000 to $200,000 annually, including personnel costs.

However, community partnerships play a pivotal role at the facilities, Fetchko says. "As we identified the needs of community residents, we worked with CBOs such as Greater Pittsburgh Community Food Bank and 412 Food Rescue to determine how to source, distribute, and provide access to nutritious food."

The food bank helped AHN convene several CBOs to learn about the community's food needs as well as about food distribution and sourcing, Fetchko says. And 412 Food Rescue, which is a nonprofit organization that sources food that would otherwise be thrown away, makes a "very large donation" to the Healthy Food Centers, she says.

Other significant CBO partnerships for the Healthy Food Centers include the Bloomfield Citizens Council, which hosts a farmers' market, and The Food Trust based in Philadelphia.

The Food Trust provides "food bucks" to the Healthy Food Centers that can be redeemed at participating corner stores, supermarkets, farmers' markets, and greengrocers for fresh produce, says Senior Healthy Food Center Manager Colleen Ereditario, MPH, RD. "Since July 2018, $15,000 worth of coupons have been redeemed from our Healthy Food Center clients alone. The clients report that, as a result, they have increased fruit and vegetable intakes and access that they would not have had otherwise."

Early longitudinal data shows the Healthy Food Centers are having a positive impact on clinical metrics, Fetchko says. "Because the first Healthy Food Center has been open for more than 18 months, we can look to see whether we have had a positive impact on hemoglobin A1c, cholesterol, and high blood pressure. As part of the longitudinal study for A1c, we have seen a 20% reduction in A1c over a six-month period and sustained that over a nine-month period."

Although no single organization can meet the emergency food needs resulting from the COVID-19 pandemic, the Healthy Food Centers have risen to the challenge, Fetchko says. "Individuals can receive bags of nutritious food at the centers that are packaged and distributed by center staff. Included in these bags are recipes to support meal preparation as well as nutrition information."

The Healthy Food Centers have also added community-based services during the pandemic, she says. "Our team has implemented a process to distribute emergency food boxes via the centers as well as home delivery for those who are quarantined or self-isolating due to health risks associated with the pandemic. These individuals are not able to access the broader drive-up food distribution, so the Healthy Food Centers' ability to try to serve these individuals is critical."

When to invest directly

Providers are also making direct investments to help combat SDOH in their communities.

In a February Health Affairs study, researchers searched for public announcements of new direct investment programs by health systems in the U.S. from January 1, 2017, to November 30, 2019. Of the 626 health systems included in the study, 57 (9.1%) made a new direct investment in an SDOH program.

"There's a handful of payers and systems that have totally bought in, are making the investment, and doubling down on social determinants," says Kate Sommerfeld, president of social determinants of health for ProMedica.

The Northwest Ohio and Southeast Michigan healthcare network has been investing heavily in SDOH projects for its patients and surrounding community for several years. After about a decade of doing piecemeal work, ProMedica created a dedicated division and president role in late 2017.

"As a system, we made a decision that social determinants are really, truly part of our strategic plan and fundamentally how we deliver care," Sommerfeld says.

ProMedica started screening patients for SDOH risk factors in 2015. Currently, all patients are screened across 11 social determinants domains (financial strain; behavioral health; food insecurity; training and employment; social connection; housing security; transportation; utilities; intimate partner violence; childcare; and education) with the most robust screening and interventions happening in primary care.

ProMedica's screening data shows the need: Over 12 months, ProMedica conducted 3.1 million food insecurity screenings (which are counted separately, since they were started prior to other screenings) and 40,093 SDOH screenings.

Of those screened for SDOH risks, 46% had needs identified and 13% had needs in four SDOH domains or more. The top needs identified were in the domains of financial strain, behavioral health, and food insecurity. In addition, ProMedica identified SDOH risk in 35% of the commercially insured population.

ProMedica's screenings are embedded in the health system's EMR, combining the SDOH information with other data, such as cost and claims data from payers.

Through a partnership with the healthcare analytics firm Socially Determined, ProMedica can analyze the data to see which social determinants drive utilization patterns. From there, they can create patient cohorts that would most benefit from targeted interventions, Sommerfeld says.

Growing the evidence base

A lack of clear evidence that SDOH investments result in improved health outcomes and a solid ROI stands in the way of many health systems making similar financial commitments. (However, progress is being made. See sidebar: "Social Determinants of Health Program Generates ROI.")

That's why ProMedica is working diligently not only to make investments, but also to demonstrate clear evidence that links certain interventions with positive outcomes for pinpointed patient cohorts.

"We're really focused on growing that evidence base," Sommerfeld says, noting that ProMedica has a number of ongoing research projects that control for different factors—ranging from age, race, and insurance type to whether a patient uses case management services—to target the effectiveness of specific interventions on specific groups, such as oncology patients.

In the meantime, Sommerfeld says overall healthcare spending continues to be "out of balance," skewing heavily toward clinical care rather than SDOH spending, despite evidence showing how much social determinants impact health outcomes.

"In fact, clinical care, while vital, is responsible for only 20% of a person's health," says Benjamin Isgur, leader of PwC's Health Research Institute. "The other 80% is attributable to health behaviors, the physical environment, and socioeconomic conditions."

Isgur points to the Health Research Institute's 2019 global consumer survey, in which one in five respondents indicated they could not afford a healthy lifestyle, and a similar share said they did not have the time to focus on healthy behaviors.

Market needs and investing

Deciding when to invest directly rather than partner with outside organizations depends on the health system's overall market and its needs.

"Food support looks very different in a smaller community than it does in a more urban environment, so it's incredibly important as we make investments that we understand local context," Sommerfeld says.

To do that, ProMedica first conducts what Sommerfeld calls a "landscape analysis" to determine which outside services the system is referring to patients. Next, ProMedica overlays that data with a community health needs assessment.

Using this system, ProMedica is able to see what the community health needs are, where existing services are to meet those needs, and the gaps in available resources. Where there's no nonprofit or other partner within the community, direct investments can fill those gaps.

ProMedica saw such a need in the realm of personal finance management. "We started to see a consistent gap around individuals struggling to pay their bills," Sommerfeld says, as well as those ensnared in other financial issues, such as predatory lending.

That's why ProMedica launched a Financial Opportunity Center (FOC) that's available to ProMedica's surrounding neighborhood in Toledo.

ProMedica funds and operates the FOC, which is based on a model from the social enterprise Local Initiatives Support Corporation and employs seven on-site financial coaches. Clients have access to housing assistance, credit-building tools, and even free tax preparation.

The program has shown success. For example, in 2019, 60% of ProMedica's FOC clients had credit score increases; 63% had net income increases; 60 clients were placed in jobs; and 93 clients had increased earnings.

Micro versus macro investments

Health system investments in SDOH projects can be broken into two groups: micro interventions that assist individual patients and macro interventions that operate on a larger, systemic level.

"As we think about the work, it is broken down into very specific, micro-level support and investment, but also broader, more community-based, place-based investments," Sommerfeld says.

ProMedica's micro-level investments include its FOCs, as well as its food support.

The health system operates three food clinics that are co-located with primary care in medical office buildings.

When a patient screens positive for food insecurity, it's documented in the EMR, and the patient is given a prescription for food, "just like for MRI or medication," Sommerfeld says.

The patient can then walk across the hall to the food clinic to get the food prescription filled. Since food insecurity happens at a household level, the prescription allows for three days of food for an entire family.

While the food prescription provides a temporary fix, within ProMedica's primary care and food clinic settings, patients can become food secure in the long term and connected with benefits, such as WIC or SNAP. They are also directed toward local food pantries and offered FOC supports.

ProMedica is also investing at the macro level, most prominently with Ebeid Neighborhood Promise (ENP), a $50 million investment. That number includes approximately $11 million from ProMedica and $28.5 million from the family of philanthropist Russell J. Ebeid, for whom the project is named.

At the heart of ENP is the idea that "place matters" in health outcomes.

"By deploying a neighborhood-based approach, you're fundamentally shifting the environment," Sommerfeld says. "If you believe place matters, then you have to make investment in 'place,' and place is a neighborhood."

For instance, if contaminated carpeting is triggering asthma, it's a better investment to rip up the carpeting rather than to continue a cycle of medication and hospitalization, Sommerfeld says.

The ENP investment intends to answer questions such as, "How do you make investments at a neighborhood level, to not just change one person at a time? How do you [create] system-level change across a larger population?" Sommerfeld says. "How do we get mass? How do we get scale?"

ENP's 10-year commitment aims to revitalize Toledo's UpTown neighborhood with a focus on health, education, jobs, family stability, and social and educational services, using a place-based model focused on health.

Among those services is a grocery store that ProMedica owns and operates; community classes on topics like parenting and nutrition; job training; and diabetes education.

ENP is also focused on ensuring stable housing for residents and is working with a developer to build 120 units of mixed-income housing across the street from the grocery store, Sommerfeld says.

Other initiatives include working with the city of Toledo and other partners to launch a universal preschool program across the city, and a college promise program at a nearby high school to provide free college to every graduate and one parent from each graduate's families.

Examining the Health Affairs study from February reveals similar micro- and macro-level commitments from other health systems that are directly investing in SDOH.

For instance, at the macro level, the authors highlight MetroHealth in Cleveland, which has made a $60 million investment to build 250 affordable housing units, and Kaiser Permanente, which committed $20 million in funding for youth workforce development in Seattle.

Geisinger, meanwhile, is making micro-level investments in systems. It offers a Fresh Food Farmacy for patients who have HbA1c levels greater than 8% and are food insecure. These patients get a prescription from their primary care physician to receive not only education and clinical interventions, but also healthy food for their entire families, cooking utensils, recipes, and nutritional information.

Measuring results and continuing funding

Quantifying the ROI of SDOH direct investments can be a challenge, but doing so is crucial to build buy-in and expand funding.

Although a mix of ProMedica's community benefit expenditures—required of nonprofit hospitals, grants, and foundation funding—seeds these investments, proving the ROI of these programs can result in payers picking up the long-term costs.

"As we get data to show that an intervention is actually effective and moving the needle, we engage payers, and have a number of payer contracts to support social determinant work today," Sommerfeld says.

For instance, because ProMedica was able to show that its food interventions produce measurable clinical results, it now has two payer contracts that are picking up the cost of food supports.

Sommerfeld says that for CMS Medicare patients who were given food support, ProMedica reduced ED usage by 18%; reduced readmissions by 5%; and reduced medical cost by 6% over 12 months of data, pre- and post-intervention for a statistically valid cohort of patients.

For patients with ProMedica's insurance product, Paramount Advantage, the program reduced ED usage by 11% and reduced readmissions by 1%, she says.

While micro-investment ROI and outcomes are easier and faster to track, doing so at a macro level takes more time.

"The ROI is much longer on that," Sommerfeld says, estimating that the ROI term on ENP, for instance, is 7–10 years.

But, she says, she believes it will get there.