Organizations from across the healthcare industry’s spectrum have in recent years come to appreciate the broad influence that social determinants of health (SDoH) have on Americans’ well-being, quality-of-life, and even life expectancy. However, implementing programs that effectively address SDoH and drive better patient outcomes has proven far more challenging.
SDoH encompass a broad array of factors, including housing, behavioral health, addiction, drugs, alcohol, social isolation, childcare issues, food insecurity, violence, financial stability or lack thereof, employment, and transportation. SDoH often strongly contribute to the wide health and wellness disparities that are found across the nation within the same cities and communities.
For example, a study by Virginia Commonwealth University that examined life expectancy in different Boston neighborhoods revealed that in the wealthy Back Bay neighborhood life expectancy was 92 years, compared to 59 years in the Roxbury neighborhood, with just a half-mile separating the two areas.
Promoting health equity to minimize SDoH disparities
Given the significant correlation between SDoH and life expectancy, the healthcare industry and federal government have placed a greater focus on promoting health equity across America’s communities. One notable example of this prioritization of health equity can be found in the U.S. Centers for Medicare and Medicaid’s (CMS) new Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model.
CMS launched the ACO REACH model in February, highlighting the federal government’s dedication to “promoting value-based care that improves the healthcare experience of people with Medicare, Medicaid and Marketplace coverage.” To that end, CMS requires all model participants to develop and implement “robust” health equity plans to identify underserved communities, in addition to implementing initiatives that “measurably” reduce health disparities within their patient populations.
The new model’s first performance year begins on Jan. 1, 2023, with the model planned to run for four performance years through 2026. Applications to participate in the first year were due near the end of April 2022.
For patients, the promise of the model is better care, but with a greater focus on addressing SDoH, such as barriers to transportation, nutrition, and healthcare. For providers, the ACO REACH model offers the potential of a more predictable revenue stream and the ability to use those funds more flexibly to meet their patients’ needs.
Using analytics to identify health disparities
Umpqua Health is an Oregon-based community care organization (CCO) that serves 35,000 Oregon Health Plan Medicaid members in rural Douglas County, an area in western Oregon that has traditionally been reliant on the logging industry. CCOs are very similar to ACOs, but were set up under a Medicaid waiver Oregon received from CMS, with the intention of state premium dollars going to local, Oregon-based provider groups as opposed to national companies or the state itself.
CCOs prioritize health equity, and accordingly, set aside a large portion of their premium dollars to devote to SDoH services that do not represent true medical costs. For Umpqua Health, examples of these services include temporary housing for patients who are homeless post-discharge and air conditioners for patients enduring heatwaves.
To improve its approach to healthcare delivery through the lens of health equity, Umpqua Health adopted a data and analytics platform that leadership hoped would help the health system address members’ SDoH through care coordination, remove barriers to successful health outcomes, and reduce disparities within the community.
Umpqua Health started by collecting SDoH data through a Health Risk Assessment (HRA), which then triggered specific workflows and helps providers identify members’ specific individual needs, whether medical, pharmacy, mental and behavioral. Analyzing SDoH data within the HRA gave Umpqua Health a clear picture of the issues impacting its community and provided direction on where the health system should focus its energy to best improve the health of its patient population.
Specifically, Umpqua Health identified a need among its patients for higher indoor air quality as a result of the rash of wildfires that western Oregon has seen in recent years. The smoke from these fires negatively impacts both indoor and outdoor air quality for extended periods of time and may cause harm to people with respiratory issues.
Earlier this year, Umpqua Health obtained funding that allowed it to obtain 420 air purifiers to proactively distribute prior to the 2022 fire season, but first health system leadership needed to determine which patients had the greatest need for the devices. Umpqua Health used its analytics platform to pinpoint the patients most at-risk for respiratory complications by running a model that predicts an individual’s future risk based on past events and claims data.
The health system then contacted those members via text message to gauge their interest, and then began distributing the purifiers to patients through its transitional care clinics, in addition to home deliveries for homebound patients. So far, 76% of patients contacted have accepted the offer of the air purifiers, and Umpqua Health has distributed 309 of its 420 total allotment.
Umpqua Health is just one example of many small, regional programs that provider organizations have employed to promote health equity while also driving higher levels of care for certain patient populations. In nearly all cases, these programs start with collecting and analyzing SDoH data to connect vulnerable populations to the resources they need to address longstanding, systemic health disparities.
Rich Parker, MD
Rich Parker, MD, is Chief Medical Officer at Arcadia, the leading population health management and health intelligence platform. Arcadia transforms data from disparate sources into targeted insights, putting them in the decision-making workflow to improve lives and outcomes.
