Although much remains uncertain about the future of U.S. healthcare, most can agree that the ecosystem has traditionally been extremely siloed. Health plan members, patients and consumers often have completely separate relationships with their insurer, provider and community resources. As a result, these groups rarely collaborate when it comes to care, often at the expense of patients’ wellbeing.
Data is inarguably at the center of quality care, and technology can serve as the key to unlocking valuable information to unite payers, providers and community partners. Insurers are uniquely positioned as they capture and aggregate critical data on claims, chronic conditions, medications and treatments. Providers typically have the richest encounter data given their direct contact with patients, and community resources are positioned to build an authentic relationship based on trust, dependability and improved wellbeing. At the root of these successful partnerships is underlying technology that allows data to flow seamlessly and analyzes the characteristics of communities in need.
Social determinants of health play an important role in pinpointing these communities. These include the conditions in which people are born, grow, live, work and age. Some of the most powerful factors are socioeconomic status, education, physical environment, access to transportation, employment, social support networks and access to care.
A meta-analysis of nearly 50 studies from the Kaiser Family Foundation found that social factors such as education, racial segregation, lack of social supports and poverty accounted for more than one third of total deaths in the U.S. in a year. Social isolation is the social determinant of health with the most severe consequences, particularly among the elderly, where loneliness and lack of companionship promote depression and its effects on chronic conditions. In fact, isolation is reported to carry the same health risk as smoking and double that of obesity.
Government organizations are beginning to recognize the tie between social determinants of health and health outcomes. Recently, the U.S. Department of Health and Human Services reported to Congress how social determinants of health negatively affect both patient outcomes and provider performance. For example, while value-based payments can help patients with poor outcomes receive more appropriate care, the standard benefits of this payment model do not help when a patient has poor health outcomes due to social determinants of health. When we take socioeconomic status into consideration, we can avoid the potential risk of providers refusing to treat poorer, sicker patients.
Notably, there is a disconnect between what actually makes people healthy and what they think makes them healthy. A staggering 88% of healthcare spending is dedicated to medical services, while just 4% supports healthy behaviors, half of which, including healthy eating and exercise, impact our health for the better. It is more and more necessary for health systems and health plans to collaborate with social service providers and community resources to fulfill members’ needs and, as a result, improve outcomes.
This type of collaboration is not just a theory – it’s been proven successful. Payers, providers and local agencies collaborated to form the Eastern Virginia Care Transitions Partnership to focus on members who are eligible for both Medicare and Medicaid in eastern Virginia. The program included a team of highly trained health coaches dedicated to transitioning patients out of hospital stays. The coaches were tasked with home visits, an important key to assessing and acting on behalf of the patients’ wellbeing.
During visits, Eastern Virginia Care Transitions Partnership witnessed, and were able to assist with, patients’ various physical, mental and logistical needs, with one of the biggest factors affecting care being access to reliable transportation. The group enrolled in this program had a hospital readmission rate of 9.1% compared to 14.4% for those not enrolled. Perhaps even more importantly, by the end of the program the patients who received home visits felt more engaged and confident in their ability to manage their own care.
The S.A.G.E. PROJECT (Summa Health System/Area Agency on Aging/Geriatric Evaluation Project) also found success through community engagement. Over a four-year period, acute hospital and medical care services in Ohio partnered with a community agency to improve the health and prevent the institutionalization of older adults at risk of nursing home placement. Thanks to personalized care plans, the number of participants transitioning from hospital settings to nursing facilities decreased by more than 20%, enabling them to continue functioning as a member of the community with enhanced self-sufficiency. The S.A.G.E. PROJECT has significantly decreased the patient-intensive resources needed to care for this group and created a population of members with dramatically better quality of life.
There is no doubt that care coordination is a collaborative effort that requires synchronization of many moving parts. Clinical care teams must combine with a holistic care team to consider the additional aspects of a member’s health beyond acute care, along with a community care team to provide critical non-clinical services, such as transportation.
When insurers tap into their massive data warehouses and make that information available to providers, local resources and family members in a meaningful way, these three entities can come together to significantly affect health outcomes for individuals. By treating the whole person (mind, body and soul) clinical, holistic and community care teams can meaningfully and positively impact health outcomes.
Harry Merkin is vice president of marketing, HealthEdge, a developer of integrated financial, administrative and clinical software platform for healthcare payers.