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Addressing Social Determinants of Health in Physician Practices: A Model for Success

by | Aug 1, 2018

Health plans and payers recognize the profound importance of social determinants of health in managing the overall health of a population. These issues first began to surface in case management programs, as nurse case managers were speaking with patients and learning firsthand about the challenges that were preventing them from properly managing their chronic conditions. Patients without access to healthy food, clean drinking water, shelter, properly functioning appliances, transportation and many other social determinants of health are limited in their ability to follow basic instructions from their health care provider.

Social determinants of health are frequently the root cause of hospital re-admissions and emergency room visits.

Forward thinking health plans soon realized that solving these types of social needs could lead to improved compliance and decreased medical costs. But health plans cannot do it alone. While health plan case management programs are a powerful way to reach patients, they have a limited scope. There are so many patients with complex social and financial needs, but only a few of those patients end up on a case manager’s caseload – often after the situation has already reached a crisis state.

Physician practices are the key to extending the reach of the health plan to identify the social determinants of health that are impacting a patient’s health and well-being. Partnering with physician practices to implement a model for screening and responding to social determinants of health can lead to improved quality of care and better outcomes for patients. It can also ensure that health plans meet the requirements for state and federal value-based care programs, as well as evolving accreditation requirements for population health management.

Medical Advantage partnered with a 450-member physician organization (PO) to assist with enhancing its capabilities as a patient-centered medical home. One of the primary objectives was to engage with patients and develop strategies around population health management. Medical Advantage employed social workers and nurses to work directly with the PO’s primary care practices. These on-site care managers focused primarily on the managed Medicaid population, which includes individuals who are generally known to be at higher risk socially and economically.

Screening for Social Determinants of Health

Managing social determinants of health begins with asking the right questions. Medical Advantage worked with 22 of the largest primary care practices within the PO to implement a screening questionnaire that is administered to all patients. All of the practices serve a sizeable managed Medicaid population. The questions are brief and include emoji’s for those patients who might have difficulty reading or interpreting the form. All questions are written so that a “yes” answer indicates that the patient has a need.

The social determinants questionnaire includes the following domains:

  • Food
  • Utilities
  • Housing
  • Access to Clean Water
  • Financial Status
  • Child Care
  • Transportation
  • Literacy
  • Home Safety
  • Alcohol and Drug Use/Abuse
  • Mental Health

The practices integrated the questionnaire in various ways. Some practices hand a paper copy to patients upon check-in and ask that they fill it out prior to being taken to a room, while other practices have a medical assistant or other staff member ask the questions once the patient is in the exam room. Other practices are utilizing their embedded care manager to meet with all managed Medicaid patients to complete the screening face to face. This allows the care manager to immediately engage with the patient and provide counseling, services, or referrals as needed.

After 18 months of implementing the screening process, the 22 practices have completed a total of 6,500 screens from all populations. This information is entered and stored in a discrete fashion so that later analyses can be conducted.

Responding to Social Determinants of Health

Based on the results of the questionnaire, care managers work face-to-face, individually with patients to address gaps and provide education for both clinical and social needs. This requires frequent utilization of evidenced-based counseling techniques such as motivational interviewing, self-management techniques, and active listening. Care managers build care plans based on both longitudinal and episodic needs, aimed at improving health status, preventing onset of chronic diseases, and reducing emergency department and inpatient utilization.

Patients are routinely screened at the onset of care management services and are rescreened on an annual basis or as needed throughout the year if a change is mentioned or suspected. If needs are identified, care managers are referring and directly linking patients to community resources that can provide services or necessities. Such programs could provide patients with short-term or long-term housing, access to bottled water or water filtration systems, clothing, food, emergency utility assistance, medical equipment, transportation, and many other provisions. Referrals are not only arranged and initiated, but care managers provide regular follow-up with both patients and community agencies to determine if the patient’s needs have been met.

In addition to the embedded care managers who work at the primary care practice, Medical Advantage also provides access to a central care team that includes a pharmacist, dietitian, and a behavioral health counselor. Care managers can refer managed Medicaid patients for these additional supports to target the areas of concern that ultimately impact the patient’s overall health.

Data Mining to Identify Needs and Monitor Trends

Unfortunately, not all patients with social needs show up in the physician’s office. Medical Advantage also provides the PO with two additional resources for data mining. These individuals review data that is available from Medicaid health plans and other sources to identify patients who may need to be seen in the office, such as:

  • Patients who are over-utilizing the emergency department or utilizing it inappropriately.
  • Patients with high medical costs or concerning utilization trends.
  • Patients with chronic conditions with lab results out of the desired range, or no lab results at all.

These patients are then contacted by Medical Advantage’s centralized care management staff and connected to their primary care office to schedule an appointment. During this call, the care management staff is also able to walk through the social determinants of health questionnaire to determine if there is anything that might prevent the patient from actually attending their visit, such as transportation or child care, so that arrangements or agency referrals can be made.

In addition to identifying individual patient needs, the social determinants of health screening questionnaire also serves a broader purpose for data collection. The PO is able to compile all of the results within Medical Advantage’s data warehouse, essentially creating a database of needs across its entire population. Through this database, Medical Advantage can build the PO a suite of population health management reports to answer questions such as:

  • What are the most common social needs among the patient population?
  • Are there geographic locations where certain social needs are highest?
  • Are there linkages between specific social needs and chronic conditions, such as high blood pressure or diabetes?

Armed with this information, the PO and the primary care practices can develop more targeted interventions and build stronger relationships with non-profit and human services agencies to serve the specific needs of their patient population.

Funding is a major challenge for POs and primary care practices who are interested in implementing similar types of programs. Health plans have an opportunity to support physician practices in their efforts to address social determinants of health by providing financial resources, data mining tools and embedded care managers to perform the work. A small investment in a few targeted practices can lead to big payoffs in terms of improved quality and reduced medical costs.


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