Twenty years; that’s how much longer someone who spends their life in an affluent neighbourhood might live compared to someone who grows up in a socioeconomically deprived section of the same city. That appears to be the case in major cities across Europe and the United States. This inequality in health outcomes is only to a small part explained by the lack of access to medical care. Last month we published our report, Breaking the dependency cycle which examined the more intransigent causes including access to and opportunities in education, employment, housing, public transport and welfare services . Our report identifies a host of case studies and urges governments and providers to break down organisational barriers and collectively address these wider social determinants of health. Throughout our research, we were able to exchange ideas with our colleagues from the US Center for Health Solutions who last week launched their report Addressing social determinants of health in hospitals that analyses, how US hospitals, in their crucial position within the care system, are investing in social needs. This week’s blog is written by our US colleague, Josh Lee, who leads the firm’s US Healthcare Provider Strategy Practice and first appeared as part of the US Center for Health Solution blog. The article highlights the motivation for the report, identifies challenges and points to key strategies that could be adopted by hospitals and integrated local health systems globally to improve health outcomes.
What are US hospitals doing to improve the health of their communities?
Across the US, and around the planet, many people are not as healthy as they could be, and their environment and social needs are critical factors.1 To understand what hospitals are doing to identify and help people whose health might be negatively affected by their environment, the Deloitte Center for Health Solutions surveyed executives from 300 hospitals and conducted phone interviews. Although the majority of US hospitals surveyed are screening and intervening with patients to address issues tied to social determinants, most efforts appear to be more ad hoc or inconsistent and targeting only segments of the population, according to our new Deloitte Center for Health Solutions research.
Health-related social needs – also known as social determinants of health – are the economic and social conditions that impact health. In general terms, this is the environment in which people are born, grow, learn, work, and age.2 The full consequences these factors have on health can play out over a lifetime, and might not be apparent until someone visits a hospital. Only about 20 percent of health outcomes are determined by clinical care, yet clinical care accounts for most of the health care investment.3 And hospitals are typically only one piece of the nation’s fragmented health care system.
Most hospitals report a range of activity, but efforts can be difficult to measure
While the UK study examines the impact that economic and social disadvantages have on families and their health in Western Europe, our paper focuses on the role hospitals can play in improving the health of their communities. Rather than highlighting specific patients or families helped by a hospital, we ask about the organization’s day-to-day activities in addressing social determinants. While our survey shows that many hospital leaders are committed to this issue, follow through appears inconsistent, and hospitals generally don’t consistently track or evaluate health and cost outcomes from their initiatives. Here’s what we found:
- Approaches are often fragmented: The vast majority of surveyed hospitals (88 percent) screen for social needs, which may be a first step to identify social needs. Hospitals surveyed tend to work more closely with their inpatient populations and high utilizers of care as opposed to targeting other members of the community who might be at risk. Once people leave the hospital, care management can help address issues once the patient returns home. Hospitals may, for example, ask patients about family support once they leave the hospital, or ask about barriers to getting healthy food, or transportation to medical appointments or to pick up prescriptions.
- There is limited short-term ROI: Health systems that invest in improving the health of their communities generally would like to see ROI in terms of improved health outcomes, reduced costs, or both. About half of our respondents say evidence of ROI would increase their organization’s investments in health-related social needs activities. However, examining ROI for health-related social needs requires hospitals to identify meaningful measures and track them. Sustainable funding can be a challenge for hospitals, and determining ROI is typically difficult to track unless a long time frame is considered.
- Some hospitals are further along than others: Some hospitals are only scratching the surface when it comes to addressing social needs, while others are making more substantial progress. Examples highlighted in the paper include hospitals with medical-legal partnerships that help patients get the required medical documentation and have protection letters from attorneys to avoid utility shut off; and hospitals partnering with community organizations such as food banks to help patients facing food insecurity have access to free or inexpensive healthy meals, and education on preparing affordable healthy meals
- Health systems that are more focused on vale-based care are investing the most: Hospitals surveyed that are moving toward value-based care models – such as accountable care organizations, capitated payment models, or bundling – report the highest level of investments and most activity around addressing social needs. Respondents from hospitals that participate in more than one value-based care model were also more likely to say that their organization’s mission and vision completely aligns with meeting health-related social needs. Additionally, these respondents were tracking more social needs measures and measuring more outcomes.
Lack of access to medical care and unhealthy lifestyles may only partially explain differences in health status as, at most, only 15-25 percent of health outcomes are determined by health care.4 Successfully addressing health-related social needs commonly requires a collective effort among stakeholders across the health care ecosystem. Hospitals and health systems could build relationships with community organizations, health plans, local governments and employers to implement initiatives that can lead to healthier communities. Many of our survey respondents recognize the potential impact the hospital can have in improving the health of their communities, but they acknowledge finances and staffing might limit their ability to address health issues tied to social determinants. After receiving care at a hospital, health problems could continue if the patient returns to the same environment.
So what is the solution for hospitals that want to advance their efforts in addressing the health-related social needs of their patients and communities? Both the UK and US papers suggest that addressing social needs will likely require an ecosystem approach. Opportunities to share leading practices, integrate data to help identify needs and measure outcomes, and collaborate on community initiatives will likely be critical to help stakeholders to make the most of their efforts. In the US, most interviewees agreed that the continued move toward value-based care may help further align social needs and clinical care. And, forthcoming results and lessons learned from the Centers for Medicare and Medicaid Services’ Accountable Health Communities Model, which will run for five years across 32 organizations, is expected by many to illuminate leading practices on linking community-based services and clinical services.
1 Paul D. Loprinzi, Adam Branscum, June Hanks, and Ellen Smit, “Healthy lifestyle characteristics and their joint association with cardiovascular disease biomarkers in US adults,” Mayo Clinic Proceedings, 2016
2 Health Policy Brief: The Relative Contribution of Multiple Determinants to Health Outcomes,” Health Affairs, August 21, 2014
3 2017 County Health Rankings
4 Health Policy Brief: The Relative Contribution of Multiple Determinants to Health Outcomes,” Health Affairs, August 21, 2014