We still have work to do to craft and articulate the business case for addressing social needs and creating health equity, says Health Leads Co-Founder Rebecca Onie. One of the foundational questions we need to ask is, “What’s the purpose of the endeavor? Are we willing to accept the parameters of the economics that we are pledging ourselves to try to prove our value as we undertake this?”
When you look at emerging measures that matter to many health systems, if not most in the U.S., very few are functionally achievable without walking through the work of addressing patients’ social and mental health needs. For example, when Health Leads launched, they had 12 months to migrate from the community benefit budget of a Boston hospital to its operating budget. “It seemed impossible,” says Onie. But when they sat down with hospital leadership, Medicaid coverage had just expanded in Massachusetts, and one of the institution’s top priorities was patient satisfaction for those patients. Health Leads was able to demonstrate that “of course patients are happier when you engage with them around their health versus just managing their disease.” The organization has now been in the operating budget of that hospital for over 5 years.
“Part of this is just getting much more clear-eyed about the fact that any of the elements of the Triple Aim that we assert we are committed to are fundamentally unachievable without addressing these realities,” says Onie. “It will take us some time to be able to have the same kind of rigorous evaluation that we built up around traditional clinical practices. But I think everybody understands that that is fundamentally the case.”
But is it really true that we know what to do to achieve health equity but are just not doing it? Toyin Ajayi, Chief Health Officer for Cityblock Health, takes issue with this assertion. Invoking hospital CEOs, CFOs, and other health care leaders, she asks, “Does that mean I’m responsible for paying for housing and for roads and for solving poverty and trauma and institutional racism and despair? Where does my job end? What exactly am I supposed to be doing around this?”
The other question is, “How can I demonstrate a return on investment? Because, like it or not, we are on 1 to 2 to 3-year cycles here and I’ve got to keep the lights on, I’ve got to pay my health care workforce, and by the way I built a new CT scan suite and I’ve got to be able to fund that, too.”
Onie recalls a conversation she had with Kaiser Permanente leader Ray Baxter. “On the one hand, we the health care system could simply pretend that these issues don’t exist in our patients’ lives, which is mostly what we’ve all done. On the other hand, we could go build affordable housing,” he said. “The question is, neither of those seem tenable, but what is the sweet spot? What is the role and the responsibility of our health care system relative to our patients’ social needs?”
“What’s so profound about it is the fact that we don’t know the answer to that question, which assures that we will not begin to reimagine what counts as health care in this country,” says Onie. In response, Health Leads brought together a group of health systems leaders and asked them, “Is there a role and responsibility to address patients’ social needs? If so, what are the boundaries of that? How do we define that?” There was unanimous confirmation that indeed it is our responsibility, and the group hammered out some guiding principles for this effort:
- We have a responsibility to understand our patients’ social needs.
- We have a responsibility to navigate those patients to the resources they need to be healthy, the same way we would any other specialist.
- We have a responsibility to have a dedicated workforce who are thinking about these other dimensions of our patients’ lives.
- We have a responsibility to collect data, not just to establish ROI, but to improve.
- We have a responsibility as leaders to commit to the answer to that question of whether we have a role and responsibility.
“The definition they created will hopefully evolve over time, but I think it’s a totally legitimate starting point,” says Onie.
“What you’re describing is making the assessment of nonmedical needs and referral to those needs a standard of care, that it becomes part of the quality equation of an organization, just like any other quality or safety standard,” says Tyler Norris, Chief Executive Officer for Well Being Trust. He quotes Baxter, as well: “How do we move from doing good things to being accountable for outcomes if in fact our mission is to provide high-quality care to our patients and improve the health of the communities we serve?”
Norris shares two examples from housing. In the first, when Hennepin Health in Minnesota received its Medicaid contract and waiver, they decided to help their frequent utilizer population by securing an apartment and a case worker who would address mental and emotional health and substance use issues. This investment stabilized care, reducing preventable utilization in the emergency department and saving money for the taxpayer.
“I keep asking, ROI to who? If in fact as nonprofit organizations we’re here to serve the community and yet we’re only looking at ourselves in the mirror . . . [but] we’re here to serve our communities and our country, not just our institution,” says Norris.
In a larger example, four health systems in Oregon — Kaiser Permanente, Providence St. Joseph Health, Oregon Health Sciences, and Legacy — built multi-unit mixed use development housing for 350 individuals. This housing not only stabilized the patients and their families who lived there, but it also reduced preventable utilization. “They just pulled money off their Wall Street investment portfolios and said, ‘We’ll put it in a community development corporation that’s building housing right in our own communities,’” explains Norris. “It still produced a stable return to protect the pension funds of the employees that the money is entrusted to, but it’s right back in the community, tied to the mission, not some separate organization that the investment officer runs.”
“We can make wise investments with the capital of organizations, create a health benefit, and return not only to the institution, but more importantly to the communities at whose charter we serve,” he concludes.
From the NEJM Catalyst event Expanding the Bounds of Care Delivery: Integrating Mental, Social, and Physical Health, held at Vanderbilt University Medical Center, January 25, 2018.