As health care organizations accept more responsibility for patient outcomes, interest in understanding the role that social determinants can play in health care outcomes is increasing. Social determinants are defined as "the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness."1 The majority of our health is determined by non-care delivery factors including our personal health behaviors, genetics, and social and environmental exposures.2 These non-care delivery factors have been linked to poorer health care outcomes including delays in diagnosis and treatment, poor treatment adherence, higher utilization and readmission levels, and increased short-term mortality. Concerted research in the United States to address the effects of social determinants on health has come largely through public health agencies and nonprofit organizations.
Health care organizations may lack the expertise and resources needed to address the effects of social determinants on health care outcomes. Before developing an internally based program, organizations should understand what programs matching identified patient needs may already exist in a community. The development of partnerships then between health care organizations and these community-based organizations (CBOs) represent one potential mechanism for addressing the health needs of underserved populations seeking care. Productive and well-coordinated collaborations allow each organization to focus on respective competencies, working efficiently together to improve patient health and health care outcomes.
Partnerships between health care organizations, public health, and CBOs are not new. However, changing financial incentives faced by health care organizations that require a population health perspective are renewing questions about the potential effects that such programs can have on health care quality and utilization. What external programs are linked to evidence-based improvements in health outcomes? Are there specific diseases or conditions for which such programs are most effective? Are the development and promotion of such partnerships by the health care organizations a cost-effective investment of limited resources?
To impact health outcomes, opportunities exist for health care organizations to develop external collaborative partnerships. Issues that limit the benefits of such partnerships include the lack of early due diligence to determine the evidence-based benefits of available programs. Early identification of the governance structure and roles of both parties is needed to ensure efficient coordination and appropriate consenting. Since many social programs are designed specifically to meet the needs of individuals in materially deprived circumstances, identification of individuals most likely impacted by social determinants is needed to best deploy scarce dollars. More robust, streamlined information sharing is needed that is fully compliant with institutional review board regulations and HIPAA patient privacy protections.
Intermountain Healthcare is advancing efforts to understand the role that external collaborative partnerships can play in quality improvement. How are we doing this? The Intermountain Healthcare community benefit program, research, and clinical teams are working to identify community- and evidence-based programs that may contribute to better health for our patient population. Once identified, we are establishing a partnership governance structure with the external program that includes clear, shared goals and defined roles to ensure effective deployment. To support this, as a health care organization, we are bringing predictive analytics to bear to identify patients most likely to benefit from external program interventions. To increase patient participation and retention rates for selected programs, we are using frontline clinical team engagement to extend warm invitations to patients to participate as an element in their clinical treatment plan. Finally, we are conducting ongoing patient monitoring to solicit patient feedback and to monitor overall program effectiveness in improving health and health care outcomes.
Our partnership with the Salt Lake County Department of Health (SLCO) highlights efforts between Intermountain Healthcare and the SLCO to improve prenatal care in vulnerable populations through the Nurse-Family Partnership (NFP) program. Proper prenatal care for an expectant mother can significantly improve the health and health care outcomes for the expectant mother and the life course results for the child. For expectant mothers at risk for not receiving proper prenatal care, nurse-based home visits, starting in pregnancy and extending for the first few years of the child's life, have been shown to be effective as a mechanism for improving health outcomes near and long-term for both the mother and the child. The NFP program is an evidence-based public health program specifically designed to provide nurse home visits to support prenatal care and early childhood development.
As a health care organization, a collaborative partnership with the SLCO was natural, given our shared mission. Within Intermountain Healthcare, a center-led governance structure was put in place, led by a pediatrician and regional medical director to coordinate program deployment. Working collaboratively, Intermountain Healthcare is responsible for patient identification and invitation and for program evaluation. The SLCO is responsible for program delivery and reporting. A working team with participants from both organizations meets regularly both to coordinate efforts and to share learning.
One early insight uncovered through this approach was that no standard criterion was being consistently followed within Intermountain Healthcare to guide the referral process. A review of past referral patterns noted that a number of patients being referred by Intermountain Healthcare were from higher-income neighborhoods or were on commercial insurance. When eligible, these patients enrolled at higher rates but were less likely to remain in the program. This information has informed development of clearly understood referral criteria, including a census-based measure of social determinants, used to narrow the field of potential candidates.3 An evaluation of program impact on patient health care outcomes is underway.
Challenges exist for health care organizations engaging patients in these external partnerships. Many health care organizations lack the patient data useful in identifying eligible patients, particularly data on social determinants, which are linked to program eligibility. Payer status is a common surrogate but has limitations in adult populations, given Medicaid eligibility requirements in many states. To address this, Intermountain Healthcare has deployed an area deprivation index (ADI) as a surrogate measure of patient socioeconomic status based upon a patient's neighborhood of residence. When combined with other patient demographic data, ADI is proving useful in efforts to efficiently identify those patients with greatest potential need who may receive the greatest benefit. Our findings are supported by external research that points to increased economic benefits for high-risk patients.4
Multiple conversations are needed early on to establish expectations and operating procedures between the parties. This includes clear, HIPAA-supported guidelines for patient consent and information sharing. Such conversations should generally be documented in writing as a memorandum of understanding with regard to how the parties will work together.
Finally, our internal evidence suggests that patients who receive an invitation from their primary care provider to consider an external program are more likely to participate and receive program benefits. Early engagement and buy-in from affected clinical teams are essential. As the obstetrics/gynecology (OB/GYN) clinic team received regular feedback from the SLCO on services provided to its patients, the OB/GYN team reciprocally became more engaged in effective referrals to the SLCO. Over time, consistent bidirectional collaboration has built a positive feedback loop of trust between service teams.
Health care is often viewed as an insular profession. With increased accountability for overall patient health, health care organizations would be wise to collaborate with expertise available through external, nonclinical partnerships to improve patient health. Evidence-based public health programs coordinated through well-designed external partnerships hold promise in curbing the effects that social determinants have on health care outcomes and in tailoring care to vulnerable populations.
REFERENCES