Health Care Steps Up to Social Determinants of Health: Current Context.
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ABSTRACT:
SUBMITTER: Solomon LS
PROVIDER: S-EPMC6207436 | biostudies-other | 2018
REPOSITORIES: biostudies-other
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Project description:ImportanceManaged care payment formulas commonly allocate more money for medically complex populations, but ignore most social determinants of health (SDH).ObjectiveTo add SDH variables to a diagnosis-based payment formula that allocates funds to managed care plans and accountable care organizations.Design, setting, and participantsUsing data from MassHealth, the Massachusetts Medicaid and Children's Health Insurance Program, we estimated regression models predicting Medicaid spending using a diagnosis-based and SDH-expanded model, and compared the accuracy of their cost predictions overall and for vulnerable populations. MassHealth members enrolled for at least 6 months in 2013 in fee-for-service (FFS) programs (n = 357 660) or managed care organizations (MCOs) (n = 524 607).ExposuresWe built cost prediction models from a fee-for-service program. Predictors in the diagnosis-based model are age, sex, and diagnoses from claims. The SDH model adds predictors describing housing instability, behavioral health issues, disability, and neighborhood-level stressors.Main outcomes and measuresOverall model explanatory power and overpayments and underpayments for subgroups of interest for all Medicaid-reimbursable expenditures excepting long-term support services (mean annual cost = $5590 per member).ResultsWe studied 357 660 people who were FFS participants and 524 607 enrolled in MCOs with a combined 806 889 person-years of experience. The FFS program experience included more men (49.6% vs 43.6%), older patients (mean age of 26.1 years vs 21.6 years), and sicker patients (mean morbidity score of 1.16 vs 0.89) than MCOs. Overall, the SDH model performed well, but only slightly better than the diagnosis-based model, explaining most of the spending variation in the managed care population (validated R2 = 62.4) and reducing underpayments for several vulnerable populations. For example, raw costs for the quintile of people living in the most stressed neighborhoods were 9.6% ($537 per member per year) higher than average. Since greater medical morbidity accounts for much of this difference, the diagnosis-based model underpredicts costs for the most stressed quintile by about 2.1% ($130 per member per year). The expanded model eliminates the neighborhood-based underpayment, as well as underpayments of 72% for clients of the Department of Mental Health (observed costs of about $30 000 per year) and of 7% for those with serious mental illness (observed costs of about $16 000 per year).Conclusions and relevanceSince October 2016, MassHealth has used an expanded model to allocate payments from a prespecified total budget to managed care organizations according to their enrollees' social and medical risk. Extra payments for socially vulnerable individuals could fund activities, such as housing assistance, that could improve health equity.
| S-EPMC5710209 | biostudies-literature
Project description:IntroductionGlobal health case studies can highlight, often in dramatic fashion, topics such as health disparities, health systems, and the social determinants of health. This resource presents a case study of an adolescent Haitian boy requiring lifesaving heart surgery in the US due to an acquired mitral valve disease from untreated streptococcal pharyngitis.MethodsWhile the case begins in a US clinic setting, it then goes on to explore the patient's home context-an impoverished village in rural Haiti-in order to demonstrate the effect of social determinants on both an individual's health and the capacity of health care systems to provide appropriate care. The case study concludes by asking the students to explore which health interventions, from a list of options, they would recommend to improve health in rural Haiti. Students discuss the advantages and disadvantages of developing health initiatives that vary by level of impact and approach.ResultsThis case study has been presented to two classes of first-year medical students during their Health Systems course and was well received.DiscussionBy providing linkages between the local and international contexts, this case provides greater relevance for global health material to all participating students.
| S-EPMC6464409 | biostudies-literature
Project description:The Millennium Development Goals (MDGs) mobilized global commitments to promote health, socioeconomic, and sustainable development. Trends indicate that the health MDGs may not be achieved by 2015, in part because of insufficient coordination across related health, socioeconomic, and environmental initiatives. Explicitly acknowledging the need for such collaboration, the Meikirch Model of Health posits that: Health is a state of wellbeing emergent from conducive interactions between individuals' potentials, life's demands, and social and environmental determinants. Health results throughout the life course when individuals' potentials--and social and environmental determinants--suffice to respond satisfactorily to the demands of life. Life's demands can be physiological, psychosocial, or environmental, and vary across contexts, but in every case unsatisfactory responses lead to disease. This conceptualization of the integrative nature of health could contribute to ongoing efforts to strengthen cooperation across actors and sectors to improve individual and population health--leading up to 2015 and beyond.
| S-EPMC4119253 | biostudies-other
Project description:BACKGROUND:Social Health Insurance (SHI) is widely used by countries attempting to move toward Universal Health Coverage (UHC). While evidence suggests that SHI is a promising strategy for achieving UHC, low-income countries often struggle to implement and sustain SHI systems. It is therefore important to understand how SHI enrollees use health insurance and how it affects their health-seeking behavior. This paper examines how SHI affects patient decision-making regarding when and where to seek care in Kenya and Ghana, two countries with established SHI systems in sub-Saharan Africa. METHODS:This paper draws from two datasets collected under the African Health Markets for Equity (AHME) program. One dataset, collected in 2013 and 2017 as part of the AHME qualitative evaluation, consists of 106 semi-structured clinic exit interviews conducted with patients in Ghana and Kenya. This data was analyzed using an inductive, thematic approach. The second dataset was collected internally by the AHME partner organizations. It derives from a cross-sectional survey of social franchise clients at three social franchise networks supported by AHME. Data collection took place from February - May 2018 and in December 2018. RESULTS:Many clients appreciated that insurance coverage made healthcare more affordable, reported seeking care more frequently when covered with SHI. Clients also noted that the coverage gave them access to a wider variety of providers, but rarely sought out SHI-accredited providers specifically. However, clients sometimes were charged for services that should have been covered by insurance. Due to a lack of understanding of SHI benefits, clients rarely knew they had been charged inappropriately. CONCLUSIONS:Clients and providers would benefit from education on what is included in the SHI package. Providers should be monitored and held accountable for charging clients inappropriately; in Ghana this should be accompanied by reforms to make government financing for SHI sustainable. Since clients valued provider proximity and both Kenya and Ghana have a dearth of providers in rural areas, both countries should incentivize providers to work in these areas and prioritize accrediting rural facilities into SHI schemes to increase accessibility and reach.
| S-EPMC7197151 | biostudies-literature
Project description:This work is an implementation science study that examines different aspects of implementing a single intervention. The intervention consists of asking community health centers to implement an outreach strategy to screen patients for colorectal cancer and for social determinants of health in community health centers at the same contact point. These are both clinical targets that the CHCs feel that their patients need and want to offer at a higher rate. The intervention consists of outreach to patients in need of colorectal cancer screening (CRC) to offer fecal immunochemical test (FIT) screening and screening for social determinants of health (SDOH). In this implementation science study, the intervention is an evidence-based intervention being implemented in real-world clinical practice. The intervention is the outreach to offer FIT and SDOH, conducted by clinic staff. Both evidence-based screening activities-FIT and SDOH screening-are used in the practices included in the study but pairing them is intended to increase efficiency and patient-centeredness by addressing health related social needs that may impact patients’ ability to engage in cancer screening. The study aims to test the effect of implementing the intervention on clinical and process outcomes. Clinical outcomes are CRC screening and SDOH screening. Analysis of process outcomes includes measuring what organizational factors influence implementation.
| 2354406 | ecrin-mdr-crc
Project description:BACKGROUND: Clinicians in ambulatory care settings are increasingly called upon to use health information technology (health IT) to improve practice efficiency and performance. Successful adoption of health IT requires an understanding of how clinical tasks and workflows will be affected; yet this has not been well described. OBJECTIVE: To describe how health IT functions within a clinical context. DESIGN: Qualitative study, using in-depth, semi-structured interviews. PARTICIPANTS: Executives and staff at 4 community health centers, 3 health center networks, and 1 large primary care organization. APPROACH: Transcribed audio-recorded interviews, analyzed using the constant comparative method. RESULTS: Systematic characterization of clinical context identified 6 primary clinical domains. These included results management, intra-clinic communication, patient education and outreach, inter-clinic coordination, medication management, and provider education and feedback. We generated clinical process diagrams to characterize these domains. Participants suggested that underlying workflows for these domains must be fully operational to ensure successful deployment of health IT. CONCLUSIONS: Understanding the clinical context is a necessary precursor to successful deployment of health IT. Process diagrams can serve as the basis for EHR certification, to identify challenges, to measure health IT adoption, or to develop curricular content regarding the role of health IT in clinical practice.
| S-EPMC2359517 | biostudies-other
Project description:To evaluate the effect of a clinic-based screening and referral system (Well Child Care, Evaluation, Community Resources, Advocacy, Referral, Education [WE CARE]) on families' receipt of community-based resources for unmet basic needs.We conducted a cluster randomized controlled trial at 8 urban community health centers, recruiting mothers of healthy infants. In the 4 WE CARE clinics, mothers completed a self-report screening instrument that assessed needs for child care, education, employment, food security, household heat, and housing. Providers made referrals for families; staff provided requisite applications and telephoned referred mothers within 1 month. Families at the 4 control community health centers received the usual care. We analyzed the results with generalized mixed-effect models.Three hundred thirty-six mothers were enrolled in the study (168 per arm). The majority of families had household incomes <$20,000 (57%), and 68% had ? 2 unmet basic needs. More WE CARE mothers received ? 1 referral at the index visit (70% vs 8%; adjusted odds ratio [aOR] = 29.6; 95% confidence interval [CI], 14.7-59.6). At the 12-month visit, more WE CARE mothers had enrolled in a new community resource (39% vs 24%; aOR = 2.1; 95% CI, 1.2-3.7). WE CARE mothers had greater odds of being employed (aOR = 44.4; 95% CI, 9.8-201.4). WE CARE children had greater odds of being in child care (aOR = 6.3; 95% CI, 1.5-26.0). WE CARE families had greater odds of receiving fuel assistance (aOR = 11.9; 95% CI, 1.7-82.9) and lower odds of being in a homeless shelter (aOR = 0.2; 95% CI, 0.1-0.9).Systematically screening and referring for social determinants during well child care can lead to the receipt of more community resources for families.
| S-EPMC4306802 | biostudies-literature
Project description:This public mental health study highlights the interactions among social determinants and resilience on mental health, PTSD and acculturation among Iraqi refugees in Sweden 2012-2013. Objectives: The study aims to understand participants' health, resilience and acculturation, paying specific attention to gender differences. Design: The study, using a convenience sampling survey design (N = 4010, 53.2% men), included measures on social determinants, general health, coping, CD-RISC, selected questions from the EMIC, PC-PTSD, and acculturation. Results: Gender differences and reported differences between life experiences in Iraq and Sweden were strong. In Sweden, religious activity was more widespread among women, whereas activity reflecting religion and spirituality as a coping mechanism decreased significantly among men. A sense of belonging both to a Swedish and an Iraqi ethnic identity was frequent. Positive self-evaluation in personal and social areas and goals in life was strong. The strongest perceived source of social support was from parents and siblings, while support from authorities generally was perceived as low. Self-rated health was high and the incidence of PTSD was low. A clear majority identified multiple social determinants contributing to mental health problems. Social or situational and emotional or developmental explanations were the most common. In general, resilience (as measured with CD-RISC) was low, with women's scores lower than that of men. Conclusions: Vulnerability manifested itself in unemployment after a long period in Sweden, weak social networks outside the family, unsupportive authorities, gender differences in acculturation, and women showing more mental health problems. Though low socially determined personal scores of resilience were found, we also identified a strong level of resilience, when using a culture-sensitive approach and appraising resilience as expressed in coping, meaning, and goals in life. Clinicians need to be aware of the risks of poorer mental health among refugees in general and women in particular, although mental health problems should not be presumed in the individual patient. Instead clinicians need to find ways of exploring the cultural and social worlds and needs of refugee patients. Authorities need to address the described post-migration problems and unmet needs of social support, together comprising the well-established area of the social determinants of health.
| S-EPMC8109031 | biostudies-literature
Project description:BackgroundVeterans increasingly utilize both the Veteran's Health Administration (VA) and non-VA hospitals (dual-users). Dual-users are at increased risk of fragmented care and adverse outcomes and often do not receive necessary follow-up care addressing social determinants of health (SDOH). We developed a Veteran-informed social worker-led Advanced Care Coordination (ACC) program to decrease fragmented care and provide longitudinal care coordination addressing SDOH for dual-users accessing non-VA emergency departments (EDs) in two communities.MethodsACC had four core components: 1. Notification from non-VA ED providers of Veterans' ED visit; 2. ACC social worker completed a comprehensive assessment with the Veteran to identify SDOH needs; 3. Clinical intervention addressing SDOH up to 90 days post-ED discharge; and 4. Warm hand-off to Veteran's VA primary care team. Data was documented in our program database. We performed propensity matching between a control group and ACC participants between 4/10/2018 - 4/1/2020 (N- = 161). A joint survival model using Markov Chain Monte Carlo technique was employed for 30-day outcomes. We performed Difference-In-Difference analyses on number of ED visits, admissions, and primary care physician (PCP) visits 120-day pre/post discharge.ResultsWhen compared to a matched control group ACC had significantly lower risk of 30-day ED visits (Hazard Ratio (HR) = 0.61, 95% Confidence Interval (CI) = (0.42, 0.92)) and a higher probability of PCP visits at 13-30 days post-ED visit (HR = 1.5, 95% CI = (1.01, 2.22)). Veterans enrolled in ACC were connected to VA PCP visits (50%), VA benefits (19%), home health care (10%), mental health and substance use treatment (7%), transportation (7%), financial assistance (5%), and homeless resources (2%).ConclusionWe developed and implemented a program addressing dual-users' SDOH needs post non-VA ED discharge. Social workers connected dual-users to needed follow-up care and resources which reduced fragmentation and adverse outcomes.
| S-EPMC8754195 | biostudies-literature
Project description:BackgroundThe Health Resources and Services Administration (HRSA), an agency within the U.S. Department of Health and Human Services (HHS), works to ensure accessible, quality, health care for the nation's underserved populations, especially those who are medically, economically, or geographically vulnerable. HRSA-designated primary care Health Professional Shortage Areas (pcHPSAs) provide a vital measure by which to identify underserved populations and prioritize locations and populations lacking access to adequate primary and preventive health care-the foundation for advancing health equity and maintaining health and wellness for individuals and populations. However, access to care is a complex, multifactorial issue that involves more than just the number of health care providers available, and pcHPSAs alone cannot fully characterize the distribution of medically, economically, and geographically vulnerable populations.Methods and findingsIn this county-level analysis, we used descriptive statistics and multiple correspondence analysis to assess how HRSA's pcHPSA designations align geographically with other established markers of medical, economic, and geographic vulnerability. Reflecting recognized social determinants of health (SDOH), markers included demographic characteristics, race and ethnicity, rates of low birth weight births, median household income, poverty, educational attainment, and rurality. Nationally, 96 percent of U.S. counties were either classified as whole county or partial county pcHPSAs or had one or more established markers of medical, economic, or geographic vulnerability in 2017, suggesting that at-risk populations were nearly ubiquitous throughout the nation. Primary care HPSA counties in HHS Regions 4 and 6 (largely lying within the southeastern and south central United States) had the most pervasive and complex patterns in population risk.ConclusionHHS Regions displayed unique signatures with respect to SDOH markers. Descriptive and analytic findings from our work may help inform health workforce and health care planning at all levels, and, by illustrating both the complexity of and differences in county-level population characteristics in pcHPSA counties, our findings may have relevance for strengthening the delivery of primary care and addressing social determinants of health in areas beset by provider shortages.
| S-EPMC7182224 | biostudies-literature