Breaking Down the Silos of Patient Care: Integration of Social Support Services into Health Care
Delivery
Robyn Golden, LCSW
Director of Health and Aging
Rush University Medical Center
National Health Policy Forum
October 19, 2012
• Started the day with 36-year-old brother of a 50-year-old man with dementia – Limited English speaking
– Low socioeconomic status
• Ended the day with a 99-year-old woman proud to not be using a walker
– High financial means, but lonely
• Both very different scenarios with implications on health outcomes
Just Yesterday…
• Social determinants influence health outcomes1
– Social gradient (SES, education, culture)
– Stress
– Early life
– Social exclusion
– Work
– Unemployment
– Social support
– Addiction
– Food
– Transportation
Social Need
Societal-level social determinants have individual-level impact2
Social Factors and Health Outcomes
Issue Outcome
Low education, lack of social support, and social
exclusion
Poor self-management3 and reduced care plan
adherence4
Housing5 and transportation6 issues
Increased health care costs
and utilization
Health disparities and psychosocial issues
Preventable hospitalizations7 and mortality8
• 2011 Robert Wood Johnson Foundation survey of 1,000 primary care physicians 9
– 85% feel social needs directly contribute to poor health10
– 4 out of 5 not confident can meet social needs, hurting their ability to provide quality care10
– Rx for social needs, if they existed, would be 1 in 7 Rx’s written10
• Psychosocial issues treated as physical concerns11
Health Care’s Blind Side
• 2012 John A. Hartford Foundation survey shows consumers feel the impact of “health care’s blind side”12 – Not treated as a whole person
– Rarely asked about issues impacting well-being • Activities of daily living
• Falls
• Mental health
– Lack of communication and coordination
• No one asks the caregiver how they are doing
What Happens to Consumers?
• Community-based services and supports system could be addressing psychosocial issues – Community-based organizations (CBOs) – Aging and disability network – Long term services and supports (LTSS) – Mental health services
• Institute of Medicine recommendation: “community links”13
– Assessing psychosocial issues – Delivering services in the community – Communicating these issues with medical team
In Health Care’s Blind Spot…
• “Siloed” health and social service systems
– Separate and distinct funding streams
– Different delivery systems and eligibility rules
– Different training programs
– Distinct terminology
• Looking at diagnosis and episodic care
– Provider-driven
– Mental health forgotten
– Not “bilingual” or “bicultural” to bridge medical and social systems
Fragmentation as a Major Obstacle
• Financing barriers to integrated care
– Social services not reimbursed
– Undercapitalization of social safety net
– No investment in team-based care and workforce development
• Value of social services, social workers to health care delivery system undefined
– Need to valuate services, negotiate fees, determine costs, and explain ROI
– Business case not clear
Other Barriers to Meeting the Demand
• Opportunities for improving care for people with chronic care needs (Georgetown Public Policy Institute)14
– Comprehensive primary care – Assessment of person and caregiver LTSS needs – Coordination of LTSS and medical care – Collaboration between care coordinators, PCPs,
patients, families – Supportive care transitions – Commitment to person- and family-centered
care
What’s Needed for Chronic Care
• Solid outcomes for interprofessional teams in inpatient and outpatient medical systems15
– Reduction in health service utilization16
– Improvements in patient satisfaction and communication with provider team17
• Rothman and Wagner: “Most successful chronic illness interventions include major roles for non-physicians. The appropriate deployment and use of practice teams seems to be far more important to improving chronic illness than physician specialty.”18
Interprofessional Teams
“Care coordination” is a person- and family-centered, assessment-based, interdisciplinary, multicultural approach
to integrating health care and social support services in a cost-effective manner in which an individual’s needs and preferences are assessed, a comprehensive care plan is
developed, and services are managed and monitored by an evidence-based process which typically involves a designated
lead care coordinator. (National Coalition on Care Coordination)19
Care Coordination
• Routes to financing effective care coordination20
– Current fee-for-service structure limited due to episodic focus
– Need incentives for effective performance: quality of care, patient experience, and health spending
• FFS system payment options (Medicare): – Modify codes or levels of payment within Physician Fee
schedule – Risk-adjusted monthly fee per eligible beneficiary tied to
performance – “Shared savings” model rewarding efficient, quality service
delivery
• Within managed care systems (Medicare Advantage and Medicaid) combine financing sources to meet needs
Financing the Ideal Model
• Improved medical and social service funding sources
– Social service investment
– Encourage and incentivize collaboration and team
– Share responsibility and align goals
• Demonstration projects through CMS and ACL
– Include integrated models
– Show cost savings across funding streams
– Improve quality of life
Financing the Ideal Model
The Healthcare Neighborhood
• Integrated model with the medical and social components of equal value
• Team-based care with the person and family on the team
• Service connection, coordination, and communication – “Boundary spanning” and “spanners” – Partnerships across sites and settings
• Community engagement and activation – Where people live – Where service providers are located – Where social determinants of health begin
and can be influenced
The Opportunities of PPACA
• Opportunities to address the social in health care through PPACA
– Enhanced primary care/Patient Centered Medical Homes
– Accountable care organizations
– Transitional care and hospital readmission reduction
– Medicare and Medicaid dual eligible demonstrations
– Medicaid Health Homes
– Independence at Home demonstration
– Bundled payment
To learn more, visit:
• Accountable Care Organizations: http://innovations.cms.gov/initiatives/aco/index.html
• Dual Eligible Demonstrations: http://innovations.cms.gov/initiatives/State-Demonstrations/index.html
• Medicaid Health Homes: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-
Topics/Long-Term-Services-and-Support/Integrating-Care/Health-Homes/Health-Homes.html
• Independence at Home: http://innovations.cms.gov/initiatives/Independence-at-Home/index.html
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Important Links
1. Wilkinson R, Marmot M. Social Determinants of Health: The Solid Facts, Copenhagen: World Health Organization Regional Office for Europe, 2003.
2. Shi L, Singh D. The Nation’s Health. 8th ed. Sudbury, MA: Jones and Bartlett Learning, LLC; 2011.
3. Gallant MP. The influence of social support on chronic illness self-management: a review and directions for research. Health Educ Behav. 2003;30(2):170-95.
4. DiMatteo MR. Social support and patient adherence to medical treatment: a meta-analysis. Health Psychol. 2004;23(2):207-18.
5. Krieger J, Higgins DL. Housing and health: time again for public health action. Am J Public Health. 2002;92(5):758-68.
6. American Public Health Association. The hidden health costs of transportation. http://www.apha.org/NR/rdonlyres/A8FAB489-BE92-4F37-BD5D-5954935D55C9/0/APHAHiddenHealthCosts_Long.pdf. Published February 2010. Accessed January 10, 2012.
7. Centers for Disease Control and Prevention. CDC health disparities and inequalities report – U.S. 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011.
8. Robert Wood Johnson Foundation. Overcoming obstacles to health care. www.commissiononhealth.org/PDF/ObstaclesToHealth-Highlights.pdf. Published February 2008. Accessed January 10, 2012.
9. Robert Wood Johnson Foundation. Health care’s blind side: the overlooked connection between social needs and good health. http://www.rwjf.org/files/research/RWJFPhysiciansSurveyExecutiveSummary.pdf. Published December 2011. Accessed January 10, 2012.
10. Physicians highlight overlooked connection between social needs and health. Robert Wood Johnson Foundation Web site. http://www.rwjf.org/vulnerablepopulations/product.jsp?id=73646. Published December 8, 2011. Accessed January 10, 2012.
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References
11. Ring A, Dowrick CF, Humphris GM, Davies J, Salmon P. The somatising effect of clinical consultation: what patients and doctors say and do not say when patients present medically unexplained physical symptoms. Soc Sci Med. 2005;61(7):1505-15.
12. John A. Hartford Foundation. How Does It Feel? The Older Adult Health Care Experience. National Survey. http://www.jhartfound.org/learning-center/hartford-poll-2012/. Published April 24, 2012.
13. Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. September 2012.
14. Komisar, HL and Feder, J. Transforming care for Medicare beneficiaries with chronic conditions and long-term care needs: Coordinating care across all services. Report from Georgetown University, 2011.
15. Interprofessional Education Collaborative Expert Panel. Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative; 2011.
16. Sommers LS, Marton KI, Barbaccia JC, Randolph J. Physician, nurse and social worker collaboration in primary care for chronically ill seniors. Arch Intern Med. 2000;160(12):1825-33.
17. Rothschild SK, Lapidos S., Minnick A, Catrambone C, Fogg, L. Using virtual teams to improve the care of chronically ill patients. J Clin Outcomes Manag. 2004;11(6):346-50.
18. Rothman AA, Wagner EH. Chronic illness management: what is the role of primary care? Ann Intern Med. 2003;138(3):256-61, 29.
19. Brown, R. The Promise of care coordination: Models that decrease hospitalizations and improve outcomes for Medicare beneficiaries with chronic illnesses, A report commissioned by the National Coalition on Care Coordination (N3C). March 2009.
20. Berenson, R. and Howell, J. Structuring, financing and paying for effective chronic care coordination: A report commissioned by the National Coalition on Care Coordination (N3C). July 2009.
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References
