Knowledge Expansion

Social determinants of health in an ACO for better population health

Insight Article

Patient Engagement

Population Health

Chris Harrop
Valerie was a 31-year-old woman with uncontrolled diabetes, asthma, hypertension and was morbidly obese; she also had a history of trauma and depression. She increasingly was a no-show for appointments and would go to the emergency room instead of her primary care visits at Massachusetts General Hospital in Boston.

It wasn’t until Mass General implemented a social determinants of health (SDoH) survey that the providers learned that Valerie faced homelessness — until then, a P.O. box and a telephone number gave no indication of the larger issue in her life. They also learned that, despite being born and raised in Boston, Valerie could not read and write in English, her primary language.

Through SDoH work, Mass General staff were able to direct Valerie to emergency housing and ask what her goals were beyond health: Learning English, getting a job, securing an apartment and reuniting with her 3-year-old daughter, who was taken at birth due to Valerie being homeless.

As with most of us, social factors such as housing, education and a safe environment largely lead to better health outcomes.1 In Valerie’s case, her factors meant insufficient healthy food, lack of refrigeration for medication and issues with blood pressure heightened by living in a van and a lower sense of personal safety — all directly affecting the care providers working with Valerie.

“If we could engage with her to encourage her to keep her primary care appointments, we could ultimately reduce Valerie’s sense of need to go to the emergency room,” said Mary Neagle, MSW, program director, primary care ACO strategy, Mass General. “And if we can work with Valerie to learn how to read and write in English, Valerie’s ability to achieve higher economic stability … would make a difference on her ability to manage her diabetes, her blood pressure and then overall quality of life.”

Adding value, not work

Before social determinants of health (SDoH) became a recognized phrase in population health, Mass General was experimenting with the types of community work that we associate with SDoH: resource specialists in psychiatry and social services, connecting people to state, federal, local and privately funded resources for high-risk patients.

So when screening every Medicaid patient annually for SDoH became part of the formula for a Medicaid accountable care organization (ACO), it was an opportunity for Mass General to “create a more comprehensive, cohesive model” in primary care for 26 adult and pediatric practices, Neagle said.

“Our goal was to maximize the output of our work while minimizing the impact of new workflows on our primary care practices,” Neagle said. That prompted creation of an operational framework focused on providing needed services and the means for patients to access the services, with the intensity and specificity of interventions heightened based on how much assistance patients needed:
  • Self-directed/self-advocate work was focused on community resource connectors
  • Patient education that required help and/or goal-setting went to community health workers, health navigators and community resource specialists
  • A population health management (PHM) care coordination program managed issues for patients with low executive function or cognitive ability.
Kristen Risley, MSW, PMP, senior project specialist, population health, Mass General, noted that mapping out the services to be offered added clarity on existing hospital resources while also building relationships with external resources.

“We look at this as a really great opportunity to build better collaborations with outside organizations who do this work already,” Risley said. “We don’t want to become a social service organization; we’re a hospital.” That also meant recognizing where those services were provided and whether transportation would be a major factor for patients to access them.

Another method Mass General used to add value to care without adding more work was the formulation of a practice engagement strategy, centered on communication from leaders and workgroups to address skeptics, mass customization of workflows to account for practice-level culture and staffing, and training for practices on both paper forms and the EHR platform for SDoH.

Benefits and challenges in technology

At first, paper tip sheets were available to direct patients to available community resources, but the Mass General team knew that for SDoH program success, an electronic workflow was necessary to integrate survey responses into patient records, including transparency of that information for staff reading records and better overall data collection for quality reporting and benchmarking.

Despite resistance from some providers about adding another click in the workflow, Mass General’s EHR was up to the task of housing the survey workflow. However, challenges remained for the staff:
  • Survey forms were not initially multilingual or accessible for certain disabilities, which required interpreters in some instances while translated and accessible versions were built
  • Maintaining a hybrid paper-electronic system meant some data entry was necessary
  • Patients needed to grasp the technology (tablets) used to issue the survey electronically.
To ease the burden, Mass General incorporated the survey prompt for the patient schedule each day, signaling which patients should get a tablet to complete the survey. Those patient inputs then flowed directly into the EHR.

Employees were given a script as part of training to explain to patients why they were being given a tablet and that the survey was composed of questions the doctor wanted answered before the patient is seen. Employees are instructed to provide the survey to patients annually for a new patient appointment or if the patient had not been seen in the past year.



Neagle and Risley noted that there was some pushback at first from patients who might have felt uncomfortable identifying their own socioeconomic limitations, but any patient could refuse to self-report. However, patient referral data on orders related to the SDoH program steadily increased between late 2017 and autumn 2018. For a five-month period in 2018, 53% of patients who were prompted to complete a survey via tablets or a patient portal did so.

Building ROI

While better patient outcomes through SDoH work is a primary focus, having the financial basis for continuing it is something that must be addressed by a practice. As payers shift toward value-based care, a practice should ensure contractual requirements align with SDoH program work and offer reimbursement for work that demonstrably improves patient care quality.

Neagle said that designing a SDoH program means understanding the relationships that can be built with community-based organizations to prioritize the factors that can be addressed: “Do we stick with the top three: Food, housing and job security? Do we add into that financial security? Do we add into that personal safety?” she noted, going on to say that standardizing SDoH survey questions with other providers in the same area allows for better benchmarking.
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“Most of our community health centers and community practices … have been doing this for ages,” Neagle said. “This is the first time we’ve been able to create an infrastructure that will track and help us inform future appointments and future ways to treat whole populations.”

The broad goal of the work — reducing utilization — means that Mass General can look at pre- and post-implementation data on utilization, but Neagle said that the human element of what they are doing means that the results cannot simply be relayed through statistics.

“We care about people and we want to do good work — we want to make a difference,” Neagle said. “So let’s start by telling the stories.” Those stories include patients who have trouble paying utility bills, are out of work, have trouble caring for children or another family member or face domestic violence.



One of those stories is Valerie, who — after connecting with resources through the Mass General SDoH program — worked to secure a part-time job and a permanent apartment with the help of an organization that aids women in job training. “It’s going to be a very long road for that young woman, but she’s invested in it,” Neagle said.

“This is the work we’ve always hoped to do in our careers. It’s the right work to do. It just feels good,” Neagle said. “At the end of the day, there’s frustration when the system isn’t working and there are bureaucratic obstacles, but this really is the good work.”

Note:

  1. Woolhandler S, Himmelstein D. “The relationship of health insurance and mortality: Is lack of insurance deadly?” Ann Intern Med. 2017; 167: 424-31.

Common barriers for SDoH programs

  • Physician training may not include awareness of social resources
  • Standard 15-minute appointments do not offer time to screen for SDoH
  • The front desk may be too busy to add SDoH work to their responsibilities
  • SDoH survey administration requires clear ownership and accountability in an organization
  • Integration of patient information is required in an EHR workflow

About the Author

Chris Harrop
Chris Harrop
Senior Editorial Manager MGMA

Chris Harrop is senior editorial manager for Medical Group Management Association. In this role, he serves as editor of MGMA's flagship print publication, MGMA Connection magazine, and oversees the publications team that produces the MGMA Member newsletter, Executive View, Student newsletter. Prior to joining MGMA, Chris was managing editor of multiple community news organizations in the Denver metropolitan area. Email Chris Harrop.

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