In the evolving healthcare landscape—one that is continuously moving toward a value-based care and payment system—industry leaders are increasingly recognizing how addressing patients’ social determinants of health (SDOH) will be a key element in improving outcomes and lowering costs.
However, the path to incorporating social determinants information into care and treatment plans has been a slow one, with a bevy of challenges, from having an infrastructure that makes it easy to screen for SDOH, to the complications in collecting and analyzing SDOH data, to determining who is responsible for addressing these elements. The good news is that these obstacles have not prevented forward-thinking patient care organizations from making inroads in this area.
Origins of the initiative started in 2012 as a Medicaid demonstration project to see how a county-run ACO model could work for Minnesota’s Medicaid expansion population. Hennepin Health, which is both a health plan and an ACO, now serves tens of thousands of members, and the ACO is a partnership between the county’s local Human Services and Public Health Department, Hennepin Healthcare System, a federally qualified health center (FQHC), and a Medicaid managed care health plan.
After an initial review of hospital readmissions data in an effort to detect and address health disparities, the healthcare system realized that Medicaid patients are more likely to readmit to the hospital within 30 days than Medicare patients or those privately insured, largely due to struggles with housing instability, food insecurity, substance use disorder, mental health issues and low health literacy.
Hennepin Health leaders then set out to further examine the predominant driving factors of readmission plaguing its specific population. An analysis of the ACO’s cohort data highlighted homelessness as a leading risk factor, noting that housing instability is a significant issue in Minneapolis and Hennepin County with over 3,000 people considered homeless on a given night.
“As a health system, we have been working on identifying these [SDOH] issues for a number of years, through [several] different projects. Housing is something we have gotten better at being able to analytically identify, and we have gone through multiple iterations of looking at risk factors, looking at overall populations, and seeing how closely we were actually identifying patients,” explains Alex Knutson, R.N., clinical informaticist at Hennepin Healthcare, an integrated health system and the largest of the four partners of Hennepin Health.
As such, an examination of internal data uncovered that more than 50 percent of patients who sought care at Hennepin County Medical Center (HCMC)—the largest safety-net hospital in Minnesota—and who were members of the Hennepin Health ACO were actively or previously homeless. But as Knutson notes, the health system has previously struggled institutionally to identify patients experiencing homelessness—missing 60 percent of cases in one evaluation—and needed an approach to respond to this information in a systematic manner that prompts patient connection to available social services.
HCMC then partnered with the Hennepin Health ACO to improve service coordination through a small pilot, but an issue arose when the ACO had to rely on the inpatient care team to make referrals on patients with these kinds of social issues. Oftentimes those providers wouldn’t even look at their patients’ insurance as they were instructed to not treat anyone differently based on insurance or lack of. And even when the ACO did receive the referral, it was difficult to connect with individuals since it would have been a “cold call,” as the patients were likely already discharged from the hospital. “So, for many reasons, we would ‘miss’ this subset of our patient population, says Christy Barich, R.N., nurse care coordinator at Hennepin Health.
Patient care leaders quickly realized that the struggle to locate patients experiencing homelessness was further hindering successful engagement in care coordination efforts. They knew that there was a need for a more proactive approach to identify patients for care, but a unique challenge presented itself: while many healthcare models provide targeted care management for specific disease states—such as heart failure—focusing on homelessness remains uncommon for patient care organizations to employ a standard process for identifying social determinants.
A novel approach for identification
The tool, which is internally dubbed the “homeless indicator,” is different from the typical clinical indicator in that it takes different pieces of data to prompt the system to report which patients are at higher risk of homelessness. Some of that data comes directly from documentation in the EHR when providers add a visit diagnosis during one of the visits they’ve had with homeless patients, while other data comes from the work that nurses, social workers, and clinical coordinators do. For instance, some of these patients had an assessment done at some point in the past indicating they had a housing insecurity or were being provided housing resources. If that were the case, this data would be pulled in, explains Knutson.
More data comes from the health system’s many different community-based partners, such as Hennepin County Health Care for the Homeless, housed within the Human Services and Public Health Department. “Many of our homeless shelters have embedded clinics, and that might just consist of a provider or nurse—or even just a provider—but from a medical perspective, it’s a resource for a patient who might only be in a shelter for one night. But if that patient connects with the provider [in the shelter], the data all flows back into our shared health record” that all staff involved—even those operating in different organizations—has access to, Knutson says.
Another important data source is patients’ demographic data—specifically the address they put down to get paper bills sent to them. Oftentimes, says Knutson, the address that’s given can be a strong indicator of homelessness since patients without housing will note their address as “general delivery,” which is a method for them to receive their mail at the post office since they don’t have an actual address. Other times, they’ll put the address of one of the housing resources in the community, such as a shelter address where they can receive mail. “It’s amazing seeing how much that address data strongly tied with patients actually experiencing some form of homelessness,” says Knutson.
The care management piece
These learnings gathered from Hennepin Health were then combined into a workflow redesign for an ACO care management assistant to perform file clearance and conduct an in-depth review of each potential patient candidate for care management.
That vetted list then moves to the ACO care managers who perform additional medical record review before visiting the patient in the hospital to confirm eligibility and complete an in-person introduction to outpatient care management. If a patient chooses to pursue outpatient community care management, he or she is added to the care manager’s case load—the person whom the patient met while hospitalized, with the goal of improving continuity, Hennepin Health project leaders explain.
Three care managers at the organization rotate to perform these duties, in addition to their full caseloads, on Mondays through Fridays. To ensure the pilot progresses smoothly, staff representing both the ACO and HCMC participate in weekly one-hour meetings in which process measures, utilization outcomes, and barriers are reviewed by the group. Readmission events are reviewed weekly, utilizing an internal report that identifies patients hospitalized with recent admissions within 30 days, according to Hennepin Health officials.
“It’s not an oversimplification to say the effort of the care managers is what drove the success [of this project],” says Heather Rhodes, performance improvement project consultant at Hennepin Healthcare. “It wasn’t uncommon for the [care managers] to go back and see these patients multiple times, or even attempt to visit them before they could get the patient to engage in conversation. The empathy they showed to patients, along with their persistence, were [critical] pieces,” she adds.
Impressive results— with leadership support
Of the 362 patients who were screened for program eligibility, 100, or 28 percent, were deemed eligible for intervention. A bulk of the patients that Hennepin Health did not pursue, but did screen, were actually not homeless or they already had care managers outside of this specific project.
At last check with Hennepin Health officials, 40 patients were engaged in care management for at least 30 days following hospital discharge; the average duration of care management was four months. Of the 63 encounters in which 30 days have elapsed since discharge, just one patient has been readmitted to HCMC, and according to claims data, no readmissions have occurred at outside hospitals.
Importantly, a naturally derived control group developed out of the patient population who declined intervention or were discharged prior to an inpatient visit by the care manager. Of the 47 patients in this group, eight, or 17 percent, have been readmitted to HCMC.
What’s more, project leaders touted, while not the primary focus, nine patients have been placed in housing, with five occurring within the first six weeks, a feat that normally takes months to years. And, in addition to helping patients experiencing homelessness navigate the transition period between hospitalization and return to outpatient status, care managers supplied an array of services depending on patients’ needs, ranging from provision of transportation vouchers during hospitalization, to ensuring patients had means to attend follow up appointments, to more complex tasks including completion of applications to expedite housing placement.
“This is a population where gaining trust is difficult. These [care managers] are very skilled individuals who can bridge those gaps by making the effort to come into the inpatient setting. It blew our expectations away,” says Heather Simon, performance improvement advisor at Hennepin Healthcare.
It’s become well understood in healthcare circles that in the industry’s ongoing migration toward a value-based payment system, addressing SDOH makes perfect sense. If stakeholders have “skin in the game,” and are financially better off if patients have better health and land in the ED less frequently, they clearly will have more interest in screening for and addressing SDOH.
Conversely, however, incorporating SDOH clearly doesn’t mesh well in a fee-for-service payment system—a business model that many organizations are still operating within. But for Hennepin Health, there was no such challenge in convincing C-suite leadership this was the right endeavor. “This was not a difficult sell in any way, shape or form. It’s really about what’s right for patients,” contends Lori Johnson, R.N., vice president of performance improvement and safety at Hennepin Healthcare.
Johnson adds, “One of our board quality committee’s favorite initiatives from this past year was this work. They were really excited to hear about how we were making a difference in individuals’ lives, and it isn’t what traditionally what people think about in the hospital setting.”
