Work around the social determinants of health (SDOH) is taking place across the healthcare landscape, including at the community level, among different types of organizations whose leaders are coming together to take on population health and health disparity issues.
One community in which a concerted effort among different stakeholder organizations has been moving forward strongly has been in the Maryland county of Prince George’s County, just east of Washington, D.C. There, the Prince George’s Healthcare Alliance, Inc., a non-profit organization, has been providing “community care coordination services to high risk, high need, high utilizers in healthcare,” as the alliance’s website explains.
“The Prince George’s Healthcare Alliance, Inc. applies evidence-based practices and workflows to effectively assist hospitals with their care transitions to home, nursing facilities, rehabilitation centers our team connects the patient to their primary care physician, specialists and other community providers. Social factors and health behaviors represent 70% of the determinants adversity impacting health outcomes,” the website notes. “We identify the social determinants impacting your patient’s health outcomes, link your patients to community resources AND provide health literacy education to help your patients improve their health behaviors,” providing “community care coordination services to high risk, high need, high utilizers in healthcare."
The organization’s website has also posted outcomes data, including both utilization and cost outcomes information. For example, the organization’s interventions have led to an average reduction in hospital visits per patient from 3.55 to 2.05, after intervention; and to an average reduction in hospital charges per patient from $18,929 to $8,6991.
In a PowerPoint presentation, the Alliance notes the following—“Who we serve:
> High-risk patients in poor control of their chronic illness
> High-risk patients needing connections to family and social services
> High-risk patients with unmet behavioral health needs
> High-risk patents in need of medication management
> Patients with no primary care physician
> Patients who have not seen a PCP in more than 12 months
> Patients with no health insurance
> Patients with care gaps
> High-risk patients with a hospital readmission within 30 days for the same condition
> Very high-need patients who have three or more inpatient visits in one year
> Patients with multiple ED visits
> Patients with multiple 9-1-1 calls for non-emergent reasons
Among other recent efforts have been collaboration between the Prince George’s Healthcare Alliance and the Prince George’s County Health Department, which began before the outbreak of the COVID-19 pandemic, and have continued all through it; the use of a population health technology platform for collaborative assessments, education, and interventions; and new care coordination and communication services and technology put into place as part of the region’s COVID-19 response.
Recently, Barbara Banks-Wiggins, executive director of the Prince George’s Healthcare Alliance; Ernest L. Carter, M.D., Ph.D., Health Officer of the Prince George’s County Health Department (PGCHD); and Caitlin Murphy, special assistant to the Health Officer at the Prince George’s County Health Department, spoke with Healthcare Innovation Editor-in-Chief Mark Hagland regarding the ongoing collaboration between the Prince George’s County Health Department and the Prince George’s Healthcare Alliance. Below are excerpts from that interview.
What are some of the major activities you’re all involved in these days?
Barbara Banks-Wiggins: We’re an independent 501(c)3 non-profit organization, providing services to high-risk and at-risk individuals in the county. We receive referrals from the health department, from providers, from the community. We focus on people with social determinants of health barriers impacting their outcomes. So we begin by doing SDOH assessments on patients. And then we are trained and experienced in connecting people with resources in the community, to address those barriers. It could be connecting them to a social service agency; to a primary care doctor; helping them with health literacy or education, or self-management principles aligned with their primary care treatment. So we really work with them as part of the care team, to help them understand what lifestyle and other changes they need to make, to improve their health—whether it be food security, transportation, medication affordability, etc.
Caitlin Murphy: I’m Dr. Carter’s special assistant. And he’s done everything from delivering babies to starting up the telehealth center at Howard University. He’s been doing public health for a long time, and has been with the health department, first as a deputy, and then the health officer, for nearly a decade. And he’s really pushed the health department in a new direction, where we’re looking at population health management, something that public health has not historically focused on; and then layering health information technology innovations on top of that.
Tell me about the population of Prince George’s County, and its demographics?
Here in Prince George’s County, we’re about 960,000 people. We have the wealthiest minority-majority communities; but there’s a great disparity between our most well-off people and our poorest, who mostly are in the areas just outside DC; and our south county is actually rural. About one-quarter of our population was not born in the U.S., so, lots of immigrants. Our median income is lower than Montgomery County just north of us. But we do have a lot of disparities. We are majority-African-American, followed by Hispanic, and other.
How has the collaboration evolved forward, and what have been the results so far?
Banks-Wiggins: The way we began collaborating is that it was the formation of the Healthcare Alliance really stems from a transition that started in 2012, when a report found that Prince George’s County was really grappling with a lot of health disparities and limited access to care. So in 2013, the health department was awarded a grant to create Healthcare Enterprise Zones. It was asked to select a community—a zip code—with sub-optimal outcomes. It represented 80 percent of the hospital readmissions, but less than 10 percent of the admissions from the community. So a University of Maryland impact assessment said that the priority for the county was to address access to primary care, so that people would have access to a doctor within their community; it was less than 1 PCP per a couple of hundred thousand residents in that zip code. So the idea was to represent a population health model for that community. So Dr. Carter, being a forward-thinking leader in HC, realized that we need to recognize the social determinants of health. 20743—several cities within that zip code.
So Dr. Carter said, we’re going to hire community health workers and introduce a population health model. First, through the grant money, we will give providers funding open new practices in this community, so we went from one to five; and then improve outcomes by addressing their social needs, including through the use of community-based social workers. And the health outcomes were astonishing. What was interesting was Dr. Carter realizing that once this grant is over, we can’t stop this work, because otherwise, people will go back to the same issues challenging their outcomes. So in 2015, we developed a primary care strategy, which stated that we needed an organization to help collaborate with providers. So the Health Department is the reason why the Health Alliance has been doing this work.
What have been the biggest challenges, and the biggest successes, so far?
Murphy: In terms of our population, the access to care is a major challenge. There’s that zip code with a severe example of shortage; but we have shortages throughout the county. The model that Dr. Carter and Barbara have created in that zip code, they’re working to scale up, to get more practitioners here and to make sure we have more information systems, which layer on top of our health information exchange, with a focus on public health. We know that doctors are trained to treat diabetes, for example, with Metformin and other medicines, but not so much through lifestyle-change programs. When you combine a pharmaceutical intervention with a public health intervention, you change the outcomes. So we’ve been combining those two, and that’s led to a lot of our gains. And we definitely have a lot of SDOC issues. We had a population that was struggling before the pandemic, but during the pandemic, it all worsened. A lot of people living on hourly wages, could not afford their rental housing. We’ve had a lot of people on the edge of falling into crisis, so we created the COVID Care Program, to address some acute-level issues. The program began on June 15, and we’ve served just over 2,000 people so far.
What have some of the biggest interventions been?
Murphy: We do a multi-pronged intervention, to make sure that people are connected to a long-term medical home, so that when this is all over, they’ll be able to continue to seek care. So Barbara’s group makes sure that all the social determinants are addressed; they’re signing up for health insurance if possible, they’re getting diapers for their children, for example. And we home-deliver a care kit including disinfectant wipes and masks, toilet paper, tissues, hand sanitizer, plus a two-week supply of food including fresh foods, and pulse oximeters and thermometers, when appropriate.
Banks-Wiggins: And we’re transitioning people out of homelessness, and we collaborate with physician practices around such issues as food insecurity, local transportation, and with FQHCs, for access to care.
Dr. Carter, can you share your core philosophy and strategy around all this work?
Ernest Carter, M.D., Ph.D.: The goal here is to meet all of the health needs of an individual, whether they have a tremendous number of needs, or few, or none. As a public health department, we need a system to help manage an entire population. And we’re developing a public health information network that will allow us to address all the factors that influence a person’s health, including their behavioral health, environment, and social determinants, as well as their clinical health. And this all stems from the development of our community care team. When someone is homeless, there are a lot of needs and issues, but there’s no information system helping to manage that. So you need to have information at your fingertips and to help you analyze their situation, right at the right time, so that you can make the right decisions, whether to refer them to a resource, for example.
And if you don’t know that a person has been in a diabetes management program or a pharmaceutical management program, for example—you need to know whether any of those programs have been effective, and whether they got housing, or lead testing in their home. And normally, you don’t know any of that. And for a 21st-century doctor needing to know all of this, they need to be able to manage all of that. And it turns out to be a heavy lift. There are a lot of stovepipe systems that aren’t connected, and there’s the 42CFR set of issues, per behavioral health.
What have been the biggest challenges and the biggest gains in your collaborative work so far?
You need the money, the financing. But also, you need to get people on board with your vision. So you have to have the partnership and cooperation. And you need an adequate level of financing. And you have to break barriers around people having vested interests. You have to come together as a collective. And a lot of organizations are doing their own care coordination or population health management; but we need a county-wide approach. And you need data standards and interoperability, to truly exchange information. And you need information, and cooperation. And people have to believe in what you’re talking about, and you have to keep talking about it and pushing it.
How do you see things developing in the next couple of years?
I think the future is bright. We’re in a state with a Medicaid waiver that allows us to move towards a system based on value-based care delivery and payment. And COVID made it clear that these sorts of systems are needed. And the technology is ripe for it, because we have the FHIR standard, and Smart on FHRI, so we can do this well. I remember when we couldn’t even video conference at 15 frames a second; now, the standard is 30 frames a second, and getting better. And these standards will lead to true enterprise-wide systems. The technology is there; we just have to do the work.
What would your advice be for those who might consider following your path?
Just start; don’t let anybody say you can’t do it. Create your roadmap, and advocate for your vision. You can’t let anybody stop you. And look towards best practices, and connect with people who are of like minds.