Innovator Awards: First-Place Winning Team: ProMedica

March 14, 2023
Making the Connection Between Social Determinant Screening, Interventions, and Clinical Outcomes

Health systems across the country are trying to determine the best way to screen patients for social determinants of health (SDOH) and develop connections with community-based organizations that can help address patient needs. But few healthcare organizations have developed the sophisticated infrastructure for screening and addressing SDOH that Toledo, Ohio-based ProMedica has. More than 150,000 screenings are completed each year and over 3 million have been completed to date. Using data analytics, the 12-hospital nonprofit health system has been able to identify connections between its interventions and improved health outcomes, making it Healthcare Innovation’s No. 1 Innovator in 2023.

ProMedica is a large nonprofit organization. It offers acute and ambulatory care in 28 counties in northwest Ohio and southeast Michigan. It has an insurance company as well as post-acute care business lines.

Kate Sommerfeld, M.P.A., president of ProMedica’s National Social Determinants of Health (SDOH) Institute and vice president of community relations and social investment, says ProMedica has been thinking holistically about health for more than 10 years. “Through our journey, we really understood two things: One is that things like housing, food access, and transportation really do impact what happens at the individual health level, so that has to be part of your care delivery model.”

The second realization, she says, involves how ProMedica facilities serve as anchor institutions in the communities they serve. “Hospitals are often the largest employer in a community, and the assets and the resources that we have directly impact the broader health of our community in a macro sense,” she explains. “We work at the individual patient level but also in terms of how we show up in a broader sense across communities and neighborhoods to drive health at more of the population health level.”

Brian Miller, M.D., ProMedica’s chief medical information officer and vice president for telehealth and value-based and primary care, says that when they began building an SDOH screening tool, there weren’t many examples to work from.

“Our very first domain was around food because we know food is medicine,” he says. “We built a screen that was integrated into our workflows, and then connected to orders for some of our food interventions that our teams could talk about. We built that from scratch in Epic. I sat in the room when our CEO at the time talked about our work and pitched the product to Judy Faulkner, who leads the Epic organization, and got her involved. In less than a year, our build was embedded into Epic’s foundational platform, and available to every customer they have from that point forward.”

Matching screening to clinical workflow

Indeed, ProMedica even has an employee, Cheryl Crowder, whose title is director of SDOH clinical applications. She says it is often difficult for clinical and technical people to work together to translate information about something like SDOH screening needs into the EHR. “Where we shine is putting the right people in the right place to get what we need.” To identify the non-clinical factors affecting health, she adds, ProMedica leaders have developed a series of validated questions that precisely pinpoint the issues with which people struggle. The tool is now part of all standard intake procedures at ProMedica, and all patients are screened across 10 core SDOH domains—housing insecurity, child care, transportation, education, intimate partner violence, purpose, employment, social isolation, financial strain and food insecurity.

One challenge was finding the right spot in the clinician workflow for the screening.

“Part of our work was to get this screening done upfront so that we could either do it on an iPad in the waiting room or in our portal, so that most of our patients answer these questions a day or two ahead of their visit,” explains Miller. “It is fresh data at the point of the visit, and not complicating that workflow.”

He adds that they automated as many of the steps as possible, so that “we have the ability to just connect you downstream and not necessarily require any additional work from our clinicians.” ProMedica officials explain that screening responses trigger practice advisories, allowing physicians to integrate non-clinical needs such as food, housing and financial strain into plan-of-care discussions, adding identified issues to their diagnosis and activating referrals to which clinical integration team partners can respond.

ProMedica has a Community Care Hub, whose care navigation team members include social workers and community health workers. They provide the intersection between clinical support and community connections. When regulations change about qualification requirements for a program, they're up to speed on it right away. The response from community members has been “overwhelmingly positive for those clients who are served,” says Mary Peavy, lead community health worker. “They like that somebody is identifying that these other issues are hindering them from getting the care they need to receive. I can say that we definitely are making strides in helping clients meet their goals for housing, food, employment, and education. I am meeting with those clients monthly while they're trying to attain those goals.”

Demonstrating health outcome improvements

Working with a Washington, D.C.-based company called Socially Determined, ProMedica has developed analytics to show that proactive interventions can become a model for decreasing healthcare costs and utilization while increasing healthier outcomes. The organization’s internal research found that individuals who used ProMedica’s food clinics, for example, saw an 18 percent reduction in ED usage, 5 percent lower readmission rates and a 6 percent decrease in per-member-per-year medical costs. Patients who benefited from financial coaching services experienced a 33 percent reduction in ED visits, a 14 percent reduction in inpatient visits and a 6 percent increase in primary care physician visits.  Healthcare cost savings per member range from $6,500 to $17,000. A post-assessment of 2,500 individuals who identified as having some type of risk in 2020 showed that more than half of them—around 56 percent—did not identify as having the same type of risk in 2021, ProMedica says.  

Adrienne Bradley, ProMedica’s director of community impact, oversees these community-based interventions. “We have a financial wellness network, where we do free one-on-one financial coaching, and work with individuals to reduce their debt, increase their savings, and get better credit scores,” she explains. “We also do free tax preparation for anyone who makes $60,000 or less. Now we are consulting with another health system on helping them stand up their own financial wellness network.”

Bradley says ProMedica has taken a place-based approach to its community work. For instance, it has focused on the UpTown neighborhood in Toledo. “It is a strategy driven by the knowledge that where you live determines how you live,” she says.

In America, food insecurity affects an estimated 13.5 million Americans. People who are hungry are nearly three times more likely to be in poor health, and the United States incurs $1.1 trillion in food-related health costs each year. UpTown was a USDA-designated food desert when ProMedica launched its 6,500-square-foot hospital-run Market on the Green grocery store in 2015. Today, Market on the Green offers cooking classes and grab-and-go giveaways as well as fresh produce, meat, dairy, baked goods, grocery, health and beauty, and other staples at affordable prices.

With a donation from the family of lifelong philanthropist Russel J. Ebeid, the UpTown effort quickly became a more encompassing community intervention to remove other barriers to health.

ProMedica announced the Ebeid Neighborhood Promise (ENP) in 2019, a place-based community development initiative to empower UpTown residents. ENP’s focus on equity required engaging the neighborhood in a deeper way.

“We talk about our community's physical and socio-economic environment,” Bradley explains. “Our goal was to bring in programming and organizations and wrap-around services to break down that traditional single-issue boundary within organizations. We're connecting with other organizations in the area in this neighborhood-based approach. We're building trust within the community, because we know that a lot of folks don't trust healthcare systems particularly. Being able to meet with them about something that's not a bill that they need to pay or service that they need to have has helped.”

Through public-private partnerships with the City of Toledo, service organizations, local and regional nonprofits, neighborhood groups, small businesses and artists, residents of UpTown not only have access to a convenient, more affordable grocery store but also to job training, tuition-free STNA (State Tested Nursing Assistant) and EMT certification programs, a mobile market for senior housing sites, cooking and wellness classes, Pre-K education, community events, small-business growth support, a technology hub and innovation center, career coaching, improved housing stock, green spaces, public art and other quality-of-life-improving resources.

With promising results, the ENP team is working with funders, residents and leaders to support improvement of education and training, health and wellness, jobs and finances, stable housing, and basic needs in other communities it serves including one of the Glass City’s oldest neighborhoods, Junction.  And last year, ProMedica announced the Adrian Ebeid Neighborhood Promise, an initiative dedicated to scaling and implementing solutions to address health disparities in the rural community of East Adrian, Mich.

Connecting interventions to outcomes

Miller describes some of the data wrangling behind the scenes that makes it possible to connect service offerings to improved outcomes. “The beauty of our EMR is that there's a lot of deep, deep clinical detail. We know what's happening longitudinally with our patients’ clinical issues. We also know very specifically when we identify an SDOH need and how we intervene,” he says.

The third piece of that triangle is around the cost of care, Miller adds. “We're lucky enough to have one of the arms of our organization be a payer organization. We get a fair amount of claims data from that. Also, we participate in an ACO and we have a lot of value-based contracts, in which other payers will share downstream costs associated with patients. Socially Determined has some proprietary tools and they helped us formulate what we call a clean room in which we can actually bump all that data up against each other, patient-match very carefully, and then track what happens to a patient from a point of intervention downstream.”

They look at both what happens to patients clinically and what happens from a cost standpoint, driven primarily around their ED utilization, their admissions and readmissions to a hospital and the depth of their connection to their primary care physician. “We've seen so much positive downstream impact in that space around cost and better medical outcomes,” Miller notes.

All of this research work is critical, Miller adds, because “if we're going to ask our clinicians to help connect patients to these interventions, we’ve got to have evidence that shows it is helping them get healthier and/or that we reduced the cost of the care because of the intervention. In cases where we get evidence, we try to scale it up.”

Sommerfield spoke about why ProMedica created a National Social Determinants of Health Institute. Besides focusing on regional initiatives, the organization is part of several national efforts, including as a founding member of the Healthcare Anchor Network. Also, in 2015, ProMedica joined with the AARP Foundation to form the Root Cause Coalition, which works to reverse and end the systemic root causes of health inequities for people and communities through cross-sector partnerships.

“We're seeing a lot of movement in this field,” Sommerfield says. “For many years, only a handful of health systems and payers were active. But now CMS and CMMI are building social determinants into value-based care models and mandates. We're seeing states requiring screening and connecting for SDOH needs. This is part of how the industry is transforming around value-based care. This is truly becoming how we deliver care as a country. We're seeing this baked into our value-based care contracts.”

While previously SDOH was seen as a stand-alone concept, she adds, “it's truly becoming table stakes for how we deliver care as a country, which is a great thing. And it's also going to continue to challenge us to think differently, to be more innovative, and make sure that we have data and technology that's enabling us to deliver this new care.”

The ProMedica executives expressed hoped that their comprehensive approach to planning and centering on the social determinants of health with a continuum of effective, replicable solutions is a model that can be deployed in other communities and by other healthcare systems to address disparities and empower residents to achieve their highest health potential.