The Revolution on Healthcare’s Doorstep: Expanding the Frontiers of Health to Encompass Housing, Food, and Social Connection

July 9, 2019
Pioneering provider organizations and health plans are moving forward to address housing, food insecurity, loneliness/social isolation, and other issues—as part of broader efforts to impact the health of communities

It was fascinating to read the report in the July issue of Health Affairs by David Tuller, “To Improve Outcomes, Health Systems Invest In Affordable Housing,” which describes the initiative began in 2016 by five integrated health systems and one Medicaid managed care plan in Portland, Oregon, to address homelessness and related social issues, by directly providing patients and plan members with housing.

As David Tuller reports, five multi-hospital systems and one not-for-profit Medicaid health plan joined together three years ago to provide direct housing to homeless and at-risk patients, through their creation of a housing collaborative, Housing Is Health, which continues forward, even as the leaders of the initiative concede that some of the core challenges that they faced at the outset, remain.

As Tuller notes, “In 2016 Providence [Health] and five other Portland health care providers made a headline-grabbing announcement that acknowledged the intimate links between housing and health: They revealed plans to invest a collective $21.5 million in the construction of affordable units. Besides Providence, the participants were three other hospital systems (Adventist Heath Portland, Kaiser Permanente Northwest, and Legacy Health); Oregon Health & Science University, which includes a major hospital facility; and CareOregon, a nonprofit health care plan for Medicaid patients. The initiative, called Housing Is Health, involved three buildings with a total of almost 400 living units for people who were homeless or at risk for homelessness. Besides the six large health care organizations, other state and local agencies and groups also contributed funds. CCC [Central City Concern, a local social service agency] owns the buildings and is developing and managing the project.”

Meanwhile, Tuller writes, “The three buildings in Portland’s Housing Is Health project were designed with specific populations in mind. One includes 51 units for families displaced by gentrification. A second has 153 units of permanent housing for people leaving transitional units. The largest building, called the Ed Blackburn Center after the former CCC executive who spearheaded the project, is scheduled to open this summer with 175 units for people in recovery. It will house additional on-site services, such as a primary care health clinic, treatment for substance abuse and mental health issues, and an employment office.”

What’s more, Tuller reports, “Addressing substance abuse by helping clients stabilize their living situations has long been a key focus of CCC’s work. The agency’s motto is Homes, Health, Jobs.”

As the Health Affairs article documents, the Portland initiative is still struggling to achieve sustained improved outcomes. But that in no way invalidates its core value. Indeed, what is being attempted around housing in Portland, is being attempted around food/nutrition, in other places.

Indeed, as I reported during the AHIP Institute last month, the annual conference of America’s Health Insurance Plans, the national health plan association, announced on June 20 that it was launching a new initiative aimed at addressing the social barriers to health.

The initiative, known as Project Link, according to AHIP officials, “will bring together health insurance providers from different markets and geographies to address an array of issues impacting all Americans, from housing to healthy eating to transportation. It will establish clear, collective strategies and goals for insurance providers, ensuring new programs addressing social determinants of health are scalable, sustainable, and measurable in improving health and affordability for everyone. Using Project Link as our foundation,” a press release published Thursday morning noted, “AHIP will develop research and policy agendas at both the state and federal level to improve the health, well-being, and financial stability for consumers, patients, and taxpayers.”

What’s more, Ghita Worcester, senior vice president for public affairs and chief marketing officer, at the Minneapolis-based UCare health plan, highlighted two groundbreaking programs that have seen successes in Minnesota. The first is the health plan’s Mobile Market, which involved the transformation of two used city buses into grocery stores on wheels, which provide access for poor people (whether UCare plan members or not) to fresh fruits and vegetables and other healthy foods, in concert with subsidies and purchase supports. The second program she highlighted, during the Project Link-focused press conference, and at a separate educational session on food insecurity, is called Circles of Health and Well-being, and is a program targeted specifically at supporting Medicaid plan members in the southern Minnesota community of Faribault. Those members are Somali women who had no familiarity with the U.S. healthcare system, and who have had the opportunity to learn how the system works and how to appropriately access primary and preventive care, and who also have been taught about nutrition and healthy cooking. Both programs have proven to be highly successful, she noted, and will be expanded over time.

Meanwhile, at that same June 20 press conference announcing AHIP’s new Project Link, Robin Caruso, chief togetherness officer at CareMore Health, a Cerritos, California-based subsidiary of the Indianapolis-based Anthem Health that provides an integrated health plan and care delivery system for Medicare and Medicaid patients, described the outlines of her provider organization’s Togetherness Program, which is aimed at reducing the social isolation of seniors. “A few years ago,” Caruso said, “our president, Dr. [Sachin] Jain, came to me, about our new disease management program. And when he said loneliness and isolation was the program, my heart leapt. You’re more likely to die of loneliness than obesity, and when I heard that statistic, that really brought it home. It’s like smoking 15 cigarettes a day.” The top three goals of the Togetherness Program, she said, are to get the plan’s Medicare Advantage (MA) members connected to healthcare; to refer them to the appropriate needed resources, whether food, transportation, or community (such as senior center activities); and to get the MA plan members to exercise.

And, at an AHIP Institute session on food insecurity, Alicia Beachy, associate project manager at the Danville, Pa.-based Geisinger Health, described the Fresh Food Farmacy initiative that is delivering food directly to food-insecure patients and families, where the patients are diabetic, with uncontrolled diabetes. The cost per family of four, per year, of the program, is $1,200 per year, which, Beachy called “amazing.”

“Food-insecure populations have an immediate interest in the free food; that compels them. And what keeps them there is the way we address food as medicine,” Beachy said on June 21. “The clinical team is engaging; we’ve have a registered dietician, who meets monthly with patients. And we’re payer- and provider-agnostic, as long as a Geisinger clinician is willing to see them on their panel.” And the results? “We’re seeing an average hemoglobin a1c reduction of 2.0 points. And studies show that every 1.0 reduction in a1c saves $8,000-12,000. So we’re seeing $16,000-24,000 in medical expense decreases, by that measure”—along with a 74-percent decrease in admission rates, a 27-percent decrease in ED visits, and a 19-percent increase in primary care physician visits.

In other words, all of the provider and health plan organizations whose leaders have committed to tackling housing, food insecurity, and loneliness/social isolation issues, have been making some kind of progress in those areas. And they are moving forward, fully aware of the statistics that have endlessly been shared in recent years, documenting that direct medical care only accounts for a tiny fraction of total health status—depending on who’s estimating, around 20 percent of overall health, or even less. Everything else is connected to the social determinants of health—and these leaders know that.

As Vivek Murthy, M.D., former U.S. Surgeon General, told the AHIP Institute audience on June 20, “Loneliness and social isolation are prevalent in countries across the world, where people are struggling with loneliness and isolation. And, as has been documented, the impact of struggling with loneliness is the equivalent of smoking 15 cigarettes a day. Heart disease risk goes up double, and other forms of illness, including diabetes, also rise. And wound recovery is slowed. And for all of those reasons, I became focused on this as Surgeon General,” Dr. Murthy said. “Gun violence, suicide rates, life expectancy, are all impacted. I started to put the pieces together, and a lot of these things are connected to loneliness and social isolation. That doesn’t mean that loneliness is the sole cause; but it is often a contributing factor. And if we want to improve health outcomes, we have to work on social connection.”

Responding to a moderator’s note that the United Kingdom now has a Minister of Loneliness, and asking what a national strategy to combat loneliness might look like, Dr. Murthy said that “We need to make loneliness and social disconnection a priority, and we need to fund research and move forward. I ultimately feel hopeful that we can address loneliness in the U.S. and around the world, because the most important element already exists in each of us, the ability to reach out to other people, to be kind, to be authentic. Because at the heart of this discussion is a much more fundamental question about what kind of society we want to live in.”

And that goes to the heart of the overall issue: part of what the U.S. healthcare system—both providers and payers—will need to do in the coming years will be to tackle these huge social issues that are not directly connected to actual medical care, as provided in situ in hospitals, medical clinics, and other formal sites of care. That is our future—and it’s gratifying to know that the pioneers are out there visioning that future, and moving towards it.

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