Social Determinants of Health: Implications and Outcomes

Ron Yee, MD, MBA, FAAFPRegion IX Leadership Institute, June 16, 2015

Social Determinants of Health (SDH)

Objectives

1. Discuss prior and current work

2. Better understand the clinical and cost

implications

3. Case study of how we can help patients

overcome negative SDH and optimize positive

SDH Definitions

World Health Organization (WHO)

“The conditions in which people are born,

grow, live, work and age, including the health

system. These circumstances are shaped by

the distribution of money, power and

resources at global, national and local levels,

which are themselves influences by policy

choices”

SDH Definitions

Centers for Disease Control and Prevention (CDC)

“The complex integrated and overlapping social structures and economic systems that are responsible for most health inequities. These social structures and economic systems include the social environment, physical environment, health services and structural and societal factors.”

SDH Definitions

Robert Wood Johnson

Foundation (RWJF)

“Health starts where we live, learn,

work and play.”

Why Do SDH Matter?

• Research demonstrates SDH–Contribute to poorer health outcomes

–Lead to health disparities

–Make it more difficult to improve quality and health outcomes

• Impact on health center populations served–Increased difficulty improving health outcomes for complex

patients

–Insufficient funds to provide or reimbursement for

comprehensive care (case managers, CHWs, navigators, etc.)

–Possible negative impact regarding payment/reimbursement

• Value-based payment models, P4P and incentive payments

So, Why Do We Study SDHs?

Serves three primary purposes:

1.Better understand root causes to provide care

management and services for individual patients.

2.Target population-based interventions in

coordination with Public Health, social service

entities and community partners.

3. Inform risk adjustment methods for fair

comparisons of safety net providers & payment

reform methodologies to ensure appropriate

compensation for the comprehensive services

health centers provide for complex patients.

The Broader Determinants of Health

Source: Dhalgren, G. and Whitehead, M. (1993). Tackling inequalities in health: What can we learn from what has been tried?

Estimates of the Impact of SDH on

Population Health

Bunker, J.P., Frazier, H.S. and Mosteller, F. (1995) The role of medical care in determining health. Oxford University Press, pp 305-341.

McGinnis, J.M., Williams-Russo, P. and Knickman, J.R. (2002). The case fr more active policy attention to health promotion. Health Affairs

21 (2) pp. 78-93.

Canadian Institute of Advanced Research, Health Canada Population and Public Health Branch (2002). Quoted in Kuznetsova, D. (2012).

New Local Government Network Website.

57% 45% 50%

Bay Area Regional Health

Inequalities Initiative

April 2008

A Framework for Health Equity

Socio-Ecologic Model Medical Model

Medical Model

Socio-Ecologic Model

Kresge Foundation

• NACHC partnership with IAF,

funded by the Kresge Foundation

• Leveraging SDH in CHCs Reccos

– Process to ID community needs &

strengths beyond clinical

– Standard health risk assessment for

each patient including SDH

– Leverage SDH in case management

– Reimburse for leveraging SDH

– Broad communication strategies

– Go beyond medical model

March 2012

AAPCHO-CDN-AHRQ

March 2013

AAPCHO SDH Study • Health based risk assessment and risk

adjustment

• Goals: equitable comparisons, minimize

incentives for selective enrollment,

adequate financing for treating higher-than-

average needs; consider LEP

• Risk adjustment – no direct impact on PC;

indirect effects through health plans

• Chronic Illness & Disability Payment

System (CDPS) – UC San Diego

• Opportunities & risk in capitated PC

• Multiple ways for CHCs to demonstrate

value via improved care coordination and

quality of care

• Opportunity to expand PC scope & services

NACHC PRAPARE Project

Protocol for Responding to & Assessing Patients’

Assets, Risks, and Experiences

Funders:

Partners:

2014-2016

NACHC PRAPARE Project

Goal

• To develop, implement and disseminate a patient risk

assessment protocol to collect standardized data on

patient complexity in terms of SDH in health centers

nationally

Progress

• Health domains, definitions and measures developed

• Determined how data is to be collected

• Four health center networks chosen in IL, IA, HI, NY

• Next: Gather, analyze & act on data regarding SDH

PRAPARE Learning Community

Social Determinants of Health: Implications and Outcomes

Ron Yee, MD, MBA, FAAFPRegion IX Leadership Institute, June 16, 2015