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Focus on Social Determinants of Health Pushes Caregivers into New Terrain

At CCO Oregon-sponsored conference, major healthcare players discussed how investments in housing, food security and transportation can play a key role in improving the health of their patients.
June 7, 2017

Oregon’s coordinated care organizations have embarked on experiments across the state aimed at learning whether spending resources outside of traditional medical care can help boost the health of their members. They convened Tuesday in Salem to share what they’re trying, and what they’ve learned, at the Social Determinants of Health Conference, convened by nonprofit trade group CCO Oregon.

The conversations that unfolded showed just how diverse the efforts to improve health beyond traditional means have been – with rural AllCare using capitation dollars to give its members a ride, not just to the doctor, but to the supermarket, Portland-based Rosewood Family Health Center deploying mental health professionals in new ways inside and outside the clinic, and big institutions like Kaiser Permanente and Providence Health & Services focusing heavily on trying to gather data about what works best.

Ben Hoyne, executive director of CCO Oregon, called the sell-out event a great success.

“Through the coordinated care Model, CCOs are empowered to create strategic partnerships with the common goal of improving health in their communities,” he told The Lund Report by email. “Over 250 people were provided an opportunity to hear about these collaborative evidence-based programs which can be replicated in an effective and efficacious manner in their organizations.”

One of the most prominent recent investments in social determinants of health was announced last fall, when six healthcare organizations announced they would partner with Central City Concern, paying $21 million to fund construction of 382 new Portland housing units. Adventist Health Portland, CareOregon, Kaiser Permanente, Legacy Health, OHSU and Providence Health & Services are donating to the project, slated to open in 2018. Housing and stability are key to health, the thinking goes – so improving access to housing should improve the health of the projects’ residents.

Despite being a prominent donor to that project, much of Kaiser’s focus on social determinants of health right now is about gathering data, rather than acting on it, Molly Haynes, director of community health, said during a lunch hour plenary discussion on investing in these programs.

“We’re really trying to dig into, how do we set up measurements?” Haynes said. “How do we create accountability, so there is skin in the game.”

Kaiser’s strengths are in healthcare delivery, and successfully improving health outside of those bounds will require partnering with other expert organizations. To do that, Kaiser will need to find the right organizations, the right approach, and the right way to track success, Haynes said, noting that school-based clinics and educational programs are among the areas her organization is exploring.

“We’re trying to find measurements that work across education and health sectors. We know that about one in five of our members spends their day in a school setting, between kids and educators. It’s a great place to impact the broader community as well,” she said.

“What does it look like if we expect our health system to have a vested interest in making sure that kids get to school and staff get to school, and are healthy?” Haynes continued. “What is our role as a care delivery system in improving the attendance rates for students who are struggling?”

Likewise, Providence is heavily engaged in learning and assessing data and opportunities, said Pam Mariea-Nason, executive of the community health division at Providence Health & Services.

“At providence, we do ask our frontline care givers, our frontline providers, what do you see?“ she said. “What we have heard from them now, consistently, is that they recognize the needs for social determinants.”

Despite Providence’s investment in the Central City Concern housing program, and its partnerships with a number of nonprofits, Mariea-Nason also expressed some discomfort with the possibility of moving beyond the health giant’s areas of expertise.

“The provocative part is, we really have to do what we can do well, first,” she said. “Then, if we want to tackle education, workforce and other things, let’s do that. But let’s make sure we are taking care of access, … and looking at social determinants that are really about health”

Northwest Health Foundation Vice President of Public Affairs Jesse Beason, who moderated the plenary discussion, pushed big healthcare players not to get bogged down in data collection and planning efforts.

“We may need evidence, but that shouldn’t stop us from trying to deploy solutions,” Beason said.

At a much smaller Oregon healthcare organization, the effort to deploy solutions is already yielding results, officials from Southern Oregon’s AllCare CCO said, in a panel presentation on their focus on social determinants of health. Because the CCO’s payments are capitated – meaning AllCare gets a fixed monthly payment for each Medicaid member on its rolls – it can choose to invest its funds outside of traditional medical spending in programs that could improve member health.

“Access to care is a very important social determinant of health. In rural areas such as Josephine or Currey counties, access to public transportation can be so very limited” Lorie Hollibaugh, non-emergent medical transportation liaison for AllCare said as she presented on the CCO’s partnership with ReadyRide, a transportation company. “Just getting from one’s home to one’s providers can be very challenging.”

Under AllCare’s contract with ReadyRide, the transportation company receives its own per-member, per-month capitated payment to drive the CCO’s members to appointments – not just within Southern Oregon, but even offering rides to medical care in Multnomah or Lane counties.

In addition, ReadyRide is compensated via an incentive program that offers quarterly payments based on six performance measures: customer satisfaction, member complaints, provider complaints, on-time performance, ridership on fleet vehicles, and on-call success.

Of about 50,000 CCO members, some 448 used the ride service in October 2016, completing a total of 1,470 trips, Hollibaugh said.

AllCare has also determined that offering rides to the doctor or the dentist is not enough.

“Transportation for care and services that are not covered by the Oregon health plan can impact a member’s health,” Hollibaugh said. Members can get rides to obtain food from grocery stores or food pantries, or to receive assistance from social service agencies, as well as to breastfeeding and parenting classes, and to cooking classes.

AllCare’s investments in social determinants of heath also extend to housing, with the nonprofit partnering closely with Rogue Retreat nonprofit housing program, said Sam Engle,coordinator of social determinants of health for the CCO.

Even within the medical and clinical system, the CCO is striving to think outside of its routine approaches – training primary care providers about dental health to reduce cavities and other oral health problems in young children, for example, said Laura McKean, oral health integration manager at AllCare.

Rosewood Family Health Center, a Portland-based clinic with about 10,000 patients, has likewise started looking at ways to structure its clinical choices to better meet the social needs of patients, Michell Lehr O’Connel said during a presentation on Rosewood’s programs.

Mental health providers who might once have filled their days with scheduled appointments now may only have one or two appointments scheduled in advance, allowing them to float between patients throughout the day as primary care providers identify mental health or social needs, for example.

“We understand that if you don’t have access to food and you’re diabetic, you are going to have problems with managing your diabetes. That’s intuitive,” Lehr O’Connell said. “But changing … It’s a very big shift in thinking, in changing out we are interacting with each other. It takes time.”

Rosewood screens all new patients with a survey aimed at identifying social determinants of health that may affect their care – and has been tweaking, adjusting and improving this survey over the course of a five-year effort.

Today, a patient with diabetes and poor blood markers might be sent to a dietician or social worker after being treated by a primary care provider. Rosewood offers diabetes support classes, and can help patients with food insecurity connect to pantries that deliver diabetic-appropriate meal options, for example.

“Doing this work and making this transformation is a journey,” Lehr O’Connel said. “It’s an iterative process. We have to try something and start somewhere. We are really excited to do this.”

Reach Courtney Sherwood at [email protected].

Correction: Due to a transcription error, an incorrect nubmer of rides was reported AllCare and ReadyRide's ride service program. The story has been updated to reflect that 1,470 trips were taken last October.