Addressing Healthcare via Non-medical, Community-based Resources and Tools

Source: Dahlgren & Whitehead - 1991

On Friday, June 17th at 9:00am PST, the weekly #HITsm tweetchat hosted by @HealthStandards will discuss topics related to “Addressing healthcare via non-medical, community-based resources and tools.”

Background

While it seems that finding cures for diseases and performing specific medical procedures would make the biggest contribution to promoting health, this just isn’t the case. It’s been established that 30% of health outcomes are due to specific health/medical issues with the balance attributed to social determinants, environment influence and behavioral health challenges. Accordingly, support from the community, through local volunteers or trusted low–cost services, has a vital role to play in meeting one’s practical healthcare needs and improving ones quality of life.

Social determinants are the conditions in the environments in which people live that impact a wide range of health, functioning and quality-of-life outcomes and risks in the community's target population. Unaddressed social needs, like food insecurity and housing instability affect millions of Americans and cost an estimated $85 billion a year in additional healthcare spending.

A “community-based organizations” is broadly defined as an organization that addresses the social determinants of health. These organizations are federally and/or locally funded and typically chartered to serve populations that are under-insured, low-income, racial and ethnic minorities, elderly, homeless, and those with chronic health conditions..

New Opportunities with Healthcare Reform

Identifying and matching appropriate community-based organizations capable of addressing the social and behavioral needs of high-risk patients will go a long way to improve overall health outcomes.

The ACA established the Community-Based Care Transitions Program provided half a billion dollars from 2011 to 2015 to healthcare systems and other community organizations that provided at least one transitional care intervention to high-risk Medicare beneficiaries. These interventions covered medication review and management, assessment and active engagement of patients and their family/caregivers through self-management support and home health visits. CMS also offered an opportunity to identify, evaluate and disseminate innovative care delivery and payment models, including transitional care, through a $10 billion allocation for the period 2011-2019.

At the federal level, the Department of Health and Human Services announced earlier this year a new funding opportunity of up to $157 million to test whether screening beneficiaries for health-related social needs and associated referrals to and navigation of community-based services will improve quality and affordability in Medicare and Medicaid.

Providers, Health Plans & Community Organizations

From this, health care providers, health plans and community organizations have a good opportunity to identify and remove barriers to healthy living their patients and members may be facing. These groups need to foster cross-collaboration between various sectors of healthcare, such as physical and behavioral health, and addressing social determinants of health, including education and housing, nutrition, employment and transportation.

The demands of living with and juggling low income to meet basic needs puts additional demands on decision-making cognitive processes that in turn drain attention and self-control that might otherwise be devoted to other investments including improving one’s own human capital, practicing good health, or being an attentive parent.

Reference Materials

How Hospitals Can Improve Chronic Care Through Addressing Nonmedical Problems

Aligning managed care with health, education, nutrition, and social services.

Federal and State Policymakers Work to Ensure Continuity of Health Care for Consumers

Groups: Identify PPACA exchange users with functional limitations

Integrating Behavioral Health into Medicaid Managed Care: Lessons from State Innovators

Integrating Health Care And Housing To Promote Healthy Aging

Core Health Metrics Present Across Various Healthcare Organizations

Join the Chat!

Come join the #HITsm tweetchat on Friday, June 17th at 9:00am PST to discuss technology and services to efficiently connect people to social programs that can help them get on the path toward good health. And for more information and ideas this and other healthcare data, technology and services topics, consider following me on Twitter.