The following blog post is written on behalf of a team of graduate students I lead at Indiana Unversity Purdue University at Indianapolis.
Seeking organizations and communities to serve as “use-case communities” to study the effect of improved coordination of food and housing interventions on health outcomes and cost.
Can technology-enabled care coordination between healthcare providers and social service providers help alleviate food and housing insecurity to achieve the Quadruple Aim: better health for individuals, improved population health, lower total cost and improved clinician experience?
On November 7, 2017, the Center for Medicare & Medicaid Services (CMS) announced a series of new policies for state directed programs to promote innovations in healthcare and social service. These policies make it easier for states and communities to design, fund and execute innovative projects that promote collaboration and coordination between healthcare and social service providers to address social determinants of health and reduce disparities to achieve the Quadruple Aim: improved individual health, improved population health, lower total cost and improved clinician experience.
We are looking for states, organizations and communities with high rates of adverse health outcomes associated with food and housing insecurity to serve as use-case communities for our study.
We are a team of graduate students in the Health Information Technology Program at Indiana University Purdue University at Indianapolis (IUPUI) working with our mentor/lecturer, Doug Dormer. In response to the new CMS funding policies, we are conducting a study to consider how technology may be used to improve care coordination and collaboration between and among healthcare and social services providers to address social determinants of health. The intent is to go beyond simple referral and navigation to consider the alignment and coordination of evidence-based practice and strategies across the continuum of healthcare needs and social determinants. The goal is to provide a foundation for funding applications under these new CMS policies for innovative programs that states and communities may pursue.
We need your real-world experience. We are looking for one primary and several secondary use-case communities where we can learn about the real world challenges and opportunities for addressing food and housing instability as it contributes to health outcomes and costs.
There is no cost for participating. We ask three things: 1) one hour for an interview; 2) a little time to answer a few follow-up questions by email after the interview, and; 3) your time to review and comment on drafts of our analysis. In return, you will have a document that describes these new funding policies, provides high level analysis of the impact food and housing insecurity has in your community, suggests a model for innovations that might improve health outcomes and lower cost, and provides background for a funding application under these new policies.
In this study, we are conducting a literature review to understand the state of evidence-based practices and strategies with respect to food and housing insecurity. We want to understand whether and how interactions between healthcare providers and social service providers and their mutual clients may build off the work flow and infrastructure that is increasingly common in physical health and behavioral health to extend to food and housing. Looking to recent and ongoing programs such as the Accountable Health Communities model and the State Innovation Models, among others, the team intends to take the next step beyond referral and navigation to consider ways of harmonizing evidence-based practices and strategies across the health and scoial services continuum.
For our primary use-case community, the study will incude an analysis of data from disparate souorces (using SAS Analytics) combined with data from Medicaid, the CDC’s Behavioral Risk Factors Surveillance System (BRFSS) along with state and local food and housing data to establish a base line showing the relationship between food and housing insecurity and health outcomes and cost. The report will include examples of evidence-based strategies and suggestions for potential metrics to evaluate these new innovations.
The New CMS Policies
The new policies announced by CMS Administrator Seema Verma on November 7 simplify application, approval and management for state demonstration programs (Section 1115 demonstrations) and waivers of certain federal requirements (1950 waivers) to promote innovative models that significantly improve outcomes and lower cost. Under these new policies, states will have the latitude to define new metrics that are more appropriate to the innovation and less burdensome. CMS Administrator, Seema Verma, made it clear that “CMS will openly consider proposals that promote community engagement and work activities.”[i]
The United States spends more on healthcare than any other nation. This is true whether measured in absolute dollars ($3.4 trillion), as a percent of gross domestic product (about 17 percent) or per capita ($9,892 per person).[ii],[iii]
Healthcare Spending as a Percentage of GDP 1980-2013[iv]
Despite this massive expenditure, out of the 35 countries that make up the Organization for Economic Co-operation and Development (OECD), the US ranks 26th out of 35 countries in life expectancy for men and 30th for women, and is similarly situated with respect to several other health outcome indices.[v]
Why does such a big investment in advanced medical care deliver such disappointing results?
Much of the answer lies in the fact that other developed nations do a far better job than the United States of preventing their vulnerable populations from suffering serious illness, by investing substantially more in social services that impact health. OECD nations on average spend about $1.70 on social services for every dollar of health care spending, compared to only about 56 cents per dollar in the United States. Factoring in these expenditures, the United States is pushed down to 13th among OECD countries in total health care expenditures.[vi]
Combined Health and Social Care Spending as a Percentage of GDP[vii]
This conclusion is also supported within the United States when comparing spending and health outcomes between states. States with a higher ratio of social to health spending also have significantly better health outcomes for such conditions as adult obesity, asthma, mental health indicators, mortality rates for lung cancer, high blood pressure, and heart attack, and Type 2 diabetes.[viii]
In the present economic and political environment in the US, it is not likely that the US will undertake the kind of funding increases for social services that would bring it on par with other OECD countries. Indeed, as the present proposed budgets now before Congress suggest, it is likely the US will see less money allocated to healthcare and social services at least for the next few years.
However, the recent policy announcement by CMS Administrator Seema Verma presents an exciting opportunity to address the challenges of social determinants of health in new, innovative ways, and to do it now.
What are social determinants of health? [ix]
The World Health Organization defines social determinants of health as the conditions in which people are born, grow, live, work, and age.[x] They are the factors most responsible for health inequities – the unfair and avoidable differences in health status seen within and between different geographic locations. Food-insecure households are uncertain of having, or unable to acquire, at some time during the year, enough food to meet the needs of all their members because they had insufficient money or other resources for food. Households with very low food security are food insecure to the extent that normal eating patterns of some household members were disrupted at times during the year, with self-reported food intake below levels considered adequate.
A review of the literature shows that it is difficult to quantify the health or economic impact of social determinants of health. Indeed, some studies contradict or are in conflict with other studies. One study from the University of Wisconsin attributes as much as 50 percent of health outcomes to social, economic and environmental factors.[xi] Nonetheless, approximately 80 percent of physicians maintain that addressing patients’ social needs is as critical as addressing their medical needs.[xii]
It is estimated that 12.3 percent of households, representing about 15 percent of the population (about 48 million people) experience low or very low food security at some point in any year. In some communities, the rate of food insecurity is much higher, reflecting the overall disparity in both determinants and health outcomes. Although few studies exist that attempt to quantify the health or financial cost of food insecurity, according to one estimate, the health related cost of hunger in the US is at least $160 billion per year.[xiii],[xiv]
Housing insecurity is even more challenging to quantify either as an individual determinant or as an identifiable component along with other social determinants of health. Few studies of associations between housing and health have focused on housing insecurity and health risk behaviors and outcomes. One study measured the association between housing insecurity and selected health risk behaviors and outcomes, adjusted for socioeconomic measures, among 8,415 respondents to the 2011 Washington State Behavioral Risk Factor Surveillance System. Housing insecure respondents were about twice as likely as those who were not housing insecure to report poor or fair health status or delay doctor visits because of costs.[xv]
Emerging Evidence-based Strategies to address food and housing
While all social determinants of health have some correlation to each other, there is no single approach or evidence-based strategy that collectively addresses all social determinants of health. The overall solution requires a coordinated approach to different sets of evidence-based practice and strategy that have traditionally operated in separate silos.[xvi]
The model of evidence-based practice (EBP) as it shapes treatment and interventions in healthcare is well established. With respect to social determinants of health, evidence-based strategies (EBS) are becoming more common, including those for food and housing.
While most health-related EBP models focus directly on the patient and the patient’s condition, EBS models that address social determinants of health have a broader scope. For example, in the case of food, hunger and nutrition, the scope of the EBS models includes production and distribution of food, services to measure and protect the quality of food as well as supports that help individuals gain access to such foods and provide education about how to improve the nutritional value of their diets. Hence, as healthcare providers consider their role in reducing food insecurity, the scope of their interaction with social service providers and consumers may be limited focusing primarily on those aspects of the EBS that involve the interaction between providers and consumers. They are less involved in the broader supply and infrastructure efforts to improve availability of enough nutritious food. Similarly, with respect to housing, EBS involves more than just interaction between providers and consumers. It also involves separate efforts to ensure that an adequate supply of affordable, safe housing is available, which is beyond the normal role of healthcare providers.
Recent changes in funding and service delivery models
Several demonstration projects funded by both public and private payers are beginning to hold providers accountable for patients’ health and health care costs and linking payments to outcomes. These new models are creating economic incentives for providers to incorporate social interventions into their approach to care. Examples of public funded demonstration projects include the State Innovation Model, the Certified Community Behavioral Health model and the Accountable Health Communities model. Each of these models includes an alternative payment model that shifts the financial reward from fee-for-service to value-based contracting that includes a focus on social determinants of health. Investing in these intervention that optimize revenue and net income under these alternative payment models can also enhance patient satisfaction and loyalty, as well as satisfaction and productivity among providers.
Based on a review of requests for proposal and interviews with several demonstration program participants, most programs focus on screening to identify patients with health-related social needs including food and housing, creating an inventory of available resources to address these social needs and referral work flow to connect patients with these service providers. Relatively few demonstration projects have focused on aligning and coordinating work flow between physical health, behavioral health and social supports. Studying the value of improving care coordination between health care providers and social service providers, particularly with respect to food and housing, presents a tremendous opportunity to leverage the new CMS policies.
For more information, please contact the team’s mentor/instructor: Doug Dormer, firstname.lastname@example.org, 734.730.2207.
 As used in healthcare practice, the phrase “evidence-based practice” (EBP) refers to the integration of clinical expertise, patient values, and the best research evidence into the decision making process for patient care. (Sackett D, 2002) With respect to social determinants of health such as food and housing, a variant of the term is more commonly used: “evidence-based strategy” (EBS) suggests a high level of understanding supported by fewer studies that are only beginning to emerge as common practices. In this document, we refer to EBP when referring to healthcare practice and EBS when referring to social supports.
 Based on review of requests for proposal issued by award recipients of grants from CMS for the Accountable Health Communities Model, awarded in March 2017. Also reflects interviews with state, community and provider organizations participating in State Innovation Model programs.
[i] “Verma Outlines Vision for Medicaid, Announces Historic Steps Taken to Improve the Program: New Policies Help Ensure States Can Focus More Resources, Time Achieving Positive Health Outcomes for Beneficiaries.” Press release. Center for Medicare and Medicaid Services, 2017/11/07.
[ii] The Sourcebook: Essentials of Public Policy, Chapter 7—Healthcare Costs. 2017/08/31. Alliance for Health Policy. http://www.allhealthpolicy.org/sourcebook/health-care-costs/. Accessed 2017/11/20.
[iii] National Health Expenditures 2015 Highlights, Center for Medicare and Medicaid Services.
[iv] D. Squires and C. Anderson, U.S. Health Care from a Global Perspective: Spending, Use of Services, Prices, and Health in 13 Countries, The Commonwealth Fund, October 2015.
[vi] To lower the cost of healthcare, invest in social services. 2015/07/14. Kenneth Davis, Health Affairs Blog, http://www.healthaffairs.org/do/10.1377/hblog20150714.049322/full/ Accessed 2017/11/20.
[vii] Butler S, Matthew d, et al. Re-balancing medical and social spending to promote health: Increasing state flexibility to improve health through housing. The Brookings Institution, Washington, DC 2017/02. https://www.brookings.edu/blog/up-front/2017/02/15/re-balancing-medical-and-social-spending-to-promote-health-increasing-state-flexibility-to-improve-health-through-housing/
[viii] Bradley, E., et al (2016). Variation in Health Outcomes: The Role of Spending on Social Services, Public Health, and Health Care, 2000-09, Health Affairs 35(5), 760-768.
[ix] Heiman H and Artiga S, Beyond Health Care: The Role of Social Determinants of Health in promoting Health and Health Equity. 2015/11/04. The Kaiser Family Foundation.
[x] World Health Organization, http://www.who.int/social_determinants/sdh_definition/en/ Accessed 2017/11/20.
[xi] Booske B, Athens J, et al. Different Perspectives for Assigning Weights to Determinants of Health. 2010/02, University of Wisconsin Population Health Institute.
[xii] Bachrach D, Pfister H et al. Addressing Patients’ Social Needs: An Emerging Business Case for Provider Investment. 2014/05.
[xiii] Cost of Hunger in the United States. Bread for the World Institute, Cook J, Pablacion A. 2016. http://www.hungerreport.org/costofhunger/?_ga=2.120923918.70434410.1511207785-1132138794.1511207785 Accessed 2017/11/20.
[xiv] United States Department of Agriculture, Economic Research Service, https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/interactive-charts-and-highlights/ Accessed 2017-11-20.
[xv] Stahre M, VanEenwyk J, Siegel P, Njai R. Housing Insecurity and the Association With Health Outcomes and Unhealthy Behaviors, Washington State, 2011. Prev Chronic Dis 2015;12:140511. DOI: http://dx.doi.org/10.5888/pcd12.140511
[xvi] Newhouse RP, Spring B. Interdisciplinary evidence-based practice: moving from silos to synergy. Nurs Outlook. 2010 Nov-Dec;58(6):309-17. doi: 10.1016/j.outlook.2010.09.001.