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Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health (2019)

Chapter: 2 Five Health Care Sector Activities to Better Integrate Social Care

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Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
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Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
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Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
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Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Page 36
Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Page 37
Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Page 38
Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Page 39
Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Page 40
Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Page 41
Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Page 42
Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Page 43
Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Page 44
Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Page 45
Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Page 46
Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Page 47
Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Page 48
Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Page 49
Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Page 50
Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Page 51
Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Page 52
Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Page 53
Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Page 54
Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Page 55
Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Page 56
Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Page 57
Suggested Citation:"2 Five Health Care Sector Activities to Better Integrate Social Care." National Academies of Sciences, Engineering, and Medicine. 2019. Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation's Health. Washington, DC: The National Academies Press. doi: 10.17226/25467.
×
Page 58

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

2 Five Health Care Sector Activities to Better Integrate Social Care H ealth care sector leaders often make decisions about improving social care through care integration and investment in the absence of information about different strategies (Alderwick et al., 2018; Bickerdike et al., 2017; De Milto and Nakashian, 2016; Gottlieb et al., 2017b; IAF, 2012). An evidence-informed taxonomy of health care–based strategies that can be used to support and strengthen integration may help guide activities in this area. Based on the existing literature and other sources, as described in Chapter 1, the committee identified five mutually complementary catego- ries of activities that health systems can adopt to strengthen integration (see Figure 2-1). While all of the categories will ultimately benefit patients, two of these (adjustment and assistance) focus on improving care delivery provided specifically to individual patients based on information about their social risks and protective factors (conditions or attributes that may mitigate or eliminate risk). Two others (alignment and advocacy) relate to roles that the health care sector can play in influencing and investing in social care resources at the community level. All of these delivery and community-level activities are informed by efforts that increase awareness (the fifth category) of individual or community-level socioeconomic risks and assets relevant to a health system’s geographic region or served population. Health care stakeholders—including providers, care de- livery organizations, health plans, and government payers—that are exploring opportunities to launch or strengthen integration should un- derstand the challenges of and interplay among these different strategies as well as the range of activities possible within each category. Each of 33 PREPUBLICATION COPY—Uncorrected Proofs

34 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE FIGURE 2-1  Health care system activities that strengthen social care integration. the five categories (awareness, adjustment, assistance, alignment, and advocacy) depends on systems-level changes to implement and sustain integration—including a defined and well-trained workforce, data and digital tool innovations, and new financing models. These systems-level elements are the focus of subsequent chapters of this report. HEALTH CARE ACTIVITIES TO STRENGTHEN SOCIAL CARE AND HEALTH CARE INTEGRATION The five complementary types of integration activities correspond to different roles that health systems can play to strengthen the deliv- ery of social care in health care settings. These activities build on the community-informed and patient-centered care1 recommendations from a previous National Academies of Sciences, Engineering, and Medicine (the National Academies) report, Systems Practices for the Care of Socially At-Risk Populations (NASEM, 2016) (see Figure 2-2) by illustrating how these two approaches can most efficiently interact to enable high-quality care, whether to keep people healthy or reduce the burden of disease. In developing its overall strategy to social care integration, the com- mittee drew on this report’s overarching theme—moving upstream to im- prove the nation’s health—and recognized that there are both “near” and “far” upstream activities for strengthening integration. Near-upstream 1 Patient-centered care is defined as providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions (IOM, 2001). PREPUBLICATION COPY—Uncorrected Proofs

FIVE HEALTH CARE SECTOR ACTIVITIES 35 FIGURE 2-2 Promising systems practices to improve care for socially at-risk populations. SOURCE: NASEM, 2016. activities are targeted toward interactions that individuals have with health care clinical providers or clinical systems, whether for primary prevention or treatment of acute and chronic illness. They include ensur- ing that health care providers adjust traditional medical care decision making based on social risk and assets data and that patients with social risk factors then receive assistance connecting with and securing available government and community resources related to identified social needs. Far-upstream activities are more community-oriented. They involve aligning health care resources and investments to facilitate collaborations with community and government sectors as well as bringing health care PREPUBLICATION COPY—Uncorrected Proofs

36 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE assets into broader advocacy activities that augment and strengthen social care resources. As an example of this could work in practice, Table 2-1 describes ways in which individuals’ access to transportation might be improved using the five categories of activities. The five broad categories are not part of a sequential process; they in- stead complement one another, and health care stakeholders might engage in multiple strategies simultaneously. These categories provide multiple pathways to achieving integration based on the evidence considered by the committee. Therefore, it would be a disservice to the field to suggest rules, guidelines, or a one size fits all approach because one size does not fit all. Any of these categories is an umbrella for many specific activities that may take different forms, including similar activities that involve different levels of intensity. For example, assistance programs can range from light touch (e.g., providing patient handouts with basic information about social resources) to high touch (offering intensive case management to patients who need more help obtaining resources). These activities are described in more detail below, accompanied by relevant examples. Awareness: Strategies to Increase the Health Care Sector’s Awareness of Social Risks Both national and local health sector activities seeking to increase social and health care integration frequently begin with elevating and sustaining awareness about the influence of social risk and protective fac- tors on health outcomes. Across both social and health sectors, the general awareness of the relevance of social factors on health is increasing rapidly. TABLE 2-1  Transportation-Related Examples Highlighting Different Categories of Social and Health Care Integration Activities Awareness Ask people about their access to transportation. Adjustment Assistance Alignment Advocacy Reduce the need for Provide Invest in community Work to promote in-person health care transportation ride-sharing or time- policies that appointments by vouchers so that bank programs. fundamentally using other options patients can travel change the such as telehealth to health care transportation appointments. appointments. infrastructure within Vouchers can be the community. used for ride-sharing services or public transit. PREPUBLICATION COPY—Uncorrected Proofs

FIVE HEALTH CARE SECTOR ACTIVITIES 37 The committee documented an exponential increase in medical literature published over the past 18 years that (1) refers to the social determinants of health (SDOH); and (2) links those determinants with health care de- livery (see Figure 2-3). The committee defined awareness as those activities that identify the social risks and assets of defined patients and populations. Awareness strategies are not limited to sector-level awareness of the intersection of social risks and health outcomes. Instead, the committee recognized that building stakeholders’ investments in social care also involves a more active, immediate awareness of a specific population’s social risks and as- sets. Though the committee acknowledged that awareness is an important component of both individual- and community-level activities aimed at improving care integration, no consensus exists regarding the most effec- tive or efficient strategies to increase awareness in ways that can facilitate subsequent actions. The strategies that health care systems already invest in to increase awareness vary across settings. The Kaiser Permanente So- cial Needs Network for Evaluation and Translation (SONNET) has high- lighted five different pathways through which information about social risks and assets can be brought to the attention of health care systems (see Figure 2-4): clinical care, screening large populations, screening high-risk groups, hotspotting, and identifying vulnerable communities. FIGURE 2-3  PubMed search results for “social determinants of health” overall and in the context of health care, 2000–2018. NOTES: Number of results of PubMed searches for “social determinants of health” (SDH) and for “social determinants of health AND health care (SDH + Health care). Search performed by the committee on January 15, 2019. SOURCE: Adapted from Gottlieb et al., 2017a. PREPUBLICATION COPY—Uncorrected Proofs

38 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE FIGURE 2-4  Pathways to identify basic resource needs. NOTE: EHR = electronic health record SOURCE: Steiner JF, Adams JL, Clausen D, Clift KM, Millan A, Nau CL, Roblin D, Schmittdiel JA, Schroeder EB. Predictive Models for Social Determinants of Health in KP Members and Communities: An Issue Brief from Kaiser Permanente’s Social Needs Network for Evaluation and Translation (SONNET). Kaiser Permanente SONNET and Kaiser Permanente Community Health, September 2018. On the clinical side, patients visiting health care organizations are increasingly being asked to answer social risk screening questions in the context of their care and care planning. In some places, screening is incentivized by payers. As part of the MassHealth Medicaid program, for instance, Massachusetts accountable care organizations now include social screening as a measure of care quality (MassHealth, 2018a,b). Simi- lar initiatives are under way in North Carolina and Rhode Island. Clinic- based screening can be universal (everyone in a health care setting is asked about social risks, such as housing or food, either at each visit or at defined intervals; see Pathway 1 in Figure 2-4), or it can be more directed at specific age groups (e.g., children and seniors) or high-risk groups (e.g., people with certain diseases or who are on government insurance) (see Pathways 2 and 3 in Figure 2-4). As an example, Geisinger Health directs food security screening and interventions specifically at patients with diabetes (Feinberg et al., 2017). It is important to note that efforts to raise awareness by collecting data (both on patient clinical history and overall community health) may be affected by unconscious or implicit biases held by program leaders and practitioners, which can create new imple- mentation barriers and workforce training demands (detailed further in Chapters 3 and 6) (Garg et al., 2005; Gottlieb and Alderwick, 2019). A wide array of social risk screening tools has emerged to meet the demand for clinic-based social risk awareness activities (UCSF, 2019). Ex- isting screening tools vary in the social domains covered, length, language accessibility, and other characteristics (see Table A-1 for adult screening tools; pediatric screening tools also are available) (UCSF, 2019). Often these tools use different measures to assess social risks even under a single domain. PREPUBLICATION COPY—Uncorrected Proofs

FIVE HEALTH CARE SECTOR ACTIVITIES 39 Though some screening tools use items from domain-specific vali- dated instruments (e.g., hunger vital signs) (Hager et al., 2010), scant research is available on the psychometric validity of grouped items (Lewis et al., 2019). Existing studies generally indicate that a strong majority of patients find clinic-based social risk screening acceptable (Fleegler et al., 2007; Pantell et al., 2019), though the unintended consequences (Garg et al., 2016) and possible opportunity costs of clinic-based screening have not been clearly articulated (NASDOH, 2019). Some health systems use neighborhood- or community-level data to help select patients for more targeted social risk screening or to help iden- tify high-risk communities (see Pathway 5 in Figure 2-4). For example, Cincinnati Children’s Hospital conducts particularly intensive outreach with patients from two high-poverty zip codes to identify children with social needs (Auger et al., 2017). To facilitate such targeted outreach ac- tivities, the American Board of Family Medicine and the University of Missouri’s Center for Applied Research and Engagement Systems have together developed the Population Health Assessment Engine (PHATE), which is provided to clinical providers enrolled in the American Board of Family Medicine’s PRIME registry (American Board of Family Medicine, 2019). PHATE uses patient address data to incorporate “community vital signs” into patient charts based on publicly available census-tract-level characteristics. These and other uses of PHATE are summarized in Box 2-1. Some nonprofit hospitals, federally qualified health centers, and local public health departments also use the community-level social risk data in community health needs assessments, which are required by the Internal Revenue Service and are intended to influence community-level invest- ments (Alberti et al., 2014). The committee searched for indicators of the prevalence of aware- ness activities (e.g., social risk assessments or data linkages across social and medical sectors). Though multiple surveys targeting different health care stakeholders (e.g., payers, health systems executives, providers, and consumers) have asked about the prevalence of social screening in health care settings, there are limited data that can be synthesized across these surveys (findings from 23 surveys are summarized by SIREN) (Cartier et al., 2019). The majority of the existing surveys ask whether the health care system conducts some form of social risk assessment broadly without ask- ing further questions about the specific strategies undertaken to obtain in- formation. For example, survey items typically fail to distinguish among universal, clinic-based social screening, targeted screening for high-risk patients, and community data integration; they do not ask respondents to report the numbers of patients who complete social risk assessments; and they do not ask about the capacity of the workforce or activities undertaken in general or by discipline to respond to any identified risks. PREPUBLICATION COPY—Uncorrected Proofs

40 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE BOX 2-1 Uses of Population Health Assessment Engine • Map physician or clinic service area • Show clusters of disease • Show clusters of poor outcomes • Pull in social determinant data (poverty, less than high school education, single parent household, unemployment, etc.) • Create a “community vital sign” for every patient • Display community resources for patients and practice The resulting reports and information help clinicians and practices better understand the characteristics of patient risks, illuminating local resources and opportunities for assistance, intervention, and improvement. SOURCE: American Board of Family Medicine, 2019. Some research has explored the adequacy of using electronic health re- cord (EHR) documentation (e.g., LOINC, SNOMED, ICD-10, CPT codes) to gauge the prevalence of individual-level social risk screening, though this would fail to capture other related activities that facilitate social needs and asset awareness. At this time, the lack of both coding standards and capacity in medical coding systems and documentation incentives makes EHRs an unreliable source of information (Arons et al., 2018; DeSilvey et al., 2018; Lewis et al., 2016; Navathe et al., 2018; Torres et al., 2017). These and other technology-based opportunities to strengthen care integration are the focus of Chapter 4. In reviewing different strategies to increase the health care sector’s awareness of patient and population social risk and protective factors, the committee went on to ask whether increasing the health care sector’s recognition of social risks alone could contribute to changes in health outcomes in the absence of dedicated social care interventions. Specifi- cally, does asking equate to an intervention? This question could be es- pecially relevant to the awareness strategies in which individual patients are asked about their social risks in the context of a health care delivery encounter. Does asking about social risks without coupling screening activities with a related social care intervention, such as, at a minimum, making a referral for a patient to follow up at his or her discretion, af- fect the provider–patient relationship in some way? Could asking have negative consequences, such as triggering or creating trauma (Garg et al., 2016)? The committee did not find a strong body of evidence to sup- port either positive or negative consequences of implementing awareness PREPUBLICATION COPY—Uncorrected Proofs

FIVE HEALTH CARE SECTOR ACTIVITIES 41 strategies in isolation. This is likely because there are few clinical systems implementing clinic-based screening without some form of intervention. Even in settings when relevant interventions are offered, patients do not consistently desire assistance, making it important to consider shared decision-making principles as part of patient-centered care planning that results from identifying social risk factors and social needs (Swavely et al., 2018; Tong et al., 2018). Some research suggests that patients do not believe that social screening needs to be accompanied by interventions and may have salutary effects in isolation, although the evidence is mixed (Byhoff et al., in press; Palakshappa et al., 2017). As an example, patients’ perceptions that they are receiving equity-oriented care—including care that is trauma-, culture-, and context-informed—are linked with comfort and confidence in care, which itself is associated with improved confi- dence in managing health problems (Ford-Gilboe et al., 2018). Lower rates of patient–provider discussions about social demographic circumstances were found to be associated with six times higher odds of poor medica- tion adherence (Schoenthaler et al., 2017). More research is needed on how screening activities themselves affect patient–provider relationships. Adjustment: Activities Where Social Risk Information Is Used to Inform Clinical Care Decision Making There are many different ways in which an awareness of social risks (collected through any of the awareness strategies described above) can subsequently influence health care sector activities, leading to such things as providing social care coordination and services and augmenting the availability of social care resources (see assistance, alignment, and advo- cacy sections below). Social risk data also could be used to inform adjust- ments to care that focus not on resolving social risks directly but instead on altering clinical care to accommodate identified social barriers. Thus social and economic barriers to high-quality care may be mitigated by changes to how the health care services are delivered in addition to any attempts to resolve the social risk itself. Many examples of adjustment strategies were identified in the lit- erature, including the delivery of language and literacy-concordant ser- vices; smaller doctor-patient panel sizes for cases with socially complex needs (e.g., teams caring for homeless patients in the U.S. Department of Veterans Affairs health system have panel sizes smaller than the size of other VA care teams); offering open-access scheduling or evening and weekend clinic access; and providing telehealth services, especially in rural areas (Felland et al., 2003; VA, 2019). Other examples of ways that providers can adjust care based on known social risks involve changing insulin dosages at the end of the month when food benefits are more PREPUBLICATION COPY—Uncorrected Proofs

42 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE likely to run out (Seligman et al., 2014) and shifting to indoor or super- vised physical activity recommendations for patients who live in unsafe neighborhoods (Waite, 2018). These adjustments can have a significant im- pact; for instance, providing last-shift or overnight dialysis beds, offering longer acting anti-hypertensive medications, or changing visit schedules may improve outcomes in homeless patients with end-stage renal disease (Holley et al., 2006; Podymow and Turnbull, 2013). These examples high- light adaptations to traditional care designed to accommodate patients’ social contexts but are not interventions focused on changing the underly- ing social risk. The amount of evidence suggesting that adjustment interventions affect health varies depending on the type of intervention since there are many different activities in this general category. For example, a strong body of evidence supports providing interpreter services, which can be considered a form of adjusted care delivery since care modifications (as opposed to English classes) are provided based on an understanding of patient social and cultural characteristics that can be gained through better communication (Ku and Flores, 2005; Wasserman et al., 2014). As described in the awareness section above, some evidence suggests that context- informed care can influence patients’ experience of care, health behaviors, and health outcomes. Health services researchers have described clinical care that incorporates an understanding of social context as “contextual- ized care” (Weiner et al., 2010). And while there is a relevant, intersecting body of evidence on shared decision making and patient-centered care approaches, research in those areas has not consistently and explicitly fo- cused on care modifications or interventions that mitigate the impacts of social and economic adversity (Sambare et al., 2017). Social risk–adjusted payments also could be considered adjustment strategies if they are not linked explicitly to requirements like social care coordination or housing supports. Massachusetts is currently experiment- ing with Medicaid capitation rates that change based on patients’ social risks (for example, neighborhood deprivation and housing status) (Breslin et al., 2017; Commonwealth of Massachusetts, 2017; Crumley and Marlise, 2018). Chapter 5 provides more details about risk-adjusted payments. The increased focus on the intersection of social risk and health out- comes at a national level provides an opportunity to recognize, evaluate, and potentially incentivize contextualized care so that it can be imple- mented more systematically throughout the U.S. health care sector. The adjustment approach to social care integration is potentially the least con- troversial of health care strategies to strengthen social care since the focus of care remains within the traditional wheelhouse of medical care. None- theless, substantial gaps in knowledge exist about how adjustment strat- egies should affect disease-specific care decisions. For example, though PREPUBLICATION COPY—Uncorrected Proofs

FIVE HEALTH CARE SECTOR ACTIVITIES 43 many expert care guidelines on diabetes, hypertension, and obesity rec- ognize the influence of social context, sparse information is provided in those social guidelines about how providers should alter their care based on specific social risks (American Diabetes Association, 2017; Armstrong, 2014; Eckel et al., 2014; Jensen et al., 2014; Stone et al., 2014). Thus, it is not surprising that some research shows that clinical care is not systemati- cally context-informed in U.S. health care settings. When social risk data are provided via verbal cues, for instance, providers inconsistently incor- porate the information into care decisions (Levinson et al., 2000; Tong et al., 2018; Weiner et al., 2010). In one study, providers given verbal cues about patients’ complex contextual circumstances subsequently provided contextually appropriate care in fewer than 23 percent of cases (Weiner et al., 2010). Health care workers may resist universal screening given the limited evidence on how to screen most effectively, insufficient support for referrals and follow up, and changes in procedures and workflow that may be necessitated by screening. There are many outstanding questions about whether there should be more explicit adjustments to care recommended for patients with spe- cific social risks (e.g., food or housing insecurity) in order to maximize the uptake of guideline-concordant care. For instance, the potential for such adjustments to widen rather than lessen health inequities must be considered. Concerns have arisen from concrete examples in the health care system where social risk factors have been wielded to deny evidence- based care to select populations. For instance, history suggests African Americans have been systematically denied adequate pain management due to both conscious and unconscious biases about pain perception and racialized depictions of addiction, substance abuse, social support, and a perceived inability to comply with pain management practices (Primm et al., 2004). To avoid such discrimination caused by the presence of social risks, new care management guidelines must be thoughtfully designed both to incorporate social risks into personalized care and to provide guardrails against discrimination. As these guidelines emerge, appropri- ately applying them will require relevant training curricula and incentives (Weiner and Schwartz, 2016). Training of the social care workforce is dis- cussed in Chapter 3, and payment and financing reform that can support this work is the focus of Chapter 5. Assistance: Strategies to Link Patients with Social Needs to Government and Community Resources Beyond increasing awareness of patients’ social risks and adjust- ing care to accommodate endorsed risks, there is a new focus on health care–based interventions on reducing social risk by providing assistance PREPUBLICATION COPY—Uncorrected Proofs

44 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE in connecting patients with relevant social care resources. The literature contains descriptions of a variety of assistance activities that have been undertaken by health systems and communities. These assistance activi- ties vary in intensity, from lighter touch (one-time provision of resources, information, or referrals) to longer and more intensive interventions that attempt to assess and address patient-prioritized social needs more com- prehensively (Bickerdike et al., 2017; Gottlieb et al., 2017b; Hannigan and Coffey, 2011). Lighter-touch assistance activities can include providing informa- tion or vouchers for patients to obtain resources in the community (e.g., through curated resource lists) or referring patients to specific programs (e.g., to medical–legal partnerships to address legal barriers to housing or benefits, to eligibility counselors to enroll in Medicaid, or to social work- ers to obtain help with heating bills or short-term rental assistance). These lighter-touch interventions can include direct assistance (e.g., sending patients home with food if they report being hungry, providing rides di- rectly to and from appointments, or offering respite care activities to sup- port caregivers) (Berkowitz et al., 2018; Chaiyachati et al., 2018; Lindau et al., 2016; Martin et al., 2015). More intensive assistance activities are often directed to medically and socially complex patients, and they typically include processes such as relationship building, comprehensive biopsychosocial needs assess- ments, care planning, interventions (e.g., resource connections, ongoing case management, and behavioral activation interventions, such as moti- vational interviewing), and long-term community-based supports (Burns and Essing, 2018; Lukens and McFarlane, 2004; Miller and Rollnick, 2012; NEJM Catalyst, 2017; Rizzo and Rowe, 2016). These more intensive as- sistance activities can enable the identification of co-occurring mental health concerns (such as low self-esteem, loneliness, and a history of trauma) and physical health barriers. As a result, intensive assistance activities can contribute to care adjustments at the same time as they are supporting the different processes. This has made the impacts of social care assistance activities difficult to disentangle from other intervention activities targeted at high-complexity patients (Gottlieb et al., 2017b). The AIMS care coordination model and the IMPaCT model are two examples of a higher-intensity assistance approach (see Box 2-2). Assistance is sometimes provided directly by clinical care team mem- bers, such as primary care providers or registered nurses. Other times, these activities are assigned to individuals whose roles are more focused on social care, such as social workers (Altfeld et al., 2012; Boutwell et al., 2016; Fabbre et al., 2011; Fraser et al., 2018; Gehlert et al., 2015; Rizzo and Rowe, 2016; Stanhope and Straussner, 2017), patient navigators, commu- nity health workers, or care coordinators (Berkowitz et al., 2018; Chinman PREPUBLICATION COPY—Uncorrected Proofs

FIVE HEALTH CARE SECTOR ACTIVITIES 45 BOX 2-2 Examples of High-Intensity Assistance Activities AIMS: A Care Coordination Model Goal: Address barriers to health and well-being by identifying medical and nonmedical risks and addressing priority needs in order to improve health, reduce the use of unnecessary health services, improve patient satisfaction with the health care delivery system, and help primary care providers maintain joy in work. Approach: AIMS embeds master’s-prepared social workers into primary and specialty care teams to assess the needs of complex patients and provide risk- focused care coordination. AIMS is implemented telephonically and/or in person and is typically completed in 6 to 8 weeks. Patients with nonmedical needs are identified by primary health care physicians or nurses and referred to the AIMS team members who deliver AIMS in four steps: patient engagement and assessment, care plan development, care management, and goal attainment. AIMS has also been replicated by community-based organizations in partnerships with local clinics. Outcome: AIMS is integrated in seven primary care clinics at RUMC and has served several thousand patients since it was developed in 2010. AIMS patients were satisfied with health care services delivery and reported better ability to understand and manage their chronic illnesses. One retrospective evaluation revealed that AIMS patients had fewer hospital admissions, emergency depart- ment visits, and 30-day readmissions than patients in the broader RUMC popula- tion. A quasi-experimental study on AIMS found that recipients’ health risks and depression scores were reduced within 6 months of the intervention, while the comparison group participants’ scores were unchanged. NOTE: AIMS = Ambulatory Integration of the Medical and Social; RUMC = Rush University Medical Center. SOURCES: Rizzo et al., 2016; Rowe et al., 2019, in press. IMPaCT Model (Individualized Management for Patient-Centered Targets) Goal: Provide high-risk, low-income individuals with tailored social support, navigation of complex health systems, and advocacy to help them achieve their health goals. Approach: Community health workers are hired from the local community to work with patients. The program is delivered in three stages: goal setting, short- term tailored supports, and connection with long-term supports. Outcome: More than 6,000 people in Philadelphia, Pennsylvania, have been served by the program. In randomized trials, IMPaCT improved participants’ access to primary care and mental health services; patient activation; and care quality. The program also reduced 30-day hospital readmissions. Outpatients with multiple chronic conditions that were enrolled in the program had improved chronic disease control and quality of care and reduced hospitalization. SOURCE: Kangovi et al., 2018. PREPUBLICATION COPY—Uncorrected Proofs

46 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE et al., 2015; Dale et al., 2008; Gunderson et al., 2018; Kangovi et al., 2015; Repper and Carter, 2011; Salzer et al., 2010). These staff may be employed by health systems or by partner community-based organizations (Schrage, 2018). Systematically integrating assistance activities into health care or- ganizations may necessitate changes in workflow, team dynamics, and or- ganizational culture, and it may demand strategies to engage patients that depart from usual care. Together these requirements can present substan- tial barriers to implementation (Helfrich et al., 2016; also see Chapter 6). Despite substantial evidence concerning the connection between so- cial risks and health outcomes and use, there are few rigorously designed studies on the impact of assistance interventions on outcomes or use among participants (Gottlieb et al., 2017a). Rather, most evaluations of in- terventions have focused on process outcomes, such as patient satisfaction and self-reported health-related measures, and have not differentiated be- tween specific intervention components (Gottlieb et al., 2017a). Moreover, many assistance interventions have evolved over time under principles of continuous quality improvement and learning health systems, using techniques such as pre–post analyses rather than more rigorous random- ized control trials (McGinnis et al., 2014). Further research is needed in this area on the wide range of interventions that are and could be used to reduce patients’ social risk. This research will need to more clearly articulate the added value of providing assistance services, particularly for specific populations who may report the same social need but have differing complexities and benefit eligibility that should inform assistance activities. The health care sector’s approach of providing assistance with basic material needs, for instance, to patients who are medically complex is likely to differ from providing assistance to healthier populations. Alignment and Advocacy: Activities Where Health Care Organizations Partner and Collaborate with Other Sectors Increasingly, health care delivery organizations, health plans, and other health care stakeholders play roles in aligning health care assets with existing social care assets in communities and advocating for more social resources to improve community health and well-being. The com- mittee defined alignment activities to include those undertaken by health care systems to understand existing social care assets in the community, organize them in such a way as to encourage synergy among the various activities, and invest in and deploy them to prevent emerging social needs and improve health outcomes. The committee defined advocacy activities as those in which health care organizations work with partner social care organizations to promote policies that facilitate the creation and rede- ployment of assets or resources in order to improve health outcomes and PREPUBLICATION COPY—Uncorrected Proofs

FIVE HEALTH CARE SECTOR ACTIVITIES 47 prevent emergence of unmet social needs. While providers, patients, and caregivers also can advocate to improve social resources for individual patients, the committee defined health care sector advocacy as activities that are aimed more broadly at increasing the availability of community resources for groups of patients. The net effect of both of these types of ac- tivities (alignment and advocacy) is to achieve what the Centers for Medi- care & Medicaid Services defined as the objective of the alignment track of the Accountable Health Communities Model, which is to “optimize community capacity to address health-related social needs” (CMS, 2019). In both the alignment and advocacy categories, health care organiza- tions leverage their political, social, and economic capital within a com- munity or local environment to encourage and enable health care and social care organizations to partner and pool resources, such as services and information, to achieve greater net benefit from the health care and social care services available in the community. Since 2009, reports from the Agency for Healthcare Research and Quality, the Institute of Medicine (now called the National Academies of Sciences, Engineering, and Medi- cine and the National Academy of Medicine), the U.S. Preventive Services Task Force, and other organizations have recommended improving the integration of clinical, public health, and community-based services and focusing on increasing the uptake of clinical preventive services (AHRQ, 2016; ASTHO, 2015; Dzau et al., 2017; IOM, 2012; Long et al., 2017; Ock- ene et al., 2007). Cross-sector collaboration is also a foundational strategy in the Robert Wood Johnson Foundation’s Action Framework to build a Culture of Health and has been described in multiple reports on how partnership-driven work can integrate health care and social care ser- vices to improve population health (Plough, 2015; Towe et al., 2016). An important limitation of these collaborations is that they often occur in the context of uneven power dynamics and historical fragmentation between sectors due to differing funding sources and workforces. Though such partnerships are not new, health care organizations are engaging in collaborative work in increasingly varied ways. However, despite national recommendations and increasing activity concerning the use of intersectoral work to strengthen community resources, the litera- ture on the effectiveness of the health care sector’s alignment and advo- cacy work in large part remains limited to case studies. Some evidence suggests that alignment and advocacy activities can improve a variety of health outcomes, from infection control to asthma and cardiovascular outcomes (Boex et al., 1998). One study demonstrating effectiveness found significantly lower death rates from potentially preventable conditions among communities with multi-sector networks supporting population health activities with alignment and advocacy strategies extending well beyond the boundaries of the traditional health care system to include PREPUBLICATION COPY—Uncorrected Proofs

48 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE policy changes supporting improved health outcomes (e.g., smoking bans and increasing access to healthy food) (Mays et al., 2016). Reporting bias may skew the literature toward positive outcomes narratives, including impacts on health care use, expenditures, and overall population level health outcomes. With the above caveats, a handful of illustrative examples are avail- able to demonstrate three strategies that health care stakeholders have taken to increase alignment and advocacy in their communities. 1. Partner with social care agencies to fill known gaps in services for beneficiaries. One approach used by health care organizations to improve alignment and advocacy is to strengthen collaborations with social care organizations to directly provide needed services. For instance, the network Area Agencies on Aging coordinates with community-based organizations to provide community case management, home-delivered meals, and caregiver respite to aging populations (Brewster et al., 2018). This partnership for- malized the referral infrastructure and established a compensa- tion mechanism for these services that supports the assistance activities of the clinics while also aligning and investing in lo- cal resources and helping sustain and strengthen local, trusted institutions. In another example, the Henry Ford Health System partnered with Uber, Lyft, and Ford Motor Company to provide transportation to its patient population, with a particular focus on those in underserved communities (Knowles, 2018; Martinez, 2018). At the same time they are campaigning to modify existing transportation infrastructure in the city of Detroit in order to fa- cilitate access in vulnerable communities. An increasing number of health care organizations are also investing in low-income housing. For example, UnitedHealth Group invested $50 million in low-income housing tax credit funds managed by the Greater Minnesota Housing Fund and Enterprise Community Invest- ment, resulting in the development of multi-family rental units for very low-income and special needs households (UnitedHealth Group, 2013). 2. Develop anchor institution strategies. A growing number of health care initiatives explore roles that the health care sector can play in improving the social, economic, and political landscape of local economies. In these cases, health care organizations adopt place- based, health-equity-focused strategies that recognize that social and economic determinants are largely responsible for health out- comes. These organizations often describe an “anchor mission” that helps them realign institutional assets to broadly combat PREPUBLICATION COPY—Uncorrected Proofs

FIVE HEALTH CARE SECTOR ACTIVITIES 49 social and economic disparities by investing in communities. Hospitals and health systems spend $782 billion annually, employ more than 5.6 million people, and hold investment portfolios of more than $400 billion (Ubhayakar et al., 2017). Investments made through anchor institution strategies sometimes rely on commu- nity development financial institutions, which provide access to capital often unavailable from traditional lenders, or on social impact bonds, in which case private funds are used to catalyze initiatives to address community needs. In 2019, more than 40 health care delivery organizations were participating in an anchor institution collaborative activity (Healthcare Anchor Network, 2019). For example, Rush University Medical Center’s (RUMC’s) anchor strategy involves hiring individuals from underserved communities to provide them with economic opportunity, estab- lishing local and minority-owned business preferences for ven- dor and supply chain contracts, and creating a local financial investment strategy (Harkavy, 2016; Ubhayakar et al., 2017). As part of this approach, since 2017 RUMC has provided $6 million in loans to community development financial institutions, such as one supporting the city of Chicago’s Neighborhood Rebuild Training pilot program. In programs like these the funding can be used in various aspects of the community, including renovations to homes in high crime areas and providing on-the-job training and credentialing opportunities to youth and ex-offenders (Chi- cago Community Loan Fund, 2018; Community Development Financial Institutions, 2019; RUMC, 2017). While it is difficult to gauge the impact of such long-term investments and collabora- tions, more outcome data will become available as more health care stakeholders undertake and report on their anchor activi- ties. Another example is Stephen and Sandra Sheller 11th Street Family Health Services, a federally qualified health center in Philadelphia, Pennsylvania (Waite, 2018). 11th Street works with neighborhood residents in cooperation with schools, churches, and community groups and agencies to provide for the biologi- cal, psychological, and social needs of its patients by offering a wide range of services, including creative arts therapies, fitness training, and nutrition classes. 3. Organize and engage in cross-sector coalitions. Other alignment and advocacy activity involve more actively organizing and engag- ing in multi-sector coalitions generally aimed at place-based community improvement. Johns Hopkins University, located in Baltimore, Maryland, is a member of the East Baltimore Develop- ment Initiative, a multi-stakeholder coalition seeking to revitalize PREPUBLICATION COPY—Uncorrected Proofs

50 INTEGRATING SOCIAL CARE INTO THE DELIVERY OF HEALTH CARE the East Baltimore neighborhood (East Baltimore Development Inc., 2010). The university has engaged with the community through the Homewood Community Partners Initiative (HCPI) in 10 neighborhoods located around its main campus (JHU, 2019). HCPI has worked with the Central Baltimore Partnership, various community and neighborhood organizations, and other stake- holders, such as foundations and anchor institutions, to develop an implementation plan for the area. This plan contains 29 prior- ity recommendations for action, including blight removal and housing and commercial development; and to invest and raise funds. From 2013 to 2016 Maryland established health enterprise zones in five communities to stimulate alignment and advocacy activities among local health departments, health care delivery organizations, and social care and community-based organiza- tions; the effort resulted in a net cost savings of $93.39 million (across all zip codes that participated) due to reduced inpatient hospital visits (Gaskin et al., 2018). Hennepin Health, a Minnesota based managed care program, reported similar notable gains co- ordinating assets at the county level, including across social care agencies, county-based health departments, multiple health sys- tems, and a nonprofit health plan (Vickery et al., 2018). Together these agencies reported reductions in emergency department use and increased primary and preventative care use for Medicaid beneficiaries. These strategies alone or in combination may be funded by health care organizations via community benefit programs—the required con- tributions that nonprofit health care delivery systems must make to earn their tax-exempt status. The committee recognizes that health care organizations can bring funds, data, and political and other forms of capital to catalyze commu- nity activities—including through the various strategies described in this chapter. But the health care sector has not consistently wielded this capital in the interest of primary prevention of clinical conditions or prevention of the complicating social conditions. Effective strategies to strengthen so- cial and health care integration are likely to require more attention to the experience and expertise of community stakeholders. This will demand organizational humility from the health care sector, particularly as it moves from health care delivery to community-focused activities. Align- ment and advocacy initiatives should incorporate patients, families, and community members in program planning and execution to help avoid historical missteps. PREPUBLICATION COPY—Uncorrected Proofs

FIVE HEALTH CARE SECTOR ACTIVITIES 51 As effective strategies emerge, attention will need to be given to implementation feasibility and program sustainability, including the workforce, technology, and payment models that will support the strate- gies and enable long-term interventions and corresponding reductions in health disparities. FINDINGS • Five complementary types of activities can facilitate the integra- tion of social and health care. They are awareness, adjustment, assistance, alignment, and advocacy. • These types of activities should not be considered mutually exclu- sive, and one does not necessarily build on another. The exception involves awareness activities, which typically are foundational to the others. • Some health care systems have had success with using these strategies to strengthen social care services and, subsequently, to link social care activities with improved health outcomes. • Robust outcome evaluations have not been conducted on social care integration activities, which limits the committee’s ability to draw conclusions and make recommendations about specific evidence-based practices. • A “one-size-fits-all” approach is neither feasible nor advisable, since context should influence the adoption of specific social and health care integration activities. REFERENCES AASWSW (American Academy of Social Work & Social Welfare). 2017. Strengthening health care sys- tems: Better health across America. http://grandchallengesforsocialwork.org/publications/ strengthening-health-care-systems-better-health-across-america-working-paper-no-22. AHRQ (Agency for Healthcare Research and Quality). 2016. Clinical–community linkages. https://www.ahrq.gov/professionals/prevention-chronic-care/improve/ community/index.html (accessed February 7, 2019). Alberti, P. M., K. Sutton, I. Baer, and J. Johnson. 2014. Community health needs assessments: Engaging community partners to improve health. Washington, DC: Association of Ameri- can Medical Colleges. Alderwick, H. A. J., L. M. Gottlieb, C. M. Fichtenberg, and N. E. Alder. 2018. Social prescrib- ing in the U.S. and England: Emerging interventions to address patients’ social needs. American Journal of Preventive Medicine 54(5):715–718. Altfeld, S. J., E. Avery, R. L. Golden, T. J. Johnson, K. Karavolos, V. Nandi, M. Rooney, G. E. Shier, and A. J. Perry. 2012. Effects of an enhanced discharge planning intervention for hospitalized older adults: A randomized trial. Gerontologist 53(3):430–440. American Board of Family Medicine. 2019. PHATE: The population health assessment engine. https://primeregistry.org/phate (accessed April 12, 2019). PREPUBLICATION COPY—Uncorrected Proofs

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The consistent and compelling evidence on how social determinants shape health has led to a growing recognition throughout the health care sector that improving health and health equity is likely to depend – at least in part – on mitigating adverse social determinants. This recognition has been bolstered by a shift in the health care sector towards value-based payment, which incentivizes improved health outcomes for persons and populations rather than service delivery alone. The combined result of these changes has been a growing emphasis on health care systems addressing patients’ social risk factors and social needs with the aim of improving health outcomes. This may involve health care systems linking individual patients with government and community social services, but important questions need to be answered about when and how health care systems should integrate social care into their practices and what kinds of infrastructure are required to facilitate such activities.

Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health examines the potential for integrating services addressing social needs and the social determinants of health into the delivery of health care to achieve better health outcomes. This report assesses approaches to social care integration currently being taken by health care providers and systems, and new or emerging approaches and opportunities; current roles in such integration by different disciplines and organizations, and new or emerging roles and types of providers; and current and emerging efforts to design health care systems to improve the nation's health and reduce health inequities.

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