Population Health Means Asking About Basic Needs: Are Your Providers Ready for That?

An individual's — and a population's - health is largely driven by social determinates. Every healthcare provider knows this, but the way that care is delivered fails to recognize this fact.

"When it comes to patients basic resource needs, we practice a don't ask don’t tell policy," said Rebecca Onie, co-founder and CEO of Health Leads and a 2009 MacArthur "Genius" Fellowship recipient, at the National Center for Healthcare Leadership's 2013 Human Capital Investment Conference in Chicago.

Health Leads operates "clinics," within hospitals that help connect patients to existing community resources. Physicians affiliated with the hospital write patients "prescriptions" for heat, food, job training, income assistance programs and other basic resources. The patients then take the prescriptions to the Health Leads clinic, which is staffed by highly trained college-aged volunteers who are overseen by social workers.

Today's don't ask, don't tell policy isn't helping patients, or providers. Health Leads recently surveyed residents at Massachusetts General Hospital in Boston, home to its newest clinic. Ninety-one percent of the residents said they didn't feel equipped to address their patients' social needs.

Patients facing pricy prescriptions and other healthcare costs face "excruciating tradeoffs" as they make decisions such as: Should I pay my rent or buy my prescription? Why bother getting my diabetes medication if I don't have electricity and can't refrigerate them?

Rebecca realized the problems this created when volunteering at Boston Medical Center during her undergraduate years at Harvard University. Working with the permission of Barry Zuckerman, MD, founder of the National Center for Medical-Legal Partnership, she interviewed physicians and nurses about their interactions with patients. Her favorite question: "If you had unlimited resources what would be the one thing you would give your patients?"

"I heard the same story again and again," she said: Physicians needed help helping patients meet their basic needs.

Health Leads was developed to give clinicians a resource to be able to do this for patients.

Health Leads fills a gap in healthcare delivery that is critical if organizations are to truly be successful in providing population-based and patient-centered care.

Population health, she said, is more than just a buzzword or a way to get paid, but could actually be the "best and most logical way for care to be delivered."

On patient-centered care, she remarked: "It's a goal so obvious, it's embarrassing we have to state it as an aspiration."

I think she's right. How will your health system ensure patients' basic needs, and not just their medical needs, are met?

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