Under value-based care, today’s healthcare leaders are challenged (and incentivized) to think differently too. Understanding how the broader social determinants of health impact patients and new care models is a good place to start this different thinking.
Care coordinators are on the forefront when it comes to understanding the impact of social determinants of health. Day in and day out, they listen to patients. They understand that some patients miss appointments because they have no transportation. They learn that other patients skip medications because they can’t afford the recurring cost. They connect the dots, recognizing that factors—outside of healthcare—directly affect the health of their patients.
The successful shift to value-based care requires that we think differently about ways to address such non-clinical factors. Failure to understand and address those factors stands in the way of moving the needle on unnecessary healthcare utilization.
In the United States we spend over two-and-a-half times more per capita on healthcare compared to other wealthy nations. And despite that investment, our citizens experience a lower life expectancy and higher infant mortality rates than the overwhelming majority of similarly economically advanced countries.
Why is that? Because despite our overspend on healthcare services, we only spend about a quarter of what other wealthy nations spend on social services that impact health. There is a direct connection/correlation between where we spend resources related to care and the outcomes we achieve.
Under value-based care, providers take on financial risk for the quality of care and patient outcomes across the care continuum. And, social determinants of health often tie into the overutilization of healthcare services, such as avoidable ER visits and preventable readmissions. But, unless efforts are made to address the social and environmental obstacles that our patients experience, success will be elusive in value-based care models.
The answer to success is patient engagement: “the regular, consistent and persistent involvement of a patient in his or her self-care.” Patient engagement is the most direct and effective strategy for bridging the gaps inherent in the social determinants of health. When providers engage their patients, they are able to ask the right questions that lead to strategies and ways to change a patient’s outcome for the better.
Success in value-based care requires new ways of thinking about how our patients get involved in their own care. Patient engagement gives providers one more powerful way to learn about and care for their unique populations.
How many hospital readmissions could you avert if you knew your patients lacked transportation? How many admissions could you avert if your patients improved their medication adherence? How many ER visits could you prevent if you identified patients suffering from social isolation and loneliness?
To deliver value-based care, you need to understand the challenges around access and health literacy. You also need to build a seamless care model that weighs the social determinants of health equally with clinical care delivery. The optimal model must:
• Screen and find these non-clinical factors
• Craft interventions to address them
• Organize the multidisciplinary resources and people needed to deliver interventions
For further reading about the social determinants of health, access the free e-book “Understand and address the non-clinical factors driving healthcare utilization.”
The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker’s Hospital Review/Becker’s Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.
