- Healthcare industry leaders have made it part of their mission to drive health equity, giving all patients equal opportunity to achieve wellness. But as many organizations work toward this goal by expanding patient access to care, others say that isn’t enough. Strategies to address the social determinants of health will be key to achieving health equity.
Such was the case at Intermountain Healthcare, the Utah-based health system that boasts 22 (soon to be 23) hospitals and its own health plan, SelectHealth.
The health system has long been invested in its community, specifically working to create seamless care access for all patients, regardless of ability to pay, according to Mikelle Moore, senior vice president of community health at Intermountain Healthcare.
“We provide extension charity care, a very rich financial assistance policy, and we reach into the community to find people to serve with those policies,” Moore told PatientEngagementHIT.com in an interview. “We've opened and operate clinics in medically-underserved areas, and we support about 50 clinics across our service area that are directly oriented to serve low-income, underserved people. We also facilitate access to specialty diagnostic services when they're needed for people.”
But despite its numerous care options, Moore and Intermountain’s community health team have continued to observe lingering issues with health equity.
“We were surprised to discover that disparities are beginning to show themselves within our community in ways that we thought of as more common in urban, eastern, and southern parts of the United States,” Moore explained.
After all, Intermountain hosts a wealth of community care options, and has done so for decades. It seemed unlikely that patients would still have trouble achieving good health. But the fact remains that health is determined by zip code in addition to genetics.
“Even in Salt Lake, if I look out one direction of my window versus another, east versus west, we now know there's a 10-year life expectancy difference in all of those zip codes,” Moore said, noting that social issues have an equal impact on patient health as genetics.
“We're not okay with that, and we recognize that just creating access to healthcare and ensuring that people get necessary or have access to necessary care when they need it isn't enough.”
To combat some of those community issues, commonly referred to as the social determinants of health, Intermountain Healthcare has invested $12 million into two Utah communities to better understand these trends.
The social determinants of health – which include transportation access, living environment, poverty levels, educational attainment, and access to nutritious food, to name a few – have long been a subject in public health, but only now has gained notoriety in the medical industry at large.
Moore and her team want to contribute to that conversation, she said. Specifically, Intermountain plans to learn about how investing in the social determinants of health can create measurable health improvements.
“Our demonstration project aims to look at how investment in addressing the social needs of people can improve outcomes,” Moore explained. “Can we create sustainability for being able to address those social needs in a scaled and replicable approach across our state, perhaps around the country?”
Intermountain will invest the $12 million in funding over a three-year period during which two communities in Weber County and Washington County will create community health programs. The health system plans to collect rigorous health outcomes data to understand whether social investment yields a return on investment, either financial or through increased wellness.
Specifically, Intermountain plans to look at healthcare utilization, health outcomes, and spending.
Creating such a program has not been a simple process, Moore shared. The health system first needed to gain support from leaders at the state level, convincing Medicaid leaders that this type of investment in high-risk populations will be appropriate.
Intermountain also had to select the best possible location for implementing these programs. This began with extensive data collection and analysis.
“We started by looking at data, and we needed that state-level support in order to have access to some of the data we wanted,” Moore recalled. “We had a lot of information about SelectHealth members certainly, that tells us what their needs are. We could map that geographically against our understanding from census data and other sources about the needs of particular zip codes.”
Intermountain also used zip code-level Medicaid data to better understand the needs and habits of beneficiaries.
Much of that zip code data led to other publicly-available information, such as food stamps or SNAP utilization, mental health and substance use treatment programs, and housing programs.
Moore and her team took every zip code within Utah and looked at social resource deprivation within those areas. They then overlaid that with how their members were utilizing services within those zip codes.
That provided an understanding and ranking of each zip code, highlighting where patient needs are. But Moore and her team needed to incorporate other key factors.
“What are the most important things for being able to impact outcomes for our communities? Do we have partners and people who are willing and able to work with us? Or interested in working on this with us?” she questioned.
Moore and her team learned that members have high mental health and substance use treatment needs, in addition to food insecurity, housing needs, and limited transportation access. Intermountain selected Weber County and Washington County because they both displayed high needs for support systems, as well as the resources for fulfilling those needs.
Since identifying those counties, Moore and her team have forged community health partnerships with different resource centers. Those partnerships are built fundamentally on trust, as well as a mutual goal of improving health and health equity throughout Utah.
Although the process for identifying high-needs communities may appear rigorous, Moore noted that taking a less granular approach was key.
“When we started our analytics work in preparation for this project we envisioned being even more rigorous and technically advanced than we actually ended up being in our approach,” she pointed out. “And that's really where the lessons learned occurred. We thought we should really try to map this data to the individual level, at first.”
But looking at the zip code level turned out to be more effective for a number of reasons. Zip code-level data is publicly-available, meaning Intermountain could easily able to obtain it. This engendered greater trust in their project.
Using zip code level data has also led Intermountain to the next steps of its projects – streamlining access to community services.
“We have food insecurity as one of the greatest needs, and also one of the greatest areas of wealth we have in our community,” Moore said. “There's food available, it's just not matched up to the people who need it very effectively.”
“We'll be able to use that same kind of non-sophisticated, if you will, review of where our food banks are located and where the people are located who need them,” she added. “What other resources are patients accessing? Could we co-locate things, and align resources more effectively?”
The program also has plans to confer with individual patients to gain their perspective on community resource access. Too often, efforts to address the social determinants of health stem from the hospital or healthcare perspective.
“We're not opening our lens to what the family or the person's perspective really is for all of their needs,” Moore noted. “We need to do a better job with that.”
Intermountain plans to conduct an ethnographic study where they meet with 15 homes in both Weber and Washington Counties to better understand patient needs holistically. Moore doesn’t want the viewpoint of the healthcare organization, or the food provider, or the housing provider. Gaining the patient perspective will be most of value.
Ultimately, getting a 360-degree view of patient health and social needs will be essential for delivering care that extends beyond the four walls of the hospital, a key initiative in today’s healthcare landscape.
“Simply creating more access isn't going to create the type of equity and health that we think is ultimately our charge to be a part of creating, if we're going to be a model healthcare system,” Moore concluded. “We truly believe that we need to be a part of creating something different in our country.”