This article was written by Lisa Miller.

SDOH Hospital Strategies

In my previous blog, I explained the importance of assessing your hospital for SDOH readiness.
The next step is to implement research-proven SDOH strategies for your hospital. This article is the first part of those strategies.
Introduction

Multiple federal, state and private initiatives have been focused on a number of issues in healthcare, such as:

• Population health
• Addressing health disparities
• Increasing access to care
• Reducing healthcare costs
• Decreasing inpatient stays and hospital readmissions

These include CMS/ Center Medicare and Medicaid Innovation, Accountable Health Communities, State Innovation Models, State Medicaid Programs and Medicaid MCOs.¹
In addition, private foundations and healthcare providers have joined the efforts to address the social needs of patients and improve healthcare across the US.
Hospitals have also become financially accountable for quality outcomes with value-based care reimbursement models and have begun to integrate Social Determinants of Health (SDoH) into their strategic plans.
In following the “Triple Aim” ², hospitals seek to:
a) Improve the patient experience of care (including quality and satisfaction).
b) Improve the health of populations.
c) Reduce the per capita cost of healthcare.
Research also demonstrates that the best clinical outcomes are achieved by addressing the patient’s medical care, as well as the patient’s social and environmental circumstances (SDoH).
The best clinical outcomes are achieved by addressing a patient’s medical care, as well as their social and environmental circumstances (SDOH). Click To Tweet
“Our analysis of the literature indicates that several interventions in the areas of housing, income support, nutritional support, and care coordination and community outreach have had a positive impact. These interventions should be of interest to health care policymakers and practitioners seeking to leverage social services to improve health or reduce costs. Importantly, 100% of the studies evaluating income support programs, 88% of the care coordination and community outreach interventions, 83% of the housing support programs, and 64% of the nutritional support programs evaluated had statistically significant, positive effects on health outcomes alone or on both health outcomes and health care spending”…
… “In summary, we found substantial evidence of improved health outcomes and/or reduced health care spending related to interventions that addressed housing, nutrition, income support, and care coordination and community outreach needs.” ³
In part one of this two-part series, we have identified four recommended hospital strategies to implement SDOH programs. These cover the following areas:

• Food insecurity
• Social support/isolation
• Housing instability

These successful initiatives were designed by hospitals in collaboration with community organizations, to support their patients and the communities they serve.
As health systems branch out into this new realm, collaboration with private and public agencies, as well as with community organizations, is essential in order to find solutions for the complex issues facing the sector. These issues include improving patient health and satisfaction, reducing the cost of care, and realizing economic benefits.
Actionable recommendations
1. Food insecurity
A) Food Rx is a food prescription program born from a collaboration between the Urban Health Initiative, the University of Chicago Medical research team, the Robert Wood Johnson Foundation, Walgreens, a local farmers’ market, and six health centers on the South Side of Chicago. On the South Side of Chicago, 19.3% of people have diabetes. Many live in food deserts, which makes it hard to source fresh, healthy food. In addition, local crime can make it unsafe to exercise outside. The Food Rx program provides fresh, nutrient-rich food to those it services, and also includes education, meal planning, exercise programs, and health screenings.
Anna P. Goddu, Tonya S. Roberson, Katie E. Raffel, Marshall H. Chin & Monica E. Peek (2015) Food Rx: A Community–University Partnership to Prescribe Healthy Eating on the South Side of Chicago, Journal of Prevention & Intervention in the Community, 43:2, 148-162, DOI: 10.1080/10852352.2014.973251
B) Produce Rx – Multiple programs throughout the country focus on providing access to healthy and nutrient-rich foods. Again, this applies especially in food deserts. Programs include access to fresh produce supplied by local farmers, coupons, low-cost incentives, personal engagement with providers and dieticians, education and food prep and meal planning.
Haley Swartz, Produce Rx Programs for Diet-Based Chronic Disease Prevention; AMA J Ethics. 2018; 20(10):E960-973. Retrieved at: https://journalofethics.ama-assn.org/article/produce-rx-programs-diet-based-chronic-disease-prevention/2018-10
C) Pilot Food Bank Program – This program includes collaboration with food banks to screen and identify patients with diabetes and provide dietician designed, diabetes appropriate, prepacked boxes of food. These foods include whole grains, lean meats, beans, low sodium vegetables, no-sugar-added fruit, and shelf-stable dairy products.
Hilary K. Seligman, Courtney Lyles, Michelle B. Marshall; A Pilot Food Bank Intervention Featuring Diabetes-Appropriate Food Improved Glycemic Control Among Clients In Three States; Health Affairs; 34, NO. 11 (2015): DOI: 10.1377/hlthaff.2015.0641
2. Social support/social isolation

The second area covers social support and the impact of social isolation.

1. A) Social Isolation – A 2018 Cigna Survey exploring the impact of loneliness in the United States found that nearly half of Americans report sometimes or always feeling alone (46 percent) or excluded (47 percent).⁴
2. Nearly half of all Americans report sometimes or always feeling alone. #SDOH Click To TweetMultiple articles have covered the loneliness epidemic in America. Loneliness has been found to negatively impact our health.“Research has linked social isolation and loneliness to higher risks for a variety of physical and mental conditions: high blood pressure, heart disease, obesity, a weakened immune system, anxiety, depression, cognitive decline, Alzheimer’s disease, and even death.”⁵
3. 
   B) Social Support – Hospitals are struggling to identify innovative ways to effectively help patients with social support. The advent of telemedicine and tele-friendly visits hold promise. While in-person interactions are ideal, the challenges of transportation – particularly in remote areas – and time constraints can prove to be a challenge. Telehealth can prove an appropriate alternative means to build connections with your patient community. Pepin, Renee et al. Tele-Behavioral Activation for social isolation in older home-delivered meals recipients: Preliminary results from an ongoing randomized controlled trial. The American Journal of Geriatric Psychiatry, Volume 27, Issue 3, S170 – S171 

1. C) Other interventions can include the following:

i. Hospital initiated interventions:

• In-home primary care visits (i.e. Independence at Home Demonstration Project”)
• Community health workers and non-traditional workers/companion visits.
• Hospital-sponsored health education programs and exercise programs with transportation provided.
• Telehealth visits.
• Telephone follow-up calls with Case Managers.

ii. Hospital collaboration with community programs:

• • Meals on Wheels.
  • Transportation to social events and senior centers.
  • Home-sharing programs.
  • Community engagement programs (Rotary, VFW, YMCA, Lions, etc).
  • Therapy dogs.
  • Religious groups and connections.
  • Athletic teams and organizations.

Teo AR, Choi HJ, Andrea SB, Valenstein M, Newsom JT, Dobscha SK and Zivin K. Does mode of contact with different types of social relationships predict depression in older adults? Evidence from a nationally representative survey. JAGS 2015; 63; 10: 2014-2022
Holt-Lunstad J, Smith TB and Baker M. Loneliness and social isolation as risk factors for mortality. A meta-analytic review. Perspectives on Psychological Science 2015; DOI: 10:2:227-237
Klinenberg E. Social isolation, loneliness, and living alone: identifying the risks for public health. Am J Public Health. 2016; 106(5):786–787.
3. Transportation
Lack of adequate transportation impacts access to healthcare and follow-up care appointments, which can prevent health conditions from deteriorating. It also limits access to pharmacies and places an economic burden on patients.

The following successful hospital programs have been designed to address these specific issues:
A) Hospitality van service- Taylor Regional Hospital, Kentucky. The hospitality van service consists of two vans, running daily. The vans pick up and drop off patients at the hospital, dialysis centers, cancer centers, rehab centers, and other facilities.
B) Volunteer driver program – Grace Cottage Family Health and Hospital, Vermont collaborated with Green Mountain RSVP, a nonprofit, nationwide program of volunteers age 55 and older, to start the volunteer driver program at the hospital.
C) Transportation vouchers/partnership with Lyft – Denver Health Medical Center offers free bus tickets, cab vouchers, and a private car service through a vehicle donated by Oprah Winfrey. The “Oprah” car is staffed by retired community residents who take patients to and from appointments. Additionally, the hospital recently collaborated with Lyft to provide transportation for patients post-discharge.
D) Mobile health center – Calvert Health Medical Center, Maryland, and Calvert Health Foundation raised funds to purchase a 40-foot state of the art Mobile Health Center. The Mobile Health Center has two fully equipped examination rooms—one for medical and dental services, and one transitional room comprised of a waiting area, a classroom space, and a wheelchair lift.
Health Research & Educational Trust (2017, November). Social determinants of health series: Transportation and the role of hospitals. Chicago, IL, AHA-Health Research & Educational Trust. Retrieved at : https://www.aha.org/system/files/hpoe/Reports-HPOE/2017/sdoh-transportation-role-of-hospitals.pdf
4. Housing instability
Housing instability is associated with poor overall patient health. Health risks for children include asthma, low weight, developmental delays and an increased lifetime risk of depression. Health risks for adults include reduced access to care, postponing essential healthcare or medications, mental distress, difficulty sleeping and increased depression. More information on proven strategies is included below.
A) AIHC program (Accelerating Investments for Health Communities) – The Center for Community Investment at the Lincoln Institute, along with the Robert Wood Foundation and 6 health systems including:
1) Bon Secours Mercy Health System (Baltimore, MD, and Cincinnati, OH),
2) Boston Medical Center (Boston, MA),
3) Dignity Health (San Bernardino, CA),
4) Kaiser Permanente (Purple Line Corridor, Prince George’s and Montgomery counties, MD),
5) Nationwide Children’s Hospital (Columbus, OH), and
6) UPMC (Pittsburgh, PA) are working to develop affordable housing in their communities.
Center for Community Investment. (2019, February 20). Announcing AIHC participants: Six hospitals and health systems step up efforts to increase affordable housing in their regions [Blog post]. Retrieved from: https://centerforcommunityinvestment.org/blog/announcing-aihc-participants-six-hospitals-and-health-systems-step-efforts-increase-affordable
Health Research & Educational Trust (2017, August). Social Determinants of Health Series: “Housing and the Role of Hospitals”; Chicago, IL, AHA-Health Research & Educational Trust: http://www.hpoe.org/Reports-HPOE/2017/housing-role-of-hospitals.pdf
American Hospital Association Issue Brief:  “Making the Case for Hospitals to Invest in Housing”, May 2019 Retrieved from: https://www.aha.org/system/files/media/file/2019/05/AIHC_issue_brief_final.pdf
Commins J. “Impact investment”: Kaiser Permanente commits $200M for housing. HealthLeaders. May 21, 2018: https://www.healthleadersmedia.com/strategy/impact-investment-kaiser-permanente-commits-200m-housing
Robin Hacke and Alyia Gaskins; How Can Clinicians Catalyze Investments to Improve Community Health? ; AMA Journal of Ethics® March 2019, Volume 21, Number 3: E262- 268: https://journalofethics.ama-assn.org/sites/journalofethics.ama-assn.org/files/2019-02/stas1-1903_0.pdf
Abrams, A. (2019, February 25). Putting healthcare dollars to work. Retrieved from https://shelterforce.org/2019/02/25/putting-health-care-dollars-to-work/
B) Ending homelessness – Poverty increases the risk of individuals and families becoming homeless. People experiencing homelessness are more likely to experience health problems and require repeat visits to the emergency room. The Housing First program employs a community-wide coordinated approach to deliver services, obtain housing, and assist with Medicaid and Social Security Disability enrollment.
Fact Sheet-April 2016- Housing First Program- National Alliance to End Homelessness. Retrieved from: https://www.va.gov/HOMELESS/nchav/resources/docs/housing-programs/housing-first/housing-first-fact-sheet-508.pdf
Conclusion
In order to be successful in developing SDOH programs, hospitals must review and analyze their specific patient landscape, while understanding patient needs and the resources available. In addition, they must customize collaboration programs with federal and state agencies, payers, and business and community organizations.
I hope that the research provided in part one of our two-part blog series offers insights and strategies for your own health system to explore and apply in this key, emerging trend.
We will explore four further strategies in the second and final part of this short series on SDOH.
 “Given the current focus on social needs from state and federal policymakers, payers, and physicians and hospitals, it seems likely that pressure on physicians and hospitals to identify and begin addressing patients’ social needs will continue. States are increasingly creating incentives for medical physicians, hospitals, and managed care organizations to integrate and address patients’ social needs.”⁶

Footnotes

1- http://www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx
2- Artiga, S. & Hinton, E. (2018, May 10). Beyond health care: The role of social determinants in promoting health and health equity. 
3- Taylor LA, Tan AX, Coyle CE, Ndumele C, Rogan E, Canavan M, et al. (2016) Leveraging the Social Determinants of Health: What Works?
4- https://www.cigna.com/newsroom/news-releases/2018/pdf/new-cigna-study-reveals-loneliness-at-epidemic-levels-in-america.pdf
5- https://www.nia.nih.gov/news/social-isolation-loneliness-older-people-pose-health-risks and https://blogs.scientificamerican.com/observations/loneliness-is-harmful-to-our-nations-health/
6- Fraze TK, Brewster AL, and Lewis VA. Prevalence of Screening for Food Insecurity, Housing Instability, Utility Needs, Transportation Needs, and Interpersonal Violence by US Physician Practices and Hospitals.