Comprehensive community care
David Meltzer, MD, PhD, a hospitalist and professor of medicine at the University of Chicago, said most hospitalists these days believe social determinants of health are part of their job responsibilities.
“That’s not to say we all do it well. We may fail at addressing some of the barriers our patients face. But I don’t know anyone who still says it’s not their job,” he said.
Since 2012, Dr. Meltzer has led a pilot called Comprehensive Care Physicians (CCP), in which the same physician cares for patients with chronic health problems in the clinic and in the hospital, working with a team of nurse practitioners, social workers, care coordinators, and other specialists. A total of 2,000 patients with chronic health problems were enrolled in the study from 2012 to 2016, half assigned to standard care and half assigned to five CCP doctors. The result: The CCP model has shown large improvements in outcomes – particularly among the more vulnerable, less activated patients, is preferred by patients, and has significantly reduced health care utilization.
The next step for the research team is another randomized controlled trial called Comprehensive Care, Community, and Culture, designed to address unmet social needs. Study group patients will also be screened for unmet social needs and have access to a community health worker and to the initiative’s Artful Living Program, which includes community and cultural activities like yoga and dance classes, cooking classes, art classes, and music concerts. To address the complex dimensions and determinants of health, Dr. Meltzer explained, efforts to improve health must extend to sectors far beyond traditional health care.
“I think trying to understand your patients’ social and nonmedical needs starts with getting to know them, and asking about their needs,” he said. “The better you know them, the better you are able to make medical decisions that will promote positive outcomes.”
Sound Physicians, a national hospitalist company based in Tacoma, Wash., and working in 350 hospitals in 41 states, recently published a blog post on its website about the importance of social determinants of health.7 Sound Physicians participates in value-based care through bundled Medicare/Medicaid contracts based on episodes of care for hospitalized patients with certain diagnoses or DRGs, explained John Dickey, MD, the company’s chief medical officer for population health.
“We’ve been heavily involved in trying to improve cost and outcomes of care since 2015. Social determinants absolutely play into trying to lower costs of care and reduce rates of readmissions, which are often multifactorial in cause,” he said. Hospitalists are uniquely equipped to impact post-acute outcomes, Dr. Dickey said, working in partnership with a position Sound Physicians calls the clinical performance nurse.
“We can also partner with primary care providers, provide education for our hospitalist staff, and work with in-home care supports for patients such as these, who otherwise might end up in a skilled nursing facility – even though they’d rather be at home,” he said.