SLIDE 1 WHAT ARE WE GOING TO DO ABOUT THE SOCIAL DETERMINANTS OF HEALTH? CHALLENGES, OPPORTUNITIES, DEAD ENDS AND SOLUTIONS
March 9th, 2018 Adam T. Perzynski, PhD Assistant Professor of Medicine and Sociology Center for Health Care Research and Policy The MetroHealth System Case Western Reserve University 2500 MetroHealth Dr. R225A Cleveland, OH E-mail: Adam.Perzynski@case.edu Phone: 216-778-2850 Twitter: @ATPerzynski
SLIDE 2 Disclosures
- I am co-founder of Global Health Metrics, LLC, a
startup software company.
- I have current book contracts including future
royalties with Springer Publishing and Taylor Francis
SLIDE 3 Objectives
- Examine the complexity of social determinants
- Have a constructive discussion of pathways to a
more socially responsive health care system
SLIDE 4 Outline
- I don’t know what you mean by social determinants.
- New developments in SBIRT models for social
determinants (Screening, Brief Intervention, Referral to Treatment)
– Update on our local digital inclusion (literacy and connectivity) and MyChart training project – Update on Social Determinants functionality in Epic 2018
- Discussion of where we go from here as Health Services
Researchers
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“More of longevity is determined by these societal aspects than is determined by the healthcare you get. Really, we're never going to reduce the cost of healthcare, substantially, and improve longevity and the quality of life until we deal with the societal issues…are we going to try and figure out how we do some of these other things that affect the greater health of the community? Is that our responsibility, is that the community's responsibility?”
Interview with Dr. Cosgrove http://www.cleveland.com/healthfit/index.ssf/2017/01/cleveland_clinic_ceo_toby_cosgrove _on_working_with_trump_obamacare_staying_healthy_and_burgers_q_a.html
SLIDE 6 “I think MetroHealth has figured out a formula for taking care
- f the highest risk socioeconomic patients, and I think we
have the opportunity to create models that engage the consumers, the providers and the payers.”
Interview with Dr. Boutros http://www.beckershospitalreview.com/hospital-management-administration/7- questions-with-metrohealth-ceo-dr-akram-boutros.html
SLIDE 7 Sociology
“Neither the life of an individual nor the history of a society can be understood without understanding both.”
From C.Wright Mills, The Sociological Imagination 1959
SLIDE 8 Braveman P, Egerter S, Williams DR. The social determinants of health: coming of age. Annual review of public health. 2011 Apr 21;32:381-98.
Social Determinants
SLIDE 9 Dahlgren & Whitehead 1991
A model of social determinants of health
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These models do not grasp the full complexity of the situation.
“Inequalities beget inequalities, and existing inequalities … can compound, sustain, and reproduce a multitude of deprivations in well-being.” (Powers and Faden 2006 p. 72).
SLIDE 11 World Health Organization Definition of Social Determinants of Health
The World Health Organization Commission on Social Determinants
- f Health uses the following definition:
“the conditions in which people are born, grow, live, work and age and the fundamental drivers of these conditions.”
SLIDE 12 Fundamental Causes
Social conditions are more than just proxies for
Link and Phelan, 1995. Social Conditions as Fundamental Causes of Disease
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SLIDE 13 Fundamental Causes
(1) people with superior resources can use those resources to garner health advantages (2) the specific mechanisms that allow advantage to accrue change from place to place and from time to time.
From Link and Phelan 2002, p. 732 13
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Galea, S., Tracy, M., Hoggatt, K. J., DiMaggio, C., & Karpati, A. (2011). Estimated Deaths Attributable to Social Factors in the United States. American Journal of Public Health, 101(8), 1456–1465. http://doi.org/10.2105/AJPH.2010.300086
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75.3% 24.7% 50,000 100,000 150,000 200,000 250,000 Do Not Use PHR Use PHR Number of Patients
Overall PHR Use 2012 - 2015
Example: Digital Divide and Health Information Technology
SLIDE 22 MyChart Use by Age
30.1 25 16.5
5 10 15 20 25 30 35 18-64 years 65-79 years 80+ years % Using PHR
SLIDE 23 MyChart Use by Ethnicity
30.7 19 18.7 23.6
5 10 15 20 25 30 35 White Black Hispanic Other % Using PHR
SLIDE 24 MyChart Use by Insurance
35.8 22.9 19.9 16.4
5 10 15 20 25 30 35 40 Commercial Medicare Medicaid Uninsured % Using PHR
SLIDE 25 MyChart Use by Broadband Access
15.2 18.6 25.5 33 31.8
5 10 15 20 25 30 35 40 0 - 20% 20 - 40% 40 - 60% 60 - 80% 80 - 100%
% Using PHR
Census Tract Broadband Coverage % of total population
SLIDE 26 Multivariate Results
Table 1. Multivariate Logistic Regression of MyChart First Sign-in (N=204,882) Variable Odds Ratio 95% Confidence Interval p Age 0.990 0.990 0.991 <.0001 Sex (female) 1.747 1.711 1.783 <.0001 African American 0.644 0.628 0.660 <.0001 Hispanic 0.615 0.587 0.645 <.0001 Other Race 0.905 0.851 0.963 <.0001 Unknown Race 0.681 0.641 0.724 <.0001 Medicaid 0.538 0.525 0.551 <.0001 Medicare 0.357 0.344 0.369 <.0001 Uninsured 0.435 0.419 0.452 <.0001 Total Number of Visits 1.046 1.045 1.047 <.0001 Charlson Co-morbidity Index 1.001 0.990 1.001 0.9071 Neighborhood Broadband Internet Access 1.242 1.227 1.242 <.0001
Adults 18 to 80, listwise deleted c-statistic = 0.724
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An SBIRT Approach to Solving the Digital Inclusion Problem in Health Care
We are conducting a quasi-experimental study of a community health worker (CHW) model implementation in an urban primary care clinic serving a disadvantaged population. CHWs introduce patient portal use, give referrals for a free, health-focused digital literacy training program, and identified connectivity barriers.
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Interim Evaluation Results
Written clinic activity logs and electronic health record data were used to evaluate efficacy. Of 186 patients seen on the 14 days when logs were kept, 2% did not have the functional English proficiency to use the portal, 18% were not interested, 26% were already using the portal and 55% expressed interest in the training program.
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Interim results continued
Results from more than 20,000 clinic visits suggest that the pilot project resulted in a three-fold increase in the rate of patient portal uptake and double the rate of portal-based visit scheduling for the intervention vs. control site (p=.0014, chi-sq=10.145, df=1). HOWEVER: The rate of increase (system wide, and at the control site) is only 0.5% per 6 months.
SLIDE 31 NEW DEVELOPMENTS IN EPIC 2018
- EPIC and other EHR vendors are rolling out social determinants features in
their software.
- There is a growing market for companies that offer combinations of
products, software and services as solutions for social determinants .
- Socially Determined
- Now Pow
- TavHealth
- Aunt Bertha
- Purple Binder
- All of these approaches utilize an SBIRT-type model, and tend to ignore
important nuances of social determinants.
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NEW DEVELOPMENTS IN EPIC 2018
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Screenings for food insecurity and transportation needs inthe History activity
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ICD-10 Z-Codes for Social Determinants of Health
National Association of Community Health Center (NACHC) Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) tool
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ICD-10 Z-Codes for Social Determinants of Health
National Association of Community Health Center (NACHC) Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) tool
SLIDE 36 Discussion
- What are the weaknesses of the SBIRT approach to
Social Determinants?
- What does excellence in addressing social
determinants in the health care system look like?
- What are the innovative research projects we can
engage in that take advantage of these new developments?
