Primary Care and Population Health: Last in a Five-Part Series

Feb 8, 2013, 12:00 PM, Posted by

Nicholas Stine, MD, and Dave Chokshi, MD, MSc, writing on behalf of the New York Academy of Medicine Primary Care and Population Health Working Group.

The New York Academy of Medicine is the National Program Office for the Robert Wood Johnson Foundation Health & Society Scholars program, which works to reduce population health disparities and improve the health of all Americans. The New York Academy recently conducted a survey of 17 thought leaders in primary care and population health. In the final of five blog posts, we share a synthesis of what those leaders had to say. All quotes are printed with permission.

Addressing Social Determinants of Health: Given the current state of the clinical delivery system, it may seem unrealistically burdensome to ask health care institutions to address the social determinants of health (SDH). “In this country it’s an accomplishment if you can reward value for delivery,” noted Arnold Milstein, MD, MPH, “and social determinants approaches are a step or two beyond that.”

Examples of clinical engagement in social determinants, however, can be quite impactful:

  • Lloyd Michener, MD, and Bob Lawrence, MD, described how Duke and Johns Hopkins both invested in SDH initially in order to repair or promote their public image. For example, Duke invested in some SDH programs and community partnerships in part to help repair their image in the setting of poor relationships with a minority, low-income community in Durham—though these investments have grown into more lasting partnerships. 
  • David Stevens, MD, pointed out the example of the 16th St Community Health Center in Milwaukee, where an environmental wing of the health center was created to combat lead poisoning—and then expanded over years into broader projects, such as combatting brownfields and creating green spaces for exercise.
  • Glen Mays, PhD, relayed the exemplar of multisectoral collaboration in Oklahoma City.  The collaboration was located on a “health campus” including a teaching hospital, community health center, public health clinic, nonprofit organizations, and an insurance company.  The health campus was situated in one particular ZIP code with the highest concentration of preventable disease burden. The collaboration identified the most pressing risk factors amenable to health care and prevention in that ZIP code and framed their community health planning around that, with the health campus serving as a “one-stop shop” for health.
  • Arnold Milstein described CareMore Health Group in California, a Medicare Advantage plan and provider that has created a multidimensional inventory, assessment and intervention set for addressing SDH, including the use of “psychosocial SWAT teams” to intervene when the main barrier to managing chronic illness is social or environmental. Other “social HMOs” provide services such as light housekeeping, personal care, transportation, home-delivered meals and caregiver relief.

Many discussants favored partnerships with social institutions rather than direct provision of services. This approach cites the natural limits to what primary care can achieve on upstream determinants of health, and the need to build linkages between primary care and both public and private community systems, including schools, housing authorities, job training programs, and churches.  In this vein, Allen Dobson, MD, explained how Community Care of North Carolina had built significant relationships with schools as a natural consequence of their pediatric initiatives on asthma and obesity.

Investing in developing these partnerships may run a deficit for any given organization. Therefore, financing is typically through grants rather than stable funding streams. Government payors may be a more natural fit for SDH given that they can adopt a societal perspective, but even then “there is an underappreciation in the clinical system of the value of the taxpayer dollar that goes into homelessness, unemployment, or other social services,” said David Fleming, MD. “This is real financial interdependence... providing services that are not tightly connected with health care delivery but that benefit health and health care.”

Bob Lawrence concurred, citing the work of an Institute of Medicine (IOM) committee on Valuing Community-Based, Non-Clinical Prevention Policies, which he chaired. “The IOM report expresses a frustration that things that really seem to have a significant benefit in reducing health risks had no traction with policy-makers. For example, Charlotte put in a light rail system and an enterprising researcher decided to sample the regular users and non-users and follow them prospectively. The users lost 6-7 lbs after one year of regular use; non-users continued to slowly add to their weight. You’d say well, that’s a non-clinical preventive intervention—but who would have thought of a light rail system as a health-promoting intervention?” 

Ultimately most discussants agreed that more should be done to address the social determinants of health, but that fundamental changes in evaluation methods and payment systems would be required for lasting impact.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.