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5 steps to address social co-morbidities of ill health

As more and more regions look to create and/or expand accountable health communities (which Cambridge Management Group senior advisers have been heavily involved in), this HealthAffairs piece offers five steps to address social co-morbidities of ill health.

They are:

1. “Health Systems Need To Commit To Real Clinical Integration Of Social Needs.”

“One way to achieve clinical integration is by adding some basic fields capturing social needs information into the electronic medical record  — so that providers can approach every clinical encounter with the full set of information they need to understand patients’ health and deliver the highest quality clinical care.”

2. “Commit To Developing A Workforce That Is Truly Focused On Addressing Social Needs.”

It’s critical to have a core group of people whose responsibility it is to come into work every day to assist patients in navigating to the resources they need to be healthy. This cannot be something that is done only in the margins of already busy jobs.”

“This workforce could be community health workers, patient navigators, community resource specialists, or ‘promotoras,’but it could also be some of the hundreds of individuals who volunteer at healthcare institutions.”

3. “Commit To Giving That Workforce The Information They Need To Do Their Jobs Well.”

“A comprehensive, searchable resource database is a necessity. Binders or Excel Spreadsheets last updated in 2011 do not work for information to guide patients’ clinical care, and will not work for their social needs either.”

“Automating resource connections through a technology platform enables clinicians and lay workforces to spend more time building relationships with patients and less time scrambling to find the resources they so desperately need. ”

“Implementations of an integrated, Web-based client management and resource database has demonstrated a 43 percent increase in total resource connections, 55 percent stronger agreement by physicians that their clinic has adequate support to address patient resource needs, and a 60 percent reduction in the time it took to conduct a social needs intake.”

4. “Commit To Follow Up.”

“Efforts to address social co-morbidities are unlikely to be successful if a physician simply tells a patient to eat healthy and exercise more, while ignoring the financial, language, information, and bureaucratic obstacles to making that advice actionable.

Weekly follow-up calls to patients produce a statistically significant increase in the odds of their connecting to the resources they need to be healthy.”

5. “Commit To Collecting And Analyzing Data.”

“As yet, data on patients’ social needs have not been appropriately captured. Physicians know that their patients’ psychosocial needs exist, but are not able to access information about them.”

“As with every other aspect of population health, including implementation of patient-centered medical homes, there will be a period of experimentation and exploration to figure out what works best in which settings. Health-system leaders have been willing to bet on medical homes ahead of such data because the notion of team-based care oriented around patients makes sense.”


Navigators in Bermuda Triangle?


The use of “patient navigators” is a rather trendy new idea wrapped up in the minds of the public and policymakers with healthcare reform. However, a Washington Post article pours some cool, if not cold, water on these folks.

It says that “so far, research shows that, with the possible exception of poor people who typically don’t receive sufficient medical care, navigators have only a modest effect on how well patients do. There is little evidence that they save money. And research on patient satisfaction is mixed.

“Those findings have relevance as the healthcare system moves from a fee-for-service model to one that rewards high-quality care. Doctors and hospitals are under growing pressure to rein in costs and show that every new initiative has value. But value can be subjective and difficult to measure. Are navigators, for example, a nice add-on service that merely reassures patients, or do they contribute much more?”

“‘I think for a lot of patients, maybe even the majority of patients with cancer, navigation may not have that big an impact on the kind of care they get,’ Scott Ramsey, a professor of public health sciences at the Fred Hutchinson Cancer Research Center, in Seattle, told The Post.”

Now if only all the navigators worked for free, then they’d be cost-effective….



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