By Kara Ralston, CEO, Camarillo Health Care District
How very fortunate it is when dedicated community health providers can come together, bring like-minded goal and skills, and assign enough resources to actually make a difference!
This is the story of how Camarillo Health Care District and Gold Coast Health Plan (GCHP), in Ventura County, found a way to address social and economic adversities known as social determinants of health, through an innovative partnership program titled “Partnership to Improve Transitions.”
Over the past six years, Camarillo Health Care District has added a variety of evidence-based programs and services, along with master level training certification, to the array of other community-health programs offered. The Partnership to Improve Transitions program utilized the Care Transitions Intervention®, developed by Eric Coleman at the University of Colorado. This model speaks to the federal Triple Aim of “simultaneously improving the health of the population, enhancing the experience and outcomes of the patient, and reducing per capita cost of care for the benefit of communities” and has resulted in reduced hospital readmissions, created net cost savings, and showed that patients reported a better quality of life and improved functional status.
Briefly, social determinants of health (SDOH) are defined as “conditions in the environments into which people are born, live, learn, work, play, worship, and age, that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” Often these adversities (such as income, education, social inequalities, living conditions, food insecurity, environmental factors, and health behaviors) can have a more significant effect on a person’s health status than the health care the person receives, even up to 80% of the influence on their health status. Recent study of the effect of SDOH on health status has shown that clinical health services alone can’t adequately address the dimension and depth of the “needs” of patients and their families. In the effort to improve health outcomes, reduce costs, and optimize health resources, it is therefore, impossible to ignore these factors when applying health care services.
About addressing SDOH, during the transition of people from one care setting to another, such as from hospital to skilled nursing facility, or from hospital to home, they are at increased risk for complication or exacerbation of health conditions, medication errors, or a host of other potential problems which can substantially affect health status. It is understood that when the social and economic adversities facing the patient in the new setting are known, discussed and addressed through care transitions work, the more likely the patient is to have successful transition and stabilization of health condition. Community-based care modules, such as those developed and provided by Camarillo Health Care District, address these potential points of failure and become like an “extension” of the primary care provider.
In 2017, GCHP, Ventura County’s Medi-Cal plan, recognizing the need to address SDOHs, allocated funds to Camarillo Health Care District to administer the Partnership to Improve Transitions program, with specific emphasis on beneficiaries who were covered by Medi-Cal, as well as those covered by both Medicare and Medi-Cal, called “dual eligible.” This population was comprised largely of low-income adults, dual-eligible older adults, and persons with disabilities with complex health and social needs (SDOHs). Because the target population is among the frailest and most vulnerable, family caregivers (informal caregivers) played a critical role in their care, often at great personal and physical cost to themselves. Due to the risk factors for informal caregivers, “wrap-around” services for the caregiver were also included in the project, which helped protect the health of the caregiver. This demonstration project tested a model of care that included plan beneficiaries, Camarillo Health Care District health coaches, physician groups, hospitals and other care centers, skilled nursing facilities and home health agencies, and other referral sources.
A 30-day intervention in this partnership program was defined as:
- One home visit by trained health promotion coach
- Three follow-up calls
- Home safety evaluation
- Health risk assessment
- Pharmaceutical review through HomeMeds, a nationally recognized evidence-based program providing medication risk screening by pharmacist
- In-home psychosocial, environmental, cognitive, and functional assessments
- Short and long-term care/service coordination that includes individual social and behavioral determinants of health, provision of nutritious meal service, knowledge of self-care, medication adherence, transportation, and other service to help reduce barriers to benefits
- Caregiver support services and education
- The patient’s choice of related evidence-based classes offered by the district
As with anything, theory and application can be very different! As this particular target population was among the frailest and most medically complex, interventions frequently required more than the 30-day intervention plan. Some required months of addressing social determinants of health before even beginning to address disease and care management issues, like Bob’s story:
Bob, age 77, was failing to manage his Type 2 diabetes, HTN, foot wound, weakness and Stage 3 kidney disease. His case opened in the fall of 2017 and didn’t close until the following July. As the health coaches made their visits and calls, they noticed that Bob was not progressing. As It turned out, it took about a month for him to trust the coach enough to share what was happening. He reported that his nephew was repeatedly breaking into his home, scaring and intimidating him, and stealing items such as his money, medications, and cell phone…to the point that Bob slept with a bat under his pillow and was declining to see his PCP or refill his medications. It was clear that multiple social determinants of health needed to be resolved before Bob would feel safe enough to focus on his health condition. The intervention health coach helped Bob initiate calls to APS, assisted with restraining orders and court visits, and facilitated getting the locks changed. That’s when things began to change for the better. The intervention coach continued to assist Bob in working with utility companies to reduce his late bills, helped him get a walker, facilitated the installation of grab bars, reading glasses, and hearing aids, and helped him navigate into physical therapy through renewed visits with his PCP. His health status stabilized.
As you can see, when Bob’s untenable home environment (SDOHs) were addressed, his health status stabilized. There is no more rewarding service than to assist someone out of a dangerous downward health spiral. The Partnership to Improve Transitions program changed Bob’s life. It also saved money and reinforced our belief in the value of addressing social determinants of health. The recorded success of addressing SDOHs in conjunction with health services makes a compelling case for broadening the overall definition of health care.