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Moving
Healthcare Upstream: Enhancing Care for Patients
with Social Needs
Rishi Manchanda MD MPH
@RishiManchanda [email protected]
May 22nd, 2014
UNITY Conference
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Roadmap
• Healthcare Value & the Social
Determinants of Health
• The Upstreamists
• Community Health Workers moving
healthcare upstream
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Me, age 22
northern India
Community Health Workers
taught me to be an Upstreamist
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What does HealthBegins do? We mobilize and equip healthcare providers to improve health where it begins
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An “IHI for Social Determinants”
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Are our clinics providing
the best value to patients?
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Rishi Manchanda. The Upstream Doctors:
Medical Innovators Track Sickness to Its Source. TED Books. June 6th, 2013
But Veronica
was still sick.
Veronica had a
chronic headache.
She sought relief in numerous
healthcare encounters.
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Is that Good Value?
Is that Good Care?
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Photo taken with permission
Propietary/ Confidential
Veronica got
better. So did
her home.
Veronica’s new clinic asked routine
questions about housing risks, identified
her problem, and developed a plan to address housing risks with a CHW.
Rishi Manchanda. The Upstream Doctors:
Medical Innovators Track Sickness to Its Source. TED Books. June 6th, 2013
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That’s Better Value
That’s Better Care
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Treating people without tackling the conditions that make them sick
is substandard care and a
losing value proposition
Propietary/ Confidential
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We spend two and half times more than other nations
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IOM. 2013. U.S. Health in International Perspective: Shorter Lives, poorer health. Washington DC: The National
Academies Press.
But we’re getting less in return
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It’s called
the “US Health Disadvantage” Compared to 16 peer countries, Americans as a group fare worse in at least nine health areas:
• infant mortality & low birth weight;
• Injuries & homicides;
• adolescent pregnancy & sexually transmitted infections;
• HIV and AIDS;
• drug-related deaths;
• obesity & diabetes;
• heart disease;
• chronic lung disease;
• disability
IOM. 2013. U.S. Health in International Perspective: Shorter Lives, poorer health. Washington DC: The National
Academies Press.
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Why aren’t we
getting better
value?
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Not a great business model
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Overuse
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IOM. 2012. Best Care at Lower Cost. The Path to Continuously Learning Health Care in America. Washington
DC: The National Academies Press.
of health care expenditures don’t improve
health – That’s $750 Billion
Waste
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Bradley , E.H and L.A. Taylor, 2013. The healthcare paradox: Why spending more is getting us less. New York: Public Affairs.
US has a lopsided health: social services ratio
Inequity
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For Richer and for Poorer
•The US Health Disadvantage cannot be fully explained by health disparities among uninsured or poor
•Even advantaged Americans experience poorer health compared to peers in other countries
•Social and Environmental Factors are key
IOM. 2013. U.S. Health in International Perspective: Shorter Lives, poorer health. Washington DC: The National
Academies Press.
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Schroeder S. N Engl J Med 2007;357:1221-1228
Contribution
of Social
Factors to
Premature
Mortality
Social factors contribute to
60% of premature death
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Social Determinants of Health
(SDOH)
“Circumstances in which
people are born, grow up, live,
work, and age, as well as the health systems they utilize”
CDC (Centers for Disease Control and Prevention). 2013. Social Determinants of Health.
http://www.cdc.gov/socialdeterminants Accessed Nov 1, 2013)
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Social factors, like food insecurity, drive health behaviors
One in seven Americans cannot reliably afford food
Food insecurity is associated with increased HIV risk behaviors and susceptibility
In California, risk for hospital admissions for hypoglycemia increased 27 percent in the last week of the month compared to the first week among low-income patients.
Wang EA et al (2013). A Pilot Study Examining Food Insecurity and HIV Risk Behaviors Among Individuals Recently Released From Prison. AIDS
Education and Prevention: Vol. 25, No. 2, pp. 112-123.
H. K. Seligman, et al Exhaustion of Food Budgets at Month's End and Hospital Admissions for Hypoglycemia," Health Affairs, Jan. 2014 33(1):116–23.
Weiser SD et al. (2007) Food Insufficiency Is Associated with High-Risk Sexual Behavior among Women in Botswana and Swaziland. PLoS Med 4(10):
e260. doi:10.1371/journal.pmed.0040260
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Zip code matters more than genetic code
Source: Mitchell & Popham, The Lancet 2008
Increased exposure to green space associated with lower death rate from heart disease
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Doctor, where did my social determinants go?
Health Care Individual Level
Disease Research & Intervention
Public Health
SDOH research &
intervention
IOM. 2013. U.S. Health in International Perspective: Shorter Lives, poorer health. Washington DC: The National
Academies Press.
Social
determinants
have not been
integrated in
clinic practice
or health care
systems
Leads
to lower value,
substandard care
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Lack of social determinants integration costs clinics a great deal
•Preventable illness & health disparities
•Less effective healthcare interventions
•Decreased efficiency and productivity
•Patient distrust
•Workforce recruitment & retention
•Wasteful spending
•Less competitive?
•Lower payments as payors shift to value instead of volume?
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How do we move to
the NEW way while
getting paid for the
OLD way?
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Healthcare can be better but
care teams and clinics need
Redesign
Training & Tools
Incentives
Actionable data
Networks & support
to tackle the social
determinants of health
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Redesign the healthcare workforce to optimize value
Population
Health
Impact
By 2020,
25,000
260,000
450,000
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“It is unreasonable
to expect that
people will change
their behavior easily
when so many
forces in the social,
cultural, and
physical
environment
conspire against
such change.”
-Institute of Medicine
Lifestyle recommendations aren’t good enough
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Let’s rethink what’s “addressable” in healthcare
Upstreamis
t
Comprehensivist
Partialist
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Upstreamists optimize value by systematically improving
their clinics’ ability to address upstream problems
Clinic asks about where patients live, work, eat,
and play using EMRs & other tools
Clinic integrates upstream data & community interventions into workflows
Clinic addresses upstream problems at patient,
clinic, and population levels
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CHWs can put us on ‘Path to Continuously Learning Health Care’
when it comes to social determinants
IOM. 2012. Best Care at Lower Cost. The Path to Continuously Learning Health Care in America
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4 out of 5 doctors believe social needs are as important as health problems Yet 4 out of 5 doctors feel under-equipped to address their patients’ social needs
RWJF “Health Care’s Blind Side” Dec 2011
Propietary/ Confidential
CHWs can equip and train doctors to address social factors
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Clinical opportunities for Upstream Interventions and CHWs
Community-
Centered
Health Home
Community-Centered Health Home
• Coordinate with policymakers and
community stakeholders to address social
and environmental conditions
Medical Neighborhood
• Coordinate care for patients and
populations with clinical and community
“neighbors”
• Potential role for ACOs
ACOs/
Medical Neighborhood
PCMH
Ambulatory ICU
• Integrate and coordinate care for high-
need, +/- high-utilizer patients with clinical
and community partners
AICU
Propietary/ Confidential
PCMH
• Coordinate care for patients and clinic
population, primarily within clinical system
R. Manchanda MD
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Vermont’s Community Health Teams are part of the PCMH
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PCMH 2014 is a big opportunity for upstream integration of CHWs
1. Health Literacy Assessments
2. Behavioral health conditions
3. High cost/high utilization
4. Poorly controlled or complex conditions
5. Barriers to Self Care
6. Social determinants of health
7. Community Resource lists
8. Referrals by outside organizations, practice staff or patient/family/caregiver
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Social Determinants are coming to EMRs: IOM Phase 1 Recommendations
IOM. 2013. U.S. Health in International Perspective: Shorter Lives, poorer health. Washington DC: The National
Academies Press.
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CHWs can lead transformation through “Community Health Detailing” model developed by HealthBegins
•A participatory curriculum for CHWs/activated community residents
•Combined with community-driven resource mapping
•A“Yelp for Health” web application helps providers find resources
•Community ‘details’ healthcare providers to improve care for patients with social risk factors
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Community Health Detailing: Building a “Yelp for Health” in South LA Over 100 high students engaged. Online tool now at UCLA
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Clinic-based CHWs can use an ‘Upstreamist Project Canvas’ to develop solutions
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We can’t get health care right without addressing social
determinants of health
We can't get health care as a right
without addressing social determinants
To improve social determinants, it is
necessary, but not sufficient, to engage and transform health care
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A Better Standard of Care
and Better Value
is possible
#CHWs can improve healthcare by moving
it Upstream #Unity2014 @HealthBegins @RishiManchanda #sdoh
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Join the Upstreamists network HealthBegins.org
1. We Mobilize:
Over 800 members & growing
2. We Equip: Trainings Coaching
Workshops for Upstreamists
Community Health Detailing
3. We Design:
Partners: Providers, Payers, Clinic Systems, Health Tech
Evaluation & Analysis
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TO LEARN MORE
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Thanks!
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Social Screening Tools UPSTREAM
TOOLS
Screen Find
Resource
Referral
Manage
EMR
Integration
Community/
Patient
Participation
SAAS +
+
+
# • Healthify
• Health
Leads + + + #
• Help Steps + +
• Purple
Binder +
• Aunt Bertha +
• Community
Detailing-HB + +
• HealtheRX + +/- +
Enterprise –
Built
+ + + + +/-
County /
Other
+