Breaking Down the Silos of Patient Care: Integration of Social Support Services into Health Care Delivery

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1 Breaking Down the Silos of Patient Care: Integration of Social Support Services into Health Care Delivery Robyn Golden, LCSW Director of Health and Aging Rush University Medical Center National Health Policy Forum October 19, 2012

2 Just Yesterday Started the day with 36-year-old brother of a 50-year-old man with dementia Limited English speaking Low socioeconomic status Ended the day with a 99-year-old woman proud to not be using a walker High financial means, but lonely Both very different scenarios with implications on health outcomes

3 Social Need Social determinants influence health outcomes 1 Social gradient (SES, education, culture) Stress Early life Social exclusion Work Unemployment Social support Addiction Food Transportation

4 Social Factors and Health Outcomes Societal-level social determinants have individual-level impact 2 Issue Low education, lack of social support, and social exclusion Outcome Poor self-management 3 and reduced care plan adherence 4 Housing 5 and transportation 6 issues Health disparities and psychosocial issues Increased health care costs and utilization Preventable hospitalizations 7 and mortality 8

5 Health Care s Blind Side 2011 Robert Wood Johnson Foundation survey of 1,000 primary care physicians 9 85% feel social needs directly contribute to poor health 10 4 out of 5 not confident can meet social needs, hurting their ability to provide quality care 10 R x for social needs, if they existed, would be 1 in 7 R x s written 10 Psychosocial issues treated as physical concerns 11

6 What Happens to Consumers? 2012 John A. Hartford Foundation survey shows consumers feel the impact of health care s blind side 12 Not treated as a whole person Rarely asked about issues impacting well-being Activities of daily living Falls Mental health Lack of communication and coordination No one asks the caregiver how they are doing

7 In Health Care s Blind Spot Community-based services and supports system could be addressing psychosocial issues Community-based organizations (CBOs) Aging and disability network Long term services and supports (LTSS) Mental health services Institute of Medicine recommendation: community links 13 Assessing psychosocial issues Delivering services in the community Communicating these issues with medical team

8 Fragmentation as a Major Obstacle Siloed health and social service systems Separate and distinct funding streams Different delivery systems and eligibility rules Different training programs Distinct terminology Looking at diagnosis and episodic care Provider-driven Mental health forgotten Not bilingual or bicultural to bridge medical and social systems

9 Other Barriers to Meeting the Demand Financing barriers to integrated care Social services not reimbursed Undercapitalization of social safety net No investment in team-based care and workforce development Value of social services, social workers to health care delivery system undefined Need to valuate services, negotiate fees, determine costs, and explain ROI Business case not clear

10 What s Needed for Chronic Care Opportunities for improving care for people with chronic care needs (Georgetown Public Policy Institute) 14 Comprehensive primary care Assessment of person and caregiver LTSS needs Coordination of LTSS and medical care Collaboration between care coordinators, PCPs, patients, families Supportive care transitions Commitment to person- and family-centered care

11 Interprofessional Teams Solid outcomes for interprofessional teams in inpatient and outpatient medical systems 15 Reduction in health service utilization 16 Improvements in patient satisfaction and communication with provider team 17 Rothman and Wagner: Most successful chronic illness interventions include major roles for nonphysicians. The appropriate deployment and use of practice teams seems to be far more important to improving chronic illness than physician specialty. 18

12 Care Coordination Care coordination is a person- and family-centered, assessment-based, interdisciplinary, multicultural approach to integrating health care and social support services in a cost-effective manner in which an individual s needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored by an evidence-based process which typically involves a designated lead care coordinator. (National Coalition on Care Coordination) 19

13 Financing the Ideal Model Routes to financing effective care coordination 20 Current fee-for-service structure limited due to episodic focus Need incentives for effective performance: quality of care, patient experience, and health spending FFS system payment options (Medicare): Modify codes or levels of payment within Physician Fee schedule Risk-adjusted monthly fee per eligible beneficiary tied to performance Shared savings model rewarding efficient, quality service delivery Within managed care systems (Medicare Advantage and Medicaid) combine financing sources to meet needs

14 Financing the Ideal Model Improved medical and social service funding sources Social service investment Encourage and incentivize collaboration and team Share responsibility and align goals Demonstration projects through CMS and ACL Include integrated models Show cost savings across funding streams Improve quality of life

15 The Healthcare Neighborhood Integrated model with the medical and social components of equal value Team-based care with the person and family on the team Service connection, coordination, and communication Boundary spanning and spanners Partnerships across sites and settings Community engagement and activation Where people live Where service providers are located Where social determinants of health begin and can be influenced

16 The Opportunities of PPACA Opportunities to address the social in health care through PPACA Enhanced primary care/patient Centered Medical Homes Accountable care organizations Transitional care and hospital readmission reduction Medicare and Medicaid dual eligible demonstrations Medicaid Health Homes Independence at Home demonstration Bundled payment

17 Important Links To learn more, visit: Accountable Care Organizations: Dual Eligible Demonstrations: Medicaid Health Homes: Topics/Long-Term-Services-and-Support/Integrating-Care/Health- Homes/Health-Homes.html Independence at Home: 17

18 Thank You Robyn Golden, LCSW

19 References 1. Wilkinson R, Marmot M. Social Determinants of Health: The Solid Facts, Copenhagen: World Health Organization Regional Office for Europe, Shi L, Singh D. The Nation s Health. 8 th ed. Sudbury, MA: Jones and Bartlett Learning, LLC; Gallant MP. The influence of social support on chronic illness self-management: a review and directions for research. Health Educ Behav. 2003;30(2): DiMatteo MR. Social support and patient adherence to medical treatment: a meta-analysis. Health Psychol. 2004;23(2): Krieger J, Higgins DL. Housing and health: time again for public health action. Am J Public Health. 2002;92(5): American Public Health Association. The hidden health costs of transportation D55C9/0/APHAHiddenHealthCosts_Long.pdf. Published February Accessed January 10, Centers for Disease Control and Prevention. CDC health disparities and inequalities report U.S Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Robert Wood Johnson Foundation. Overcoming obstacles to health care. Published February Accessed January 10, Robert Wood Johnson Foundation. Health care s blind side: the overlooked connection between social needs and good health. Published December Accessed January 10, Physicians highlight overlooked connection between social needs and health. Robert Wood Johnson Foundation Web site. Published December 8, Accessed January 10,

20 References 11. Ring A, Dowrick CF, Humphris GM, Davies J, Salmon P. The somatising effect of clinical consultation: what patients and doctors say and do not say when patients present medically unexplained physical symptoms. Soc Sci Med. 2005;61(7): John A. Hartford Foundation. How Does It Feel? The Older Adult Health Care Experience. National Survey. Published April 24, Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. September Komisar, HL and Feder, J. Transforming care for Medicare beneficiaries with chronic conditions and long-term care needs: Coordinating care across all services. Report from Georgetown University, Interprofessional Education Collaborative Expert Panel. Core competencies for interprofessional collaborative practice: Report of an expert panel. Washington, D.C.: Interprofessional Education Collaborative; Sommers LS, Marton KI, Barbaccia JC, Randolph J. Physician, nurse and social worker collaboration in primary care for chronically ill seniors. Arch Intern Med. 2000;160(12): Rothschild SK, Lapidos S., Minnick A, Catrambone C, Fogg, L. Using virtual teams to improve the care of chronically ill patients. J Clin Outcomes Manag. 2004;11(6): Rothman AA, Wagner EH. Chronic illness management: what is the role of primary care? Ann Intern Med. 2003;138(3):256-61, Brown, R. The Promise of care coordination: Models that decrease hospitalizations and improve outcomes for Medicare beneficiaries with chronic illnesses, A report commissioned by the National Coalition on Care Coordination (N3C). March Berenson, R. and Howell, J. Structuring, financing and paying for effective chronic care coordination: A report commissioned by the National Coalition on Care Coordination (N3C). July