When Social Needs Are Medical Needs

When a patient checks into an emergency room in Baltimore today, her doctor will be just a few clicks away from seeing a record of every previous hospital visit, test result, prescription, and even risk calculation for a heart attack or stroke.

This accessibility came thanks to nearly a decade of investments, including funding from the 2009 federal stimulus package that provided incentives for doctors to switch from paper to electronic medical records and for states to connect these digitized systems so institutions could share information easily. The government has poured billions of dollars into these and similar programs aimed at helping hospitals modernize their medical care, reduce costs, and improve patient outcomes.

But something is still missing. A report from the Kaiser Family Foundation estimates that just 10 percent of our health is determined by the care we receive within a clinic’s walls. Individual behavior and social circumstances, including where we live, how we make a living, and what services we have access to, contribute about 60 percent. (An individual’s genetics make up the remaining 30 percent.) And until our health care system—including the technology that supports it—addresses those factors, we won’t see the significant improvements in quality of care or cost savings these investments were supposed to bring.

As leaders at the Baltimore City Health Department, we think about this issue every day. (Disclosure: In addition to her work as accountable health communities advisor with the BCHD, Sonia Sarkar is also a public interest technology fellow at New America, a partner with Slate and Arizona State University in Future Tense.) Many of the residents that we serve face barriers to care that can’t be addressed with just a prescription or clinical procedure.

Consider the hypothetical case of Ellen, a 58-year-old diabetic patient working two part-time jobs and living in a South Baltimore food desert. She struggles to put healthy, affordable meals on the table for herself and her family of five. Her electricity was recently shut off, spoiling the insulin in her fridge. Until recently, she was uninsured and lacked a primary care doctor, causing her to seek care at multiple clinics and emergency rooms across the city. Now that she is enrolled in Medicaid, she has to take three different bus lines to get to her new physician’s office. Every time she gets a new clinical team or case manager or goes to the emergency room for symptoms related to her uncontrolled diabetes, she has to explain it all again, because her medical records don’t reflect any of these circumstances.

Clinical staffs often have a tough time with these conversations. A national survey of primary care providers and pediatricians found that 4 in 5 physicians agreed that addressing patients’ social needs is as important as addressing their medical conditions. But more than 80 percent said they do not feel confident in their capacity to address these outside issues and believe this impedes their ability to provide quality care and leads to worse health outcomes. Even more frequently, providers just don’t have enough time in their 15-minute visit to delve into both medical and social concerns.

So Ellen ends up returning to the emergency room six months later with the same symptoms, a costly situation both for her and the health care system. It’s a story we see all too often: Baltimore is home to some of the best health care institutions in the world. Yet residents of Baltimore’s affluent neighborhoods have a life expectancy about 20 years longer than people living in lower-wealth areas just blocks away.

We’ve known for decades that social needs have an outsize impact on health outcomes. So why isn’t our health care system—or the technology that supports it—better set up to identify and address them?

The most obvious reason is that, historically, there have been few financial incentives to engage in this work. As long as hospitals and doctors’ offices are paid on a fee-for-service basis, it’s challenging to prioritize investment in programs that prevent illness or focus on nonclinical care.

It’s also difficult for large institutions to change. When the first rollout of electronic medical records began, capacity-strapped clinicians were understandably skeptical and frustrated. With all of the training, checklists, and paperwork health care providers already have to go through, additional requirements can take a toll. In order to be successful, any additional patient screenings, referrals, and other steps to close the loop on patients’ social needs would need to integrate as tightly as possible with a clinic’s existing workflows.

Many past attempts to remedy this issue have also fallen short. For example, we’ve had dozens of conversations with partners across our city who have shared how demoralizing it is to, say, call a local food program for a patient, only to find that the number listed in the community resource directory is out of service. Though hundreds of databases, Excel spreadsheets, and apps have been created to point clinicians and patients to available resources, few vendors keep the resource information fresh and accessible.

Despite these challenges, there are precedents for building systems where patients’ social needs are addressed as part of clinical care. HIV and AIDS programs, for example, including those we oversee at BCHD, have long incorporated necessary external services such as transportation or housing assistance into a patient’s overall health plan and assigned case managers to follow up with patients to help them navigate their care inside and outside clinic walls. We are starting to see this approach reflected in projects that use technology, too. Companies such as Healthify, Health Leads, and Aunt Bertha aim to give providers, governments, and health plan managers simple platforms to track social needs, coordinate referrals, and connect patients to community organizations that can help address issues like affordable housing. And the Camden Coalition, a group of New Jersey–based providers, became well-known in public health circles for its “hotspotting” model, which attempts to drive down the cost of care by using data to focus resources on the highest-need, highest-cost patients.

In April 2017, the federal government got involved too, with a $157 million fund from the Centers for Medicaid and Medicare Innovation to fund groups that are committed to building and scaling up tech-aided systems that address patients’ social needs over the next five years. (The grants went to 32 “Accountable Health Community” demonstration sites across the country, including BCHD.) As part of the program, awardees each will screen up to 75,000 Medicaid and Medicare beneficiaries for social needs per year and then navigate them to the community resources that address those needs. The feds will then assess whether these screening, referral, and community service navigation programs improve health outcomes and reduce health care costs—and could serve as models for other health care systems in the country.

So what would this look like? We imagine that in the future, Ellen could complete a survey on a tablet at her hospital or kiosk at the local health center. With that information in hand, a community health worker may be able to identify resources that can accommodate Ellen’s language or literacy needs and provide ongoing coaching and follow-ups, such as confirming that she has successfully enrolled in a specific service. We also plan to build an online interface where patients can manage and review their own care, such as controlling who gets to see their medical and social data and see relevant information related to their treatment and prevention plans.

Because we’ll be screening thousands of patients each year, we’ll also have access to community-level data about the availability and volume of these services in each neighborhood and work to address gaps in the service landscape. For example, if 50 percent of patients in a particular area demonstrate housing insecurity, but there are limited affordable options for them, our coalition of health care institutions, local and state government partners, and community-based organizations can jointly advocate to create and fund policies to address it.

These kinds of projects won’t solve the broader challenges that perpetuate health inequities—structural racism, exclusionary policies, historical disinvestment in social services. But they can provide community-level insight into the challenges that patients face outside the exam room. We’ve already seen the ways that investments in modern technologies like electronic health records have made medical care safer and more efficient. But to get real improvements in health costs and outcomes, particularly in communities that face significant disparities, we need to leverage these same systems so they not only address patients when they’re sick but also enable us to keep them well. Achieving health requires us to address what’s making patients sick in the first place.

This article is part of Future Tense, a collaboration among Arizona State University, New America, and Slate.