WHAT ARE WE GOING TO DO ABOUT THE SOCIAL DETERMINANTS OF HEALTH? - PowerPoint PPT Presentation

WHAT ARE WE GOING TO DO ABOUT THE SOCIAL DETERMINANTS OF HEALTH? CHALLENGES, OPPORTUNITIES, DEAD ENDS AND SOLUTIONS March 9 th , 2018 Adam T. Perzynski, PhD Assistant Professor of Medicine and Sociology Center for Health Care Research and Policy The MetroHealth System Case Western Reserve University 2500 MetroHealth Dr. R225A Cleveland, OH E-mail: Adam.Perzynski@case.edu Phone: 216-778-2850 Twitter: @ATPerzynski

Disclosures • I am co-founder of Global Health Metrics, LLC, a startup software company. • I have current book contracts including future royalties with Springer Publishing and Taylor Francis

Objectives • Examine the complexity of social determinants • Have a constructive discussion of pathways to a more socially responsive health care system

Outline • I don’t know what you mean by social determinants. • New developments in SBIRT models for social determinants (Screening, Brief Intervention, Referral to Treatment) – Update on our local digital inclusion (literacy and connectivity) and MyChart training project – Update on Social Determinants functionality in Epic 2018 • Discussion of where we go from here as Health Services Researchers

“More of longevity is determined by these societal aspects than is determined by the healthcare you get. Really, we're never going to reduce the cost of healthcare, substantially, and improve longevity and the quality of life until we deal with the societal issues…are we going to try and figure out how we do some of these other things that affect the greater health of the community? Is that our responsibility, is that the community's responsibility?” Interview with Dr. Cosgrove http://www.cleveland.com/healthfit/index.ssf/2017/01/cleveland_clinic_ceo_toby_cosgrove _on_working_with_trump_obamacare_staying_healthy_and_burgers_q_a.html

“I think MetroHealth has figured out a formula for taking care of the highest risk socioeconomic patients, and I think we have the opportunity to create models that engage the consumers, the providers and the payers.” Interview with Dr. Boutros http://www.beckershospitalreview.com/hospital-management-administration/7- questions-with-metrohealth-ceo-dr-akram-boutros.html

Sociology “Neither the life of an individual nor the history of a society can be understood without understanding both.” From C.Wright Mills, The Sociological Imagination 1959

Social Determinants Braveman P, Egerter S, Williams DR. The social determinants of health: coming of age. Annual review of public health. 2011 Apr 21;32:381-98.

A model of social determinants of health Dahlgren & Whitehead 1991

These models do not grasp the full complexity of the situation. “Inequalities beget inequalities, and existing inequalities … can compound, sustain, and reproduce a multitude of deprivations in well-being.” (Powers and Faden 2006 p. 72).

World Health Organization Definition of Social Determinants of Health The World Health Organization Commission on Social Determinants of Health uses the following definition: “the conditions in which people are born, grow, live, work and age and the fundamental drivers of these conditions.”

Fundamental Causes Social conditions are more than just proxies for other “true” causes. Link and Phelan, 1995. Social Conditions as Fundamental Causes of Disease 12

Fundamental Causes (1) people with superior resources can use those resources to garner health advantages (2) the specific mechanisms that allow advantage to accrue change from place to place and from time to time. From Link and Phelan 2002, p. 732 13

Galea, S., Tracy, M., Hoggatt, K. J., DiMaggio, C., & Karpati, A. (2011). Estimated Deaths Attributable to Social Factors in the United States. American Journal of Public Health , 101 (8), 1456–1465. http://doi.org/10.2105/AJPH.2010.300086

Example: Digital Divide and Health Information Technology Overall PHR Use 2012 - 2015 250,000 75.3% 200,000 Number of Patients 150,000 100,000 24.7% 50,000 0 Do Not Use PHR Use PHR

MyChart Use by Age 35 30 30.1 25 25 % Using PHR 20 15 16.5 10 5 0 18-64 years 65-79 years 80+ years

MyChart Use by Ethnicity 35 30 30.7 25 23.6 % Using PHR 20 19 18.7 15 10 5 0 White Black Hispanic Other

MyChart Use by Insurance 40 35 35.8 30 25 % Using PHR 22.9 20 19.9 15 16.4 10 5 0 Commercial Medicare Medicaid Uninsured

MyChart Use by Broadband Access 40 35 33 30 31.8 25 25.5 % Using PHR 20 18.6 15 15.2 10 5 0 0 - 20% 20 - 40% 40 - 60% 60 - 80% 80 - 100% Census Tract Broadband Coverage % of total population

Multivariate Results Table 1. Multivariate Logistic Regression of MyChart First Sign-in (N=204,882) 95% p Variable Odds Ratio Confidence Interval Age 0.990 0.990 0.991 <.0001 Sex (female) 1.747 1.711 1.783 <.0001 African American 0.644 0.628 0.660 <.0001 Hispanic 0.615 0.587 0.645 <.0001 Other Race 0.905 0.851 0.963 <.0001 Unknown Race 0.681 0.641 0.724 <.0001 Medicaid 0.538 0.525 0.551 <.0001 Medicare 0.357 0.344 0.369 <.0001 Uninsured 0.435 0.419 0.452 <.0001 Total Number of Visits 1.046 1.045 1.047 <.0001 Charlson Co-morbidity Index 1.001 0.990 1.001 0.9071 Neighborhood Broadband 1.242 1.227 1.242 <.0001 Internet Access Adults 18 to 80, listwise deleted c-statistic = 0.724

An SBIRT Approach to Solving the Digital Inclusion Problem in Health Care We are conducting a quasi-experimental study of a community health worker (CHW) model implementation in an urban primary care clinic serving a disadvantaged population. CHWs introduce patient portal use, give referrals for a free, health-focused digital literacy training program, and identified connectivity barriers.

Interim Evaluation Results Written clinic activity logs and electronic health record data were used to evaluate efficacy. Of 186 patients seen on the 14 days when logs were kept, 2% did not have the functional English proficiency to use the portal, 18% were not interested, 26% were already using the portal and 55% expressed interest in the training program.

Interim results continued Results from more than 20,000 clinic visits suggest that the pilot project resulted in a three-fold increase in the rate of patient portal uptake and double the rate of portal-based visit scheduling for the intervention vs. control site (p=.0014, chi-sq=10.145, df=1). HOWEVER: The rate of increase (system wide, and at the control site) is only 0.5% per 6 months.

NEW DEVELOPMENTS IN EPIC 2018 EPIC and other EHR vendors are rolling out social determinants features in • their software. There is a growing market for companies that offer combinations of • products, software and services as solutions for social determinants . Socially Determined • Now Pow • TavHealth • Aunt Bertha • Purple Binder • All of these approaches utilize an SBIRT-type model, and tend to ignore • important nuances of social determinants.

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Screenings for food insecurity and transportation needs inthe History activity Slide left intentionally blank

ICD-10 Z-Codes for Social Determinants of Health National Association of Community Health Center (NACHC) Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) tool

ICD-10 Z-Codes for Social Determinants of Health National Association of Community Health Center (NACHC) Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) tool

Discussion • What are the weaknesses of the SBIRT approach to Social Determinants? • What does excellence in addressing social determinants in the health care system look like? • What are the innovative research projects we can engage in that take advantage of these new developments?