PowerPoint Template (Rush)Dig Deeper: Screening for Social Determinants
Michael Hanak, MD, FAAFP Associate Professor, Dept. of Family Medicine Associate Chief Medical Officer for Population Health Rush University Medical Center
There are no relevant financial relationships with ACCME-defined commercial interests for anyone who was in control of the content of this activity
Objectives 1. Understand the meaning of health equity and the
role it plays in ensuring delivery of accessible, high quality care across a community.
2. Identify what social determinants of health (SDoH) are, why they matter, and the risks of failing to address them.
3. Recognize the role of risk assessment in achieving success in value-based care.
4. Learn one organization’s approach to screening and addressing social needs in an effort to better manage high-risk patients
Definitions
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“Social determinants of health have taken center stage in recent health
policy discussions particularly with the growing focus on global payment,
accountable care organizations, and other initiatives focusing on improving
population health.”
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Social Determinants of Health 101 for Health Care: Five Plus Five
Magnan, S. 2017. Social determinants of health 101 for health care: five plus five. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. https://nam.edu/social-determinants-of-health-101-for-health-care-five-plus-five.
Source: https://www.cdc.gov/chronicdisease/index.htm https://www.cdc.gov/reproductivehealth/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Freproductivehealth%2 Findex.htm
U.S. Maternal Mortality Ratios by Race, 2011-2015
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12.7
14.4
43.5
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Leslie Spry, MD, FACP, Contributor Spokesperson for the National Kidney Foundation
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Renal Disease in the U.S.
Source: Nicholas, Susanne B. et al. Racial Disparities in Kidney Disease Outcomes. Seminars in Nephrology, Volume 33, Issue 5, 409 - 415
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Neighborhoods between Rush University Medical Center and Rush Oak Park have some of the highest levels of economic hardship, lowest life expectancy and highest unemployment rates
Ubhayakar S, Capeless M, Owens R, Snorrason K, Zuckerman D. Anchor Mission Playbook [Report]. Chicago, IL: Rush University Medical Center; June 2017.
https://richblockspoorblocks.com/
https://richblockspoorblocks.com/
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Barriers in Access and Quality
Source: Nicholas, Susanne B. et al. Racial Disparities in Kidney Disease Outcomes. Seminars in Nephrology, Volume 33, Issue 5, 409 - 415
“Never ask for permission to do the right thing, if no is a possible answer”
“If you’re going to be a bear, be a Grizzly!”
- David Ansell, MD, MPH, Senior Vice President, Community Health Equity,
Rush University Medical Center
Start of a Journey…
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IHI Pursuing Equity Collaborative •Two-year learning and action network (Mar 2017-2019) •Facilitated by the Institute for Healthcare Improvement (IHI) •Builds on the foundation of IHI’s Triple Aim •8 healthcare organizations •Aim: To narrow equity gaps and outline a national blueprint for how healthcare organizations can advance equity. •What’s next after 2 years?
– From 8 systems to 40!
IHI Pursuing Equity Workshop - Participants
Diverse in size, geography and patient populations served. 21
Rush Pursuing Equity Projects
Hypertension Prevalence Among Adults in Chicago
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U.S. Hypertension Prevalence (2016): 32% https://www.cdc.gov/dhdsp/data_statistics/fact_she ets/fs_bloodpressure.htm
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Chicago Health Atlas, 2016 https://www.chicagohealthatlas. org/indicators/diabetes
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Social and Economic Indicators on the West Side Percentage of Residents/Households
Community Area Household Poverty
East Garfield Park 44.2% 58.7% 24.7% 21.6% 20.3% 13,103.5
Humboldt Park 32.2% 45.9% 21.9% 30.9% 17.4% 6,684.7
Lower West Side 26.2% 37.9% 13.1% 35.1% 11.4% 3,212.3
Near West Side 21.4% 31.6% 6.8% 8.2% 10.0% 6,025.8
North Lawndale 43.1% 63.2% 29.0% 26.4% 23.4% 12,714.4
South Lawndale 33.3% 51.5% 19.9% 50.7% 13.2% 3,148.0
West Garfield Park 43.6% 62.6% 26.6% 27.6% 17.8% 13,904.8
West Town 13.3% 24.5% 6.3% 11.3% 6.3% 3,057.1
West Side Average 27.2% 41.2% 17.2% 28.4% 14.2% 5,804.8
The Loop 14.6% 15.3% 1.4% 1.8% 5.3% 7,540.2
Chicago 18.9% 31.4% 9.9% 15.9% 9.5% 4,491.1
• Source: Chicago Health Atlas and 500 Cities Project * Rate of reporter violent crime per 100,000 people
>20% higher than Chicago average
10-20% higher than Chicago average
0-10% higher than Chicago average
Below Chicago average
Community Area Population Heart Disease
Cancer Diabetes- Related
Injury Deaths
Opioid Overdoses
Austin 97,643 257.8 258.2 92.2 88.7 49.9 Belmont-Cragin 79,201 189.4 158.4 66.8 36.1 17.4 East Garfield Park 20,665 283.7 239.6 83.9 106.9 66.6 Humboldt Park 55,011 267 192.6 97.5 71.9 55.6 Lower West Side 61,768 144.4 158.1 65.5 38.7 21.3 Near West Side 34,410 199.3 193.5 72.1 50.9 29.5 North Lawndale 35,276 243.5 266.1 84.3 101.3 86.1 South Lawndale 73,826 155.4 141.7 63.7 42.5 12.3 West Garfield Park 17,733 269.3 270.7 100.4 132.6 84.5 West Town 85,582 199.9 159.7 78.3 41.2 23.8 West Side Average 211.1 192.6 78.5 61.3 36.5 The Loop 139.7 144.9 21.7 30.6 6.4 Chicago 207.4 190.4 64.6 55.5 22.0 National 168.5 158.5 29.4* 63.9 13.3
•Source: Chicago Health Atlas, 500 Cities Project, and 2017 CDC National Vital Statistics Reports •* Chicago rate reflects “diabetes-related” deaths (ICD-10 codes E10-E14 as underlying or multiple cause of death), whereas national rate reflects deaths in which ICD-10 codes E10-E14 were the primary cause of death)
>20% higher than Chicago average
10-20% higher than Chicago average
0-10% higher than Chicago average
Below Chicago average
Smoking Blood Pressure Medication*
East Garfield Park 36.8% 76.3% 63.0%
Humboldt Park 27.5% 71.2% 30.9% 70.6%
Lower West Side 65.4% 26.8% 73.1%
Near West Side 10.1% 64.5% 21.3% 84.4%
North Lawndale 34.6% 76.2% 24.6% 60.5%
South Lawndale 12.4% 64.1% 23.9% 69.4%
West Garfield Park 39.5% 77.6% 20.2% 60.8%
West Town 14.6% 61.0% 15.4% 88.9%
West Side Average 20.4% 69.0% 24.4% 73.3%
The Loop 9.8% 64.2% 18.8% 87.9%
Chicago 18.4% 73.2% 26.5% 73.6%
• Source: Chicago Health Atlas and 500 Cities Project • * Below average = positive; colors reflect appropriate valence of deviation from city average
>20% higher than Chicago average
10-20% higher than Chicago average
0-10% higher than Chicago average
Below Chicago average
Selected Chronic Conditions Overall
Other Race
N = 2,026
p-value
Hypertensive, N (%) 26,727 (53.9) 10,628 (45.4) 11,640 (68.6) 3,357 (49.4) 973 (48.0) <.0001
BMI ≥ 30, N (%) 23,504 (47.5) 9,283 (39.8) 10,034 (59.2) 3,541 (52.3) 488 (24.1) <.0001
Diabetes, N (%) 10,855 (21.9) 3,500 (15.0) 4,739 (27.9) 2,078 (30.6) 489 (24.1) <.0001
Type II Diabetes, N (%) 10,499 (21.2) 3,162 (13.5) 4,770 (28.1) 2,065 (30.4) 460 (22.7) <.0001
CVD, N (%) 2,548 (5.1) 967 (4.1) 1,173 (6.9) 314 (4.6) 80 (3.9) <.0001
CAD, N (%) 5,495 (11.1) 2,794 (11.9) 1,754 (10.3) 644 (9.5) 274 (13.5) <.0001
Asthma, N (%) 4,072 (8.2) 1,519 (6.5) 1,867 (11.0) 542 (8.0) 116 (5.7) <.0001
CHF, N (%) 2,292 (4.6) 671 (2.9) 1,287 (7.6) 246 (3.6) 80 (3.9) <.0001
Family History, N (%) 33,628 (67.8) 15,536 (66.4) 12,410 (73.2) 4,229 (62.2) 1,227 (60.6) <.0001
Data prepared by: Center for Community Health Equity
Plan-Do-Study-Act (PDSA)
• Oct 2017-Jan 2018 • 80 patients identified for screening • 33% screened positive for 1 or more need
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10 9
3 2
• African American • English Speaking • Ages 40-85 • Medicare • Female
Data
Is
FUNDAMENTAL!
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• Equity incorporated into quality metrics
• Equity dashboard for CV outcomes made available to physicians
What Did We Ask?
Registry % of Patients
Heart Failure 6%
Top Quartile Cost 29%
• One-third of patients screened identified SDoH need • Utilities, food, and transportation were top three needs • HTN and DM prevalence was similar across populations,
but disease control was disproportional
Emergency Department
Ambulatory Settings
Inpatient Setting
Pediatric Patients
Community Settings
Nursing & Care Mgt
PDSA continues
Our Journey: Commitment to Expand SDoH Screening Efforts
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Key Community Partnerships Rush has partnered with the leadership of West Side ConnectED to expand community offerings.
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• Rush has partnered with NowPow to provide social referrals to patients
• Rush was the first hospital to integrate NowPow into Epic, to ensure better continuity of care
Social Referral Platform to Improve Health
“I don’t need any of those resources and I am an exception because Rush is a teaching hospital, it’s nice to have questions like these.”
“I am very grateful for screening, I have only $3 dollars in my bank account after paying bills.”
What Patients Are Saying
“If it helps people, I’m OK with it”
“Fine, as I have the opportunity to express how I feel about the care I’m receiving”
“I love it, not only because I have a need, but also because my background is in behavioral health and I think Rush is doing well to service patients in this way.”
Challenges 1. Clinician engagement (“not in scope of my care”)
2. Support staff burnout ---> “not my job” and/or “not enough time”
3. Requires social work investment for complex needs
4. Operational challenges ---> “where and when and what’s the ROI”
5. Closing the loop on referrals requires follow-up
6. Integrated platform onboarding
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Resources
IHI White Paper - Achieving Health Equity: A Guide for Health Care Organizations http://www.ihi.org/resources/Pages/IHIWhitePapers/Achieving-Health- Equity.aspx
Videos 1. Dr. Camara Jones - Achieving Health Equity: Tools for a National
Campaign Against Racism https://www.youtube.com/watch?v=3aXoBfmSBNQ (1:16:38)
2. Allegories on Race and Racism | Camara Jones | TEDxEmory https://www.youtube.com/watch?v=GNhcY6fTyBM (20:31)
3. Global Hands - Social Determinants of Health https://www.youtube.com/watch?v=SXcSjTcrskM (6:39)
Dig Deeper:Screening for Social Determinants
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Social and Economic Indicators on the West Side Percentage of Residents/Households
Mortality on the West SideDeaths per 100,000 Population
Health Behaviors on the West Side
Chronic Conditions by Race/EthnicityRush University Medical Center
Plan-Do-Study-Act (PDSA)
Our Journey:Commitment to Expand SDoH Screening Efforts
Key Community Partnerships
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