The Social Determinants of Health

- Changing the way we see health and social program management

Jia Chen

Director, Health Solutions, Smarter Cities

What are the social 'determinants' of health?

“The social determinants of health are the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness. These circumstances are in turn shaped by a wider set of forces: economics, social policies, and politics.” [ from WHO]

• Availability of resources to meet daily needs, such as educational and job opportunities, living wages, or healthful foods

• Social norms and attitudes, such as discrimination• Exposure to crime, violence, and social disorder• Social support and social interactions• Exposure to mass media and emerging technologies,

such as the Internet or cell phones• Socioeconomic conditions, such as concentrated

poverty• Quality schools• Transportation options• Public safety• Residential segregation

• Natural environment• Built environment, such as buildings

or transportation• Worksites, schools, and recreational

settings• Housing, homes, and neighborhoods• Exposure to toxic substances and

other physical hazards• Physical barriers, especially for

people with disabilities• Aesthetic elements, such as good

lighting, trees, or benches

NYC Department City Planning, IOM 092010New York City Department of City PlanningIOM, Public health Strategies to Improve Population Health, 09 2010

High school grads: 90%Unemployment: 4%

Poverty: 7%Home ownership: 64%

Non-White: 49%

ALAMEDA COUNTY

High school grads: 81%Unemployment: 6%

Poverty: 10%Home ownership: 52%

Non-White: 59%

ALAMEDA COUNTY

High school grads: 65%Unemployment: 12%

Poverty: 25%Home ownership: 38%

Non-White: 89%

ALAMEDA COUNTY

Social determinants impact a person’s wellness and life expectancy• It has been estimated that the healthcare delivery system accounts for less than a

quarter of the health status of populations.• Most of the 20th century’s 30 year increase in life expectancy has been attributable

to public health interventions in societal sectors other than the health care delivery system, e.g. water, food transportation, workplace safety and smoking reductions

6 miles apart with a 20 year difference in life

expectancySource: Lloyd B. Minor, M.D. John

Hopkins

Source: Sowad, Barbara J. A call to be whole: the fundamentals of health care reform, CT. 53

The medical systems treats people and then sends them back to the

socio-economic conditions that made them ill

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Michigan

“… attention to the social determinants of health that may have greater impact on the individual health status than does medical care” 1

New Jersey“Better care … is disruptive change … it takes a community to begin to address these issues (of high cost, high need patients)”

Dr. Jeffrey Brenner, Camden Coalition of Healthcare Providers (CCHP)56% reduction in costs and 46% reduction in visits with an integrated care model

Oregon

U.S. Integrated Social and Health Care Examples

The team focuses on the 25% of CareOregon adult patients who account for 83% of the spending last year -- $311 million. 

… 65 patients enrolled with a community outreach worker … cut emergency room visits in half and average costs per patient by 62%. Total saved: about $726,000. 

 http://www.oregonlive.com/health/index.ssf/2012/02/to_save_money_on_health_care_o.html

CoordinationEngage, convene, collaborate and cross boundaries to deliver an integrated plan to achieve optimal outcomes and lower costs

Understand

Engage

FoundationKnow individuals and populations; recognize intervention opportunities to apply evidence-based and standardized care planning

Know

The path forward… enabling holistic and individualized care to optimize outcomes and lower costs

Wellness

Analytics and Cognitive ComputingGain understanding through data-driven insights that enable providers to act with greater visibility into outcomes and cost

IBM integrated portfolio for Smarter Care

Care identification

Coordination

Care planning Care collaboration Outcome evaluation

Analytics and Cognitive Computing

Foundation

Data warehouse and data models

“Single view” customer EMPI (MDM)

Portals, mobile and collaboration

Remote monitoring and medical device connectivity

Paper and Fax capture, conversion and extraction

Population analytics Diagnostic support Care pathways Operational reporting

Cognitive computing

BI, reports and dashboards

Comprehensive global consulting, technology, infrastructure and managed services

• China is aging rapidly, by 2015 there will be 220 million over-60s and 500 million within 40 years, roughly 1/3 of a population that is expected to be just shy of 1.5 billion.

• However, eldercare is in severe shortage. At one of Beijing's most popular nursing homes, the waiting list is currently 100 years long.

• Beijing government leverages a 3-tiered delivery model for eldercare:

- Home Care (90%); Home Care + Day Care Centers (6%); Nursing Home for disabled (4%)

• Many services are available (safety, companionship, hygiene care, meals, housekeeping etc) but not delivered in a coordinated way; and there is no holistic view of the citizen, in terms of his/her integrated social and health needs.

• Solution - Deploy a program for coordinated care planning and delivery - Leverage telehealth and ambient intelligence sensing capabilities to monitor senior citizen's physical environmental safety and personal health

Eldercare in China

Sensors, health monitors, wearable devices

Real time data

Remote Monitoring

Hospitals Community Health Centers

Specialist Therapist GP

Health S

ervices

Call Center Cleaning services

Volunteer

Home Services CenterClub House Day care

Living S

ervicesLong term care facilities

Service management

Care Team Outcome management

Assessment Care Plan Care Management

Elderly Personal Health Record

ElderCare Management Platform

Coordinated Eldercare Framework

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Historical values

Alerts based on threshold

List of contributing factors

Improve prediction provides a list of informative factors

Bolzano - Safe Living

• 3 people over the age of 65 for every 2 under the age of 20

• City & council budgets fixed or being reduced over the next 10 years.

• A group of citizens of age 80s were remotely monitored with in-home

sensor gear.

• Aimed at improving the quality of life of elderly people by integrating a net of sensors that send data to a control room where data will be analyzed.

• 31% saving to the Bolzano City Council for the cost of related care for the elderly.

Medication expenses by chronic disease patients

Coordinate care across silo’s of organization to reduce cost - an example in Europe

• Nationalized Healthcare – Government Payor• ~7M residents/$4B annual budget• Complex Chronic Disease Management

– CRG – 7 Rating (3 or more Chronic conditions)– 2 or more inpatient incidents

Integrated Care Plan360 view of citizen

Multi-discipline Team Collaboration

Knowledge Shared view of best practices and a holistic view of the patient allows individualized care plans that engage both clinical and social providers

Collaboration across stakeholders allows a unified view of care plan status, effectiveness and informs adjustments and reassessments required

Coordination Of resources to support care delivery in home settings and referral management to timely and collaboratively support incoming requests

Action Impact

Engagement 15% increase of mean number of contacts with health services

Emergency Room Admission 10% reduction in emergency room admission

Hospital Admission 10-15% reduction in hospital admission

30-day Readmission 10% reduction in 30-day readmission

Patient Satisfaction Satisfaction over 85 score

Quality of Life Improved Quality of Life (Euroqol) score

Intervention Over 80% medication plan reviewed at least 2 times a year

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Coordinated Health Management improves care efficiency

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Thank you !

Questions: jiachenjc@cn.ibm.comPhone: +86 1365 1850 498

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Create Home Visit Task

Assign HomeVisit Task

Accept HomeVisit Task

Home VisitInformationCollection

Eligibility Check

CreateIntegrated

Case

CreateOutcome

Plan

MedicalAssessment

LivingAssessment

AddServices

ServiceDelivery

MonitorProgress

Sign Agreement

Eligibile?

结束

no

Client Director Care Team

Client Registration

HomeVisit

BuildCare Plan

MonitorProgress

Decision

yes

RegisterPeron

Create Home Visit Task

Assign HomeVisit Task

Accept HomeVisit Task

Home VisitInformationCollection

Eligibility Check

CreateIntegrated

Case

CreateOutcome

Plan

MedicalAssessment

LivingAssessment

AddServices

ServiceDelivery

MonitorProgress

Sign Agreement

Eligibile?

结束

no

Client Director Care Team

Client Registration

HomeVisit

BuildCare Plan

MonitorProgress

Decision

Coordinated Eldercare Management Platform

Health System: More Maternal Education, Better Life Expectancy and Infant Survival

Health System: Higher Income, Longer Life

Dubuque - Smarter City Living Laboratory

Only American city in FastCompany’s Top 10 Smart Cities on the Planet

Partnership – Living LabIBM Research, City of Dubuque, ECIA,

Dubuque 2.0 (NGO), 1000+ Volunteer householdsBusiness partners – Neptune Technology, Alliant

Energy, Black Hills Natural Gas, Verizon Wireless, Airsage

City planning

Chinese State Physical Culture Administration invests in thousands

of fitness centers in parks, schools and other convenient urban locations with the goal of 40% of the

population exercise regularly

City of Toronto reduces incidents of diabetes through investment in 1500 parks

Brookings Institution ranked Rochester the 3rd Best metro

economy in the U.S. and 46th in the world. Low cost and high quality

cited as a major contributor