New model seeks to address social factors shaping health
April 24, 2014 § Leave a comment
This story was originally published on the Reporting on Health Affordable Care Act blog.
As Obamacare’s first open enrollment period came to an end last month, the vast majority of media coverage focused on just a few questions. How many people actually enrolled through the exchanges? Were attitudes changing towards the law? And what kind of political consequences would Republicans and Democrats face in the upcoming election cycle? Less prevalent, however, was the discussion of the social conditions that often exert a powerful influence over people’s health.
But consider the recently announced move by the Robert Wood Johnson Foundation (RWJF) to commit $16 million to Health Leads, the Boston-based organization that helps health care providers address the non-medical health needs of their most vulnerable patients. Under the Health Leads model, physicians and health care providers “prescribe” basic resources to their patients such as food, housing, electricity, heating, even job training, alongside medication.
Health Leads “advocates” – trained college students who man a desk in the clinic waiting room – help “fill” the prescriptions by connecting patients to community services and public benefits. As an integrated part of the health care team, such advocates follow up with their clients and report progress on the non-medical prescriptions to their patients’ providers.
The organization currently collaborates with 20 clinical partners in six cities and has reportedly served 23,000 patients since 2010. In 2013, Health Leads says 92% of the patients they worked with obtained at least one resource or were successfully aided in tracking down the needed help on their own.
So what makes this particular grant worthy of notice? For starters, the award is the single largest grant made to Health Leads in its 18-year history. It’s also among the 20 largest grants RWJF has ever made in its own 40-plus years of supporting health care projects.
But more importantly, the grant represents a growing shift toward creatively addressing the social factors that shape health.
“I think there is still debate to some extent, but for the most part people recognize the impact of social and economic conditions on patient health,” said Jim Mangia, CEO of St. John’s Well Child and Family Center and a pioneer in a medical practice that takes social conditions into account. In the South Los Angeles neighborhoods where St. John’s free and low-cost community clinics are located, rates of coronary disease, diabetes, and lung cancer far outpace that of other nearby regions. The area also claims the highest morbidity and mortality rates in all of L.A. County.
“Many of our patients live in slum housing conditions and are treated for slum housing-related conditions such as chronic sinusitis, asthma, elevated blood lead levels, rat bites, etc.,” Mangia said. “Couple [these conditions] with other social determinants such as a lack of access to fresh fruit and vegetables, lack of green space or healthy places to exercise, and you will see this kind of prevalence of chronic disease.”
St. John’s clinics partner with Neighborhood Legal Services, a nonprofit public interest law firm, so that patients have representation when it comes to tenants’ rights issues. “The socioeconomic conditions in which our families live are slapping our doctors in the face,” Mangia told the Los Angeles Times in 2010. “Someone has to hold slum lords accountable for the slum housing conditions, which are poisoning our children.”
The idea that promoting health requires more than managing disease isn’t new, as Mangia points out. Public safety, food access, safe housing, and economic equality have been a growing part of the public health conversation for decades, and physicians have long been familiar with the ways in which housing and neighborhoods shape their patients’ health – they are among the root causes of visits to clinics such as St. John’s.
But that awareness hasn’t always connected in meaningful ways for patients, and it’s left some health care providers frustrated. A national survey conducted in 2011 by Harris Interactive (on behalf of RWJF) found that four out of five physicians said that addressing their patients’ social needs was just as important as addressing their medical needs. However, four in five physicians also did not feel “confident in their capacity to meet their patients’ social needs.” Without programs such as Health Leads to turn to, many doctors are left treating symptoms rather than taking a more comprehensive approach to their patients’ health.
“It’s obviously an iterative and ongoing process,” Mangia said, referring to his clinics’ emphasis on holistic healthcare. St. John’s collaborates with local organizations to offer programs such as exercise and healthy cooking classes. Recently, Mangia has been pushing for a “wellness trust,” a fund that would support prevention programming and could offer health coverage programs for undocumented immigrants in L.A. But the trust is a long way from launch and, according to Mangia, there hasn’t been much movement on the initiative since the clinic launched the campaign in December.
That’s why programs like Health Leads are especially interesting at this moment in time when health care systems are shifting priorities. With ACA proponents betting heavily on improving health outcomes and lowering costs through preventative care, we should see more creative experiments designed to address the social determinants of health and the health disparities they create.