Communities, Connections and Metrics That Sustain SDoH Programs

Published on August 12, 2019

When Carrot Health Founder and CEO Kurt Waltenbaugh attended the RISE Health National Summit on Social Determinants of Health in Washington D.C., he delivered a Power Breakfast Series talk on implementing successful, scalable #SDoH programs. While he was there, he had the opportunity to talk with payers, providers and policy makers and to attend several panels. This is the final of three blog posts with highlights from that experience. You can read Part 1, a summary of the Summit’s key themes, here and Part 2, Roadmaps for SDoH Programs, here.

By Kurt Waltenbaugh

Among the most important topics addressed at the RISE Health SDoH summit were collaborations and analytics that make long term sustainability of SDoH programs possible. Here are key lessons on those themes from three panels.

Leveraging SDoH to Innovate the Payer/Provider Relationship

Creagh Milford from Healthcare Highways and Jim Walton from Genesis Physicians Group presented on how payers and providers can work together despite having different missions and visions. Often, one of the parties is a for-profit entity, the other not-for profit. How can they align better around the needs of the consumer?

Milford and Walton say the key is to identify the right providers, share data to empower decisions on both sides, create value-based incentives to align, reward, and – most importantly – engage providers as partners, not adversaries.

In Dallas, Texas, a community still dominated by traditional fee-for-service incentives for commercially insured populations, Milford and Walton have built a lasting partnership that improves outcomes and provides real value to all parties. At the center is a process to collect and measure SDoH status, increasing

  • the precision of risk identification,
  • the accuracy of social intervention choice (what is the next best action), and
  • the success of the intervention itself.

They demonstrate this value with a $190 PMPM reduction in total cost of care over a control group.

Purpose Built Communities

A panel on purpose built communities featured Doug Jutte from Build Healthy Places Network, William Barnet from Barnet Development Company, Phil Feisal from Spartanburg Medical Center, Eddy Moratin from LIFT Orlando, and Lee Johnson from AdventHealth. They discussed how – using the principles of “placemaking” to design or re-design a community around behaviors that induce health – purpose built communities are organizing groups across the country to improve SDoH, increase equity, and create generational improvement in health.

Three pillars guide their work:

  • mixed income housing
  • cradle-to-College education pipeline and
  • community wellness.

In addition, they emphasize the importance of an identified “community quarterback” to guide the work and a focus on a defined geographic neighborhood that you can draw a boundary around. Tapping into funders like community development corporations and payers/providers, they raise funding for capital improvements and ongoing operating costs.

They provided two examples: Spartanburg, South Carolina, and Orlando, Florida.

  • In Spartanburg, the medical center funded the creation of a job training center providing a certificate in various construction disciplines. With the median income in the neighborhood of $15,000 annually, their graduates enter into $36-40,000 jobs out of the gate. These individuals provide significant stability for their families and, in turn, the neighborhood as a whole. The economic success leads to housing and food stability, which leads to health improvements.
  • In Orlando, AdventHealth has invested in housing community creation, parks, and early children education. The child center even has on-site medical care so that sick children still have a place to go for the day and their parents are able to continue working. Why did AdventHealth get involved? In Johnson’s words: “We tried just doing health improvements. It worked for a while but didn’t address the underlying issues. We needed a program that was measurable and sustainable and lifted our community out of poverty.”

Creating Appropriate Evaluation Metrics for Long Term Sustainability of SDoH Programs

How do we measure our results? A panel by Anthem Indiana Medicaid’s Katie Zito and Green River’s Michael Knapp and Ian Kozak offered guidance, using an example from Anthem.

Anthem asked if it could divert resources from the emergency department and hospital into supporting its Medicaid community members with services like housing that exacerbate the clinical needs. First stop: homelessness. Second stop: knowing if it works.

Anthem has a 42% Medicaid share in Indianapolis (170,000 members that grew through the Medicaid expansion). Like many organizations, it struggles to locate homeless members and connect them to care. Most often these are seen only during crisis which leads to very high costs.

Based on evidence from other communities, Anthem created “Blue Triangle,” a housing-first, temporary shelter for this population. Housing-first means low-barrier: no requirements… just get them into place. Then, when the individual is ready, connect them to additional support services (for example, drug rehab or behavioral therapies). This safe haven is paid for by the City of Indianapolis and Anthem and run by a non-profit. It is only open to Anthem Medicaid members.

Measurement of the pilot was key to preserving funding and scaling. Out of the pilot, 56 members were moved into permanent housing. For all members reached, TCOC came down by $337 PMPM, with much higher reductions for the 56 in permanent housing.

The lessons? Finding permanent housing is very difficult but worth it. Support services are key, and it may take the member three to six months in the shelter before they are ready to try those services. This is not a one-size fits all model and has to be tailored to each individual in need.

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