Why Teamwork Is Key to Addressing Social Determinants of Health

“It takes a village” takes on a whole new meaning when you apply it to healthcare. For Desha Dickson, associate vice president of Community Wellness at Reading Hospital, it takes a literal village — or in her words, community — to identify high-risk patients and successfully connect them to social determinants of health solutions.

That much has become clear in the years in which Reading Hospital, located in Berks County, Pennsylvania, has been dedicating itself to address social determinants of health and barriers to care for its patients.

As a Centers for Medicare & Medicaid Services (CMS) Accountable Health Community grant recipient, the hospital has become well-versed in assessing and then addressing social needs for patients. And the biggest lesson learned?

You can’t go it alone.

“COVID-19 has definitely shined a light on this issue now,” Dickson told PatientEngagementHIT, referencing the number of social health needs that have come to the surface during the global pandemic. “A lot of people are jumping to it and wanting to look at social determinants of health more closely, but you have to do it with your community. You have to have partners to do this work in the hospital.”

Dickson and her team at Reading Hospital should know; they’ve been conducting community health needs assessments for years and using those results to design community health efforts in partnership with social services and data platforms.

“Reading is not unlike any other health system where you may have populations of patients that struggle to get well and stay well,” Dickson explained.

The notion that those challenges have more to do with what goes on outside the hospital than in has been around for a while, Dickson added, but there wasn’t always a great way to articulate that. Then energy around the social determinants of health, which quickly become a buzzword as part of the industry’s efforts to transition from volume to value, began to build.

“The community health needs assessment, which falls under my purview, was an excellent tool for us to survey our community in one-on-one interviews or focus groups, to be able to ascertain what specifically are patient barriers to care,” Dickson noted.

Community health needs assessments, CHNAs for short, are expansive community surveys that look at the health needs of a broad population. Healthcare organizations seeking non-profit status are mandated to complete a CHNA and publicly report on the results once every three years. Organizations are also required to outline a community health action plan.

Healthcare organizations are generally left to their own devices to outline what they want to know from their communities. This gives them the opportunity to truly cater to what they believe may be a community health need, rather than be tethered to a one-size-fits-all assessment.

In 2016, Reading decided to take their CHNA in a different direction than it had in the past, and that’s had a waterfall effect on the rest of its social determinants of health work.

“We decided in 2016 that we wanted to take it beyond who's getting breast exams, who's getting prostate exams? We wanted to take it a step further because a lot of that information you really can find anywhere,” Dickson explained.

“What we knew we were lacking was that one-on-one patient feedback about what are institutional or environmental or community barriers to health care? That's really important for people who are starting out to do this work. There may be certain SDOH domains that are specific to your community, that if you incorporate those questions in your CHNA, it may provide you with direction.”

That new approach to the CHNA shed a light on pressing healthcare needs Reading hadn’t documented before. In 2013, for example, the CHNA noted insurance access as the most pressing barrier to healthcare access, Dickson recalled. But the 2016 survey painted a different picture.

“In 2016, we had almost the same percentage of people who report having barrier issues, but we had far greater patients that had insurance coverage,” she said.

That signaled to Dickson and her team that insurance wasn’t the great barrier to healthcare that they initially thought it was. Through Reading’s Street Medicine program, which set out to do outreach among homeless or housing insecure populations, physicians and nurses determined that there were other factors at play.

“What we found, again, was that a large majority of those homeless or housing insecure patients had insurance,” Dickson said. “Insurance was not their barrier to care. Transportation was their barrier to care. A lack of stable housing was their barrier to care. Food was their barrier to care. So there were other things that were taking priority to primary care.”

It was those findings that pushed Reading Hospital to take part in that CMS Accountable Health Communities program as part of the alignment track. This gave the hospital an opportunity to take their community health work a step further and work with a data system that would give actionable solutions to reported social health needs.

In fact, this was the crux of Reading Hospital’s mission. Dickson and her team did not want providers screening patients for social needs like housing security without an actionable solution to that need.

“What do you do if you ask your patients if they are homeless or housing insecure and they say yes? What do you do from that point?” Dickson posited. “Do you say, ‘thanks for answering my survey. Good luck.’ We were not comfortable having that conversation unless we could connect our patients with the right resources.”

Now, when patients present at Reading Hospital they get an in-person screening for social determinants of health. Basing these screenings within the patient-provider interaction was important for gaining patient trust, which is essential when discussing social needs.

Clinicians then enter screenings and other survey results into Reading’s data platform, Healthify, which churns out different social services that could help fill patient needs.

Again, having that type of a data platform has been central to Reading’s success, Dickson stated.

“You can't do this without a strong data system,” she asserted, noting that it’s important for a data platform and referral system to be able to pivot where necessary during the SDOH intervention journey.

“What you think in theory and how you imagine serving your patients and doing this work, I can guarantee you, it's not going to be what actually happens,” Dickson advised. “You need a group of people around the table who are willing to scrap an idea and start over and keep doing that until you get it right.”

Those people around the table also include community health partners, Dickson continued.

“I'm not sure anyone can be successful doing this work in-house, and I would strongly suggest that before anybody would take this on as an institutional initiative, that you start with building those community relationships,” Dickson recommended.

Again, these types of relationships are what have helped Reading be successful in addressing social determinants of health.

“Quite a bit of work that my department does is forming those relationships. That is the crux of our work,” Dickson explained. “You need them to be able to quickly respond to your patients who are saying, ‘I don't have food.’ If you're discharging your patient from the hospital, you need to be able to pick up the phone and call that community organization and get that patient food.”

From there, Reading leans on patient navigators to ensure patients are actually able to connect with social services. Before using a data and referral platform, Reading did not have a way to track whether a social service was actually a fit for patient needs.

Now, patient navigators are able to both follow up with the patient personally and track whether they have accessed a social service via the referral platform. This is important, considering the overlap among patients who have social health needs, who frequently visit the emergency department, and who get readmitted into the hospital, Dickson observed.

This might sound like a lot of moving parts and players which hospitals have to trust, but that in many ways is the point. Hospitals and health systems are traditionally practiced in delivering medicine, not feeding high-risk people or getting them housed. Although those factors, along with the other social determinants of health, have downstream impacts on health, Dickson reiterated that this isn’t a hospital’s area of expertise.

And as such, hospitals can’t go it alone. It’s going to take a village.

“This is not necessarily our wheelhouse,” Dickson concluded. “To address social determinants of health effectively and be able to wrap our arms around the patient, we have to partner with our community. We have to have good technology in place and we have to be committed to the end goal and not necessarily the process. If you start a workflow that doesn't work or it doesn't pan out, don't be afraid to start over.”