A
discussion with members of Humana’s Bold Goal team identified best practices
for building a successful social determinants of health strategy.
Addressing the social
determinants of health (SDOH) in a community can seem like an insurmountable
task, but Humana’s best practices show that a changing health system is ready
to tackle these problems.
The SDOH are factors outside of the traditional
health care setting that impact an individual’s health, with common
determinants including food insecurity, transportation, job training, and
housing. A patient’s SDOH contribute more to her health than the medical care
she receives or her genetic code.
Increasingly, the
health care industry has begun to understand how these factors influence health
outcomes and focus on preventive strategies that improve SDOH.
Humana was one of the
first payers to begin addressing SDOH. In 2015, they began their Bold Goal strategy to address the
SDOH needs in their population. The goal was to improve the health of its
communities by 20 percent by 2020.
Humana has been transparent with their implementation
strategies and documenting their success in improving the health of their
member populations through addressing SDOH.
The organization uses
the Center for Disease Control and Prevention’s Healthy Days questionnaire to
measure the health of the population. The tool asks respondents about the
number of physically and mentally unhealthy days they have experienced in the
last month.
Through SDOH
strategies, Humana has been decreasing the number of unhealthy days in its Bold
Goal Communities.
PROMOTE
BUY-IN AT ALL LEVELS
Strategy
implementation requires organizational buy-in from key stakeholders involved in
the implementation of the strategy. The challenge with a SDOH strategy is that
it requires buy-in from both within and outside the organization. Providers are
often the ones implementing the strategy and the larger health care industry
needs to support a focus on the SDOH.
At Humana, leaders
needed three key levels of buy-in in order for their SDOH strategies to
succeed, according to Andrew Renda, MD, the associate vice president for
Humana’s population health strategy.
“On the one hand, we
have internal stakeholders, because we had to convince our management team that
they want to invest in social determinants of health for our members,” Renda
told HealthITAnalytics.com.
“Then we have
physicians. Buy-in there is education about how social determinants of health
impact health and health outcomes. It's convincing them that we’ll support them
with the data analytics and the referral sources that they need to maintain the
relationship with their patients. The third stakeholder is CMS and convincing
them that social determinants are important, that there’s a clinical case, a
business case.”
Buy-in from within
the organization was simple for Humana as the request for a SDOH strategy came
directly from the CEO. But getting buy-in from other stakeholders proved more
challenging.
To generate provider
buy-in, Humana built a continuing education course to give providers an
overview of why social determinants are important for health, walking providers
through validated screeners for social determinants, coaching them on best
practices and how to have conversations about screenings with patients, and
offering referral resources.
Buy-n required a
larger shift in the healthcare industry to get CMS on board, Renda said. As
more research revealed the importance of social determinants of health and more
organizations began to address them, it was easier for Humana and CMS to work
together.
Caraline Coats, vice
president of Bold Goal and Population Health Strategy at Humana said obtaining
buy-in for a SDOH strategy was easier because there was a shift in the
industry’s emphasis on social determinants of health.
“It’s a mindset
change not just for Humana but for our industry,” Coats stated. The industry
began to look at gaps in SDOH the same as gaps in clinical care.
DRAW DATA
FROM MULTIPLE SOURCES
Next, Humana needed
to outline its strategy, and in order to do so, it needed ample patient and
SDOH data.
Data helps make a
case for buy-in, demonstrates targeted goals and a means of measuring the
goals, shows key improvement areas, and helps monitor outcomes. If just
beginning a SDOH strategy, though, data on a specific member’s SDOH may be
difficult to obtain.
Humana utilized large
amounts of publicly available data.
“We get data wherever
we can,” Renda remarked.
Humana worked with
the Robert Wood Johnson Foundation’s county health rankings and the census data
to understand the unmet social needs in their various markets. They synthesized
this data, as well as member collected data through routine telephonic surveys
and home visits.
But payers need to be
wary of “analysis paralysis,” Coats warned, noting that too much data can shift
the focus from making a change to overanalyzing data.
“There’s so much
information out there right now,” Coats explained. “We’re all trying to prove
the relationship between health outcomes and social determinants of health. I
think we know the answer and that there’s value. The question is what is the
value? We’ll answer that question eventually, but we have to go in with the
assumption that investing in social determinants of health has value.”
While obtaining data
from all sources and utilizing data collection tools that already exist help to
inform strategy, becoming inundated with the data can stall improvement plans.
ENCOURAGE
COMMUNITY INVOLVEMENT
The next step for
Humana was picking up community partners. Implementing a SDOH strategy requires
community involvement to help identify areas of need and community resources to
aid the strategy.
“Health care is local
and it is even more so when you're addressing social determinants of health,”
said Coats. “Whether it's anxiety and depression, stress in a market that's
prone to hurricanes, or a market that has a higher prevalence of suicide,
understanding with whom you need to build trust to develop a collective
impact and rally around is fundamental to scaling and operationalizing a strategy.”
A community-based
organization might be trying to address the same problems as a plan’s SDOH
strategy. These organizations receive grants to fund their work and look for
partners to aid in their mission. The options within a community are abundant
and partnering with local organizations will allow both parties to accomplish
their goals.
“There are community
resources that you have easy access to, or you can figure out the resources
within your own specific geographic area,” explained Renda. “There are food
banks everywhere. There are community centers everywhere. You just have to
figure out where those are. A lot of those are no-cost. It doesn't necessarily
require a lot of money.”
Those in a community
understand best what a community needs. Having a relationship with the
community will help grow an SDOH strategy and can even point to areas of
improvement a payer might not have thought of originally.
“I see now in our
most mature markets, those relationships that we've now been nurturing and
working on and building, they're paying off not in a business way but through
innovative ideas to co-create solutions on how to then tackle these social
determinants of health. We would have had never had the idea to approach them
in such new ways. That local presence and focus is really important,” stated
Coats.
REMEMBER
THAT GOOD THINGS TAKE TIME
SDOH impact health in
the long run, not necessarily the short-term. The effects of an SDOH strategy
might also take several years to see results that ultimately impact the business
case for investment.
“This isn't something
you can just flip a switch and turn on overnight. I think an important piece to
underscore to anyone who's taking this on is it takes some time to invest in
local markets,” Coats said.
Being flexible and open
to building the strategy simultaneously with new data and analysis is what has
helped Humana succeed. Their strategy is adjusted in real-time as new research
is published and new community organizations begin partnerships.
“We’re building the
plane as it’s going down the runway,” Renda noted.
Tuning a strategy
based on new insights rather than being anchored to a specific plan will help a
strategy succeed.
BUILD FOR
THE FUTURE
When Humana began
undertaking its Bold Goal Initiative, the payer set its sights on a 20 percent
increase in health by 2020. Now that the initiative has been successful, the
health plan is starting to make a new strategy focused on sustaining success
and continuing to improve the health of its populations.
Implementing SDOH
monitoring and referrals into routine practice is one way Humana plans to
continuously sustain its program. If providers are regularly monitoring the
social needs of their patients and have the proper tools for referral, the
strategies implemented by Humana become a part of the routine workflow and no
longer need to be heavily monitored by the plan.
“One really good and
efficient way to scale is actually by integrating social determinants into
current clinical operation models. We can scale really quickly if we’re
integrating directly into established clinical programs,” said Renda.
For example, the
payer’s Humana at Home program, which serves as a care management program that
helps members remain independent at home, leverages community health workers to
track SDOH. While those home care workers coordinate medication, clinical care,
and other routine tasks, they also screen Humana members for SDOH needs,
allowing for a more holistic view of the patient.
Humana has also
developed a population health department which has now become a part of its
budgeting framework. Development of this department integrates population
health and SDOH into the framework of Humana’s organizational structure making
it a part of long-term investment plans.
This sustainability
will improve as the health care industry continues to shift from a fee for
service model of payment to a more value-based payment system.
“We’re just now
seeing maturation in different value-based models,” Coats concluded. “We are
diligently working with our value-based strategy team right now to co-create
some different value-based payment models that include social determinants of
health screenings or referrals or not necessarily one model. It depends on what
physicians are doing today and what resources they have and what capabilities
they have.”
Originally published
on August 1, 2019
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