Health Equity

Focus on social needs helps heart patients avoid readmissions

Andis Robeznieks , Senior News Writer

As health systems move beyond their traditional roles and boundaries to improve their patients’ outcomes by addressing social determinants of health (SDOH), physician-led care teams will be asked to do more—but experience is showing that success is more likely if they don’t try to do it all.

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That’s been the story at Bayhealth, a Delaware-based organization with 400 physicians on staff that is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

A pilot program centered on Bayhealth’s cardiovascular service line and testing a SDOH-focused approach for patients with heart failure helped lower readmission rates for these patients by a whopping 67%.

Bayhealth is using a Centers for Medicare & Medicaid Services-recommended screening questionnaire, plugging the responses into the EHR and then, with the help of Unite Delaware—a third-party community organization partner—connecting patients to the resources they need.

Bayhealth’s program sprung from participation in a six-month national learning collaborative. From there, a workgroup was formed that developed the SDOH program and its initial cardiovascular focus.

“Some of the challenges were just about deciding what questions to ask and then what we could do with the information,” said John Fink, MD, Bayhealth vice president for quality and medical affairs. “The most important final step was what do you do with it when you capture all the information? How do you get these folks connected to the resources that they need?”

Partnering with Unite Delaware, Bayhealth was able to connect patients with resources for food, transportation and other needs.

“Traditionally—why those questions didn’t get asked was if you don't have an answer to give a patient, why would you ask the questions?” Dr. Fink said. “So now we had this resource where we can at least connect folks, so they could get help with transportation vouchers or some help with food insecurity.

“They were really instrumental in getting patients to close those gaps a little bit more,” he added.

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“That's what we hope contributed to some of that decrease in readmissions. Folks were able to get to their follow-up appointment with their cardiologist, because now they had that transportation or maybe they would get some healthier food with a lower salt content.”

Learn more with the AMA about why asking about social determinants of health is so important.

That Bayhealth’s effort is contributing to better patient outcomes shouldn’t be surprising. It is consistent with results seen in the peer-reviewed literature, as found in a systematic review of 35 studies examining programs using similar approaches that was published last year.

The review, published in the journal Preventing Chronic Disease: Public Health Research, Practice, and Policy, notes that up to 80% of patients’ health outcomes can be attributed to social determinants of health—“the conditions in which we grow, live and work.” Researchers identified a number of studies in which health care organizations’ screening for, and acting to meet, patients’ social needs led to improved health outcomes, including better:

  • Medication adherence.
  • Adherence to infant immunization schedules.
  • Systolic and diastolic blood-pressure trends during pregnancy.
  • Low-density lipoprotein cholesterol among patients with diabetes.

Researchers also found that links between patients and resources were stronger when a community-based organization partnered with the health system and provided hands-on assistance to access resources, noting in particular the “lengthy and complex” application process for the Supplemental Nutrition Assistance Program.

Bayhealth social workers have been helping eligible patients with such applications for years, and the health system also partners with Food Bank of Delaware to provide assistance to patients, including having food boxes on-site to give to patients.

But “instead of just giving patients vouchers or giving them the number to the food bank, we're actually giving patients who are in need a box of food to cover about two weeks,” Dr. Fink said. “That’s in addition to making that referral to get them connected, and to be able to continue that healthy eating afterward.”

Learn more about the AMA’s call for an “all-hands-on-deck approach” on social determinants of health.

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Although the food is available, Dr. Fink said some patients are reluctant to acknowledge that they need it.

“It's hard to share that you can't afford to provide the right kind of food for your family,” Dr. Fink said. “That’s as big a barrier as any.”

Bayhealth family physician Preeti Gupta, MD, said a solid patient-doctor relationship is the key to overcoming this barrier.

“Being their primary care physician, they have trust in us, and they know this information is not going to leak outside,” Dr. Gupta said. “Nobody feels comfortable telling their information to a stranger.

“They know that we are not getting this information just to get it, but so that we can help them,” she added. “So that the bond of trust between the physician and the patient helps them to share their personal information—they don't want to share with everybody that they don’t have money for their medication.”

The success of the pilot for patients with heart failure has prompted Bayhealth to roll out the program systemwide.

On the outpatient side, Dr. Gupta said an initial focus has been on medication affordability and involves a physician-led multidisciplinary team that includes a registered nurse, chronic care manager and embedded pharmacist.

Patients are educated about online tools such as GoodRx, which shows them what different pharmacies in their neighborhood charge for the same medications. Physicians have been encouraged to consider prescribing generic medications and pharmacists work with drugmakers to provide samples or other low-cost options.

Discover the seven terms doctors should know about social determinants of health.