An “aha moment” that Mandy Cohen, MD, MPH—North Carolina’s Health and Human Services Secretary—had as a third-year internal medicine resident, demonstrates the importance of addressing patient’s social needs and incorporating social determinants of health (SDOH) into health care systems.

Fostering healthier communities

This episode of AMA Doc Talk explores how physicians can better serve their patients by thinking beyond the walls of the exam room.  

Dr. Cohen is moving the state’s Medicaid program to value-based care and piloting a program to address the conditions in which people live that directly impact health. She gave a progress report to hundreds of physicians and state medical society executives and staffers at the AMA State Advocacy Summit in Bonita Springs, Florida.

The former Centers for Medicare & Medicaid Services (CMS) chief operating officer and chief of staff told attendees she traces her focus on social needs back years ago to her experience as a resident. She was having trouble ascertaining the source of a patient’s illness, despite ordering test after test. After a computed tomography scan came back normal, the next step was going to be referring the patient to a specialist—as soon as she figured out what kind of specialist to refer her to.

Then a nurse suggested Dr. Cohen ask the patient whether she was getting enough to eat.

So Dr. Cohen, now a champion of standardized questions, asked her patient an “unstandardized” question: What’s going on at home?

That’s when the patient shared that she had left the abusive boyfriend she had been living with, was living out of her car because almost all her money was going toward college tuition, and that she was too ashamed to ask her parents for help. So what presented as hair loss, weight loss and declining health, was linked to housing insecurity, food insecurity and exposure to personal violence.

Instead of referring her to a specialist, Dr. Cohen said she did an online search and found food banks operating in the patient’s ZIP code and printed out the information for her.

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This experience illustrates the importance of two tools that are key to North Carolina’s vision for “buying better health.”

The first is a nine-question screening tool developed with input from patients, physicians and hospitals that was then field tested and includes questions on social determinants such on housing, food, transportation, utilities and exposure to violence.

Dr. Cohen maintains a pediatric practice and the questions are part of the patient check-in procedure. But she said the tool is intended to be used wherever folks interact with the social safety net and is meant to also be used for patients covered by Medicare or commercial insurance.

“You cannot tell by looking at someone how they’re going to answer these questions,” she said.

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Standardized screening “is not the game-changer,” Dr. Cohen added, but she called it a “necessary first step” to bring patients’ social issues to the surface.

What she did call the game-changer is NCCARE360, a coordinated network described as unifying health care and social service organizations with a shared technology platform to provide a coordinated “community-oriented, patient-centered” approach to delivering care.

The platform can connect patients to food banks or other resources and tells the physician whether the patient receives what is needed—the same as when an EHR confirms that a prescription was filled or that a patient referred to a specialist made the appointment.

The unanticipated reward has been that the platform has worked to build relationships that strengthen community “connection points.”

“What I didn't appreciate when we started this project is how important this has been to actually connect the community organizations,” she said. “What has been great is that the housing provider has now linked to the employment folks who, frankly, they had never met before.”

NCCARE360 is now operating in 50 of North Carolina’s 100 counties, linking 655 licensed organizations that have responded to 2,000 referrals.

Secretary Cohen envisions the program to include payment for services such as removing a moldy carpet from the home of a child with severe asthma. CMS has authorized $650 million in Medicaid funds to be used over five years to develop pilot programs addressing housing, food, transportation and violence.

The fact that North Carolina’s legislature has not expanded Medicaid creates a challenge. Other challenges include the need for workflow redesign, an insufficient workforce and the need for culture change, which—Secretary Cohen said, “only happens at the speed of trust.” 

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