Demystifying Medicine One Month at a Time

Tag: social determinants (Page 1 of 2)

The ‘One Stop Shop’

“How can you expect patients to look after their health, when they don’t know where they will be living next week? You can not separate people’s physical health from their psychological, social and spiritual health.”

So asked community health nurse Ruth Chorley, in an article by Rachel Pugh in the Guardian.

The story reported on a local program in Oldham, one of the UK’s National Health Service districts, in which nurse specialists work to help people whose social and economic problems prevent them from managing their health.

From the story:

Chorley is a focused care practitioner – one of four employed by Hope Citadel Healthcare, a not-for-profit community interest company, to lead a pioneering approach to delivering healthcare to the most needy families in its four Greater Manchester NHS GP practices, by filling in the gaps between health and social care.

I think this small scale NHS experiment is one right way to truly improve a  community’s health.

Caring Center is a Win-Win

Bama stacks wwwThe Bama Companies of Tulsa, Okla. made what I see as an historic announcement last month.

The company, a privately-owned global manufacturer of pies, biscuits (McDonald’s) and dough (Pizza Hut) has more than 1000 employees.

CEO Paula Marshall believes in second chances, making a practice of hiring parolees and those (particularly women) out of treatment for chemical dependency.

Marshall noted that there is a critical threshold, at 3-4 months of employment, where tardiness and absenteeism start to occur in many of these new hires — often resulting in termination or resignation.

Since it’s costly for the company to recruit and train new talent (Marshall puts the number at $5500 per employee), she figured it is wise to invest in helping employees surmount the challenges they face in maintaining employment — factors outside the workplace — like childcare, financial planning, transportation, and counseling.

[For decades the company has offered in-house medical services, which will continue with the new initiative.]

The company frames the decision to open it’s “Caring Center” as a business decision, but it’s clearly one with a heart.

To me, the plan reinforces the idea that it’s not strictly what happens within the walls of a medical setting that impacts people’s health. It’s the social determinants of health that have a bigger impact on health– education, environment, employment, access to adequate nutrition.

Opinions on the project vary. Some say Bama’s ‘Caring Center’ is nothing more than a glorified Employee Assistance Program (EAP). But in my view, EAPs are usually handled by 3rd party contractors, have limited uptake, and are focused more exclusively on mental health (important, to be sure, but not as broad as Bama’s effort).

Others ask, “Why not simply pay the employees more?” That is indeed a laudable goal. But arguably it’s the educational efforts and resource-matching that the Caring Center provides that will make more of a difference in employment sustainability. If an employee can keep his/her job, s/he will have more opportunity to climb the economic ladder. Bama, for example, like many companies, seeks to retain and grow talent from within.

Only time will tell if Bama’s Caring Center is impactful or not. Marshall has set the bar at what seems like an achieveable level: She hopes to lower the rate of employee loss from 8/10 to five or six out of ten to achieve financial success for the company. But if she succeeds, that’s many lives that will be impacted.

Will more companies choose to make these types of investments?

Game Changer.

Well, 2016 is off and running. Though the markets seem in peril due to China’s economic cooling, the health care arena in the U.S continues to burn like a hot stove.

For one thing, a now-unified Republican Congress passed the 62nd or so attempted repeal of ObamaCare, which the President unsurprisingly vetoed. The new year will likely decide the fate of the Affordable Care Act — and whether it continues its evolution and improvement in providing coverage to more Americans and helping control health care costs, or whether it is substantially rolled back.

Whatever your position on the law, here are some incontestable facts about it:

  • marmotsdhThe law has survived two (2) different Supreme Court challenges.
  • More than 20 million Americans previously without insurance coverage now have it.
  • The percentage of uninsured Americans is the lowest since the government began tracking the statistic in 1972. [Percentages were much higher in the early 1960s before the passage of Medicare and Medicaid in 1965.]
  • Millions more are eligible to gain insurance through the law’s mechanisms, provided those people elect to sign up rather than pay a tax penalty.

But here’s what I find really interesting:

More than just a coverage law, the Affordable Care Act is also a health care delivery law. Parts of the statute are directed at improving how health care is delivered and how our menu(s) of options are developed and prioritized. Fundamentally, it’s reasonable to ask: If the U.S. spends the most in health care (both per capita and in aggregate), and our outcomes are worse than other nations (in measures like life expectancy, infant mortality, etc.), shouldn’t we seriously reconsider how we prioritize our health care spending?

CMS, the federal agency that administers Medicare and Medicaid announced this week its first ever pilot initiative to fund programs addressing social determinants of health: housing, food security, utilities, transportation. [Other key determinants not covered under this pilot are education and employment.]

This is a game changer because it’s the first time the biggest driver of health care services and innovation is directly attempting to address issues that undergird our collective poor health attainment. Rather than just continuing to pour money into “sick care” (i.e. where most of the spending in health care occurs), this initiative provides dollars “upstream” to see if together we can find ways to prevent both major and chronic illnesses.

Couple new initiatives like this with ongoing efforts to reform medical education, and one gets hopeful that we can change health care to become smarter, more compassionate, and achieve better results.

What Really Makes People Sick

Medical science has evolved rapidly. With the newest computing and laboratory technologies, the pace of knowledge generation only increases. Our biggest challenge today is in processing data, and finding the patterns within that can unlock more secrets of life and health.

sep2011_AWSI_03 bigPublic health improvements in the 20th century like sewer systems and a clean water supply, coupled with childhood vaccinations and the advent of antibiotics radically increased the human life span to its all time high–roughly 80 years for men and women in the ‘industrialized’ western world.

Some in the scientific community think an achievable human life span is closer to 120 years; that if we can alter some of the problems caused by senescence and aging, more of us will live past 100. It’s at about 120 years that current science guesses that cellular and tissue breakdown is genetically programmed to occur to such an extent that further life as we know it is near impossible.

As the list of causes of death in the U.S. has changed dramatically over the 20th century, you can now see that much of what kills us is chronic disease. Interestingly, our ability to make inroads on this list has not been as successful as it was in fighting the original infectious causes of death. We manage chronic conditions like diabetes, heart disease and cancer; very rarely do we cure them. This despite a nearly half century “war on cancer” and billions of dollars spent on research and development in heart disease.

What we’ve come to understand in the medical world, by listening to our social science colleagues, is that social factors have a profound impact on our health — such that the World Health Organization estimates that medical care (over which we spend $3 trillion annually in the U.S.) only impacts about 10% of our health. It’s the social (non-medical) factors that play an outsize role in our health as individuals and communities.

NPR Health ran a short series of radio stories and web posts called “What Shapes Health” that looked at these phenomena. They’re well worth indulging in if you didn’t catch them when they aired. Among the highlights:

  • What is an adverse childhood experience (“ACE”) and how does it impact your future health? Take a short quiz and get your own ACE score.
  • Survey research showing that people with lower incomes perceive that they pay a price with poorer health. Not surprising news, but important knowledge of the effects of inequality.
  • Housing impacts health…in a big way. If you don’t have housing, can’t afford it, or live in housing that is unsafe or substandard, in all likelihood you will die younger than others in your age cohort.

Each of these social factors (and another HUGE one: education) lead to that amorphous concept we call “stress.” It has real impact, and quite frankly we’re only in our infancy of being able to quantify what it does to us. Stay tuned.

Is it Health Care or Beyond?

This story from the radio program Marketplace caught my attention (you can listen to it at the bottom of this post).

_MG_6278It details the travails of Mariano Garcia, 45, who was at a medical visit to have bandages changed on an open leg wound.

In a bit of graphic detail, we learn that Garcia is not having his bandages changed daily, as he’s instructed to do, but rather once a week. By the end of each week, the healing flesh is matted onto the bandages and each dressing change is subsequently much harder because of the constant sloughing off of tissue. The healing process is thereby greatly slowed.

Garcia is in Camden, N.J., the locale of MacArthur genius grant winner Jeffrey Brenner, he of “hot spotting” fame. [Hot spotting involves targeting people that use the “most” healthcare: things like frequent ambulance rides, ER visits, CT scans, etc., which result in excessive cost to the “system;” and designing care plans around such high users to improve their health and save health care dollars.]

The story quotes Rebecca Onie, founder and CEO of Health Leads (herself a MacArthur genius grant recipient):

Onie says now that hospitals either must drive down costs, or face what could be crippling financial penalties. Healthcare executives must leave the medical map behind and head out for the uncharted territory.

“They are going to have to begin paying for a set of things that have historically [been] considered outside the scope of traditional healthcare,” she says.

And so we are beginning to see healthcare’s first, hesitant steps, where doctors and hospitals wade into the world of social services.

Having worked in several hospitals, I find this daunting but welcome. Too often we see chronically ill patients that are deprived of necessary (and lower cost) follow up care return to the hospital to “put out fires” when a bit of maintenance could have kept things running.

Could you imagine your local hospital offering services outside its doors, in community-wide fashion? Or does this seem beyond the scope of the hospital’s job?

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