Social determinants of health: The ProMedica story

The health care community is showing a significant and growing interest in the social determinants of health. The rise of population health, providers’ embracing risk, increased focus on community benefits and growing scientific evidence have all driven an appreciation that social factors such as income, education and food security can determine health status, health needs and health outcomes.

I’ve previously reviewed population health and population health management approaches from 30,000 feet. But a real question remains: How do health systems translate understanding about the social determinants of health into action?

The American Hospital Association has launched a valuable new set of tools focused on eight social determinants: food, housing, education, transportation, violence, social support, health behaviors and employment. These are the subjects of guides being published nearly monthly through early next year.

At the AHA Leadership Summit in July in San Diego, keynoter Rishi Manchanda, M.D., an evangelist for “upstreaming,” as he terms it, urged health systems to get ready, get set and go upstream to deal with social determinants.

In my travels, I see many health systems addressing the social determinants of health. But few organizations, in my view, have done more to operationalize their approach than ProMedica, a leading health system based in Toledo, Ohio. ProMedica serves as a role model for building a strategy that fully embraces the social determinants of health and makes it real for the community it serves. This is its story.

A thriving health system, a community in need

ProMedica is a highly successful, well-respected, integrated delivery system with 332 sites of care, 4.7 million patient encounters systemwide, 13 hospitals and 323,000 lives covered by its owned health plan, and with 800-plus employed physicians, $3.1 billion revenue and strong financial ratings.

Yet, when ProMedica leaders looked at their community recently, they found that:

• Toledo rated 99th out of 100 communities in the Gallup Well-Being Index.
• 70 percent of adults were overweight.
• 36 percent of low-income families were concerned about having enough food.
• Lucas County, of which Toledo is the county seat, ranked last among Ohio's 88 counties for infant mortality and low birth weight babies. 
• 28 percent of youth reported they felt sad or hopeless two weeks in row.

The juxtaposition of a thriving health care system and a community with poor health status galvanized ProMedica leaders to think more broadly of how to engage the community to improve health and well-being.

Starting with obesity

A decade ago, ProMedica leaders undertook a community needs assessment, focusing on the obesity epidemic affecting the Toledo community. But as they dug deeper into the causal factors, there was a surprise. As ProMedica CEO Randy Oostra explains, “The more we kept peeling back the layers, the more we found that the problem was hunger and food insecurity.”

Research has shown that food insecurity leads to health problems throughout a person's life. Pregnant women who live in food-insecure households are more likely to deliver underweight babies, while children suffer from more ear infections, colds, stomachaches and iron deficiency. Without an adequate food supply, children also develop more cognitive and physical development problems. In adults, dietary shortfalls and irregular eating patterns can lead to obesity, chronic disease and behavioral health problems. And seniors who are food-insecure experience more disability, less resistance to infection and longer hospital stays.

These facts led ProMedica to become a pioneer in the use of a food pharmacy (prescribing food as medicine) and investing in inner-city grocery stores with healthy food. ProMedica employees started with a visit to Boston Medical Center’s Grow Clinic, a successful program that had been operating for a decade, to learn how to start their own program. They opened the first ProMedica Food Pharmacy in April 2015 in Toledo.

As the ProMedica food security program description states, “The idea of the Food Pharmacy is simple: Food is medicine. As such, a health care professional writes a referral to the food pharmacy for patients that are identified as food insecure. These patients are then able to visit the pharmacy to pick up a supplemental supply of healthy food for their family.”

The results are impressive. According to ProMedica’s internal monitoring, 57,244 patients were screened for food security in 2016; of those patients, 2,243 screened positive. Their average age was 50, and 1,100 of them became new food pharmacy clients.

Among the 4,000 Medicaid patients completing a screen and food pharmacy referral in 2016, ProMedica found that emergency department usage dropped 3 percent, readmission rates dropped 53 percent, and primary care visit rates increased 4 percent.

These are impressive outcomes from an intervention in which food is medicine. If this were a pill, it would be a billion-dollar drug.

Beyond food

Building on its success with the food pharmacy, ProMedica focused on clinical excellence, economic and social determinants, and anchor institutions. (Anchor institutions are nonprofit institutions that, once established, tend not to move location. They include hospitals, universities, arts, churches, entertainment and sports venues — organizations that are place-based and are focused on the long-term welfare of their communities.)

As an anchor institution, ProMedica has used its resources to drive economic well-being; improve housing, education and training opportunities; and create and retain jobs and opportunity.

For example, Oostra and his leadership team have bought and sold a hotel property to keep jobs in the community, invested in real estate development initiatives, relocated ProMedica’s headquarters as part of a downtown revitalization, and used their resources to secure loans and funding investments that have driven an estimated $500 million of new economic development in the Toledo area.

Hospitals are ideally suited to be anchor institutions in creating a virtuous economic cycle: They’re not leaving; they bring resources as an investor; and, in many cases, they are the largest employer in their community.

Screening for social determinants

ProMedica is applying a social determinants of health screening tool to all patients, whether in the inpatient or outpatient environment. The tool covers many of the same factors identified by the AHA, including education, employment, food, housing, transportation and violence. The screeners also ask a series of questions about the patients' motivation.

It is early in ProMedica’s journey of data collection and review to guide action, but the results to date are encouraging. For the initial 340 patients in the pilot program from Jan. 31 to June 30:

• Two hundred forty-seven patients completed screenings out of 340 patient encounters (73 percent); a quarter of patients declined to be screened.
• Of patients encountered, 54 percent had positive needs identified and elected connection to services through ProMedica’s Community Care partners.
• A full 38 percent of those screened had needs in four or more domains.
• To date, a total of 320 patient needs have been validated.
• A remarkable 97 percent of needs are either in the process of being resolved (55 percent) or have been confirmed resolved (42 percent). (Only 3 percent remain unresolved or are cases in which patients are unable to be reached.)
• To date, 317 patient community resource referrals have been made as a result of social determinants screening (41 percent to a community food resource, 21 percent to a community financial resource, 11 percent to a community utilities resource and 9 percent to a community training or employment resource).
• Perhaps most important, a remarkable 87 percent of respondents have high motivation scores to address their challenges.
• And the punchline is that outcomes and costs are improved. For example, unnecessary neonatal intensive care unit use is declining because of improved treatment for pregnant women as a result of screenings.

ProMedica is embedding this screening tool in clinical workflows and in the electronic health care record, working with a data company partner. It intends to develop an evidence base for continuous evaluation, learning and innovation for its social determinants of health initiatives. 

Sound strategies

ProMedica’s journey teaches us how to turn noble concepts into actions. In particular, the system is addressing governance, advocacy, outreach and leadership opportunities:

Governance: The ProMedica board is composed of sophisticated business and community leaders in Toledo. They are supportive of the strategy and in many instances use their own institutions’ economic and civic advantage to advance initiatives that address social determinants. For example, KeyBank, a leading financial institution in Toledo, has partnered with ProMedica through grants and loans to advance the economic development agenda.

Advocacy: ProMedica and the AARP Foundation have founded a coalition to focus on social determinants. It is a nonprofit organization of 35 members that engages health professionals — from all disciplines and provider models, public health organizations, government officials, the nutrition and food industry, and other organizations — to develop and implement sustainable solutions to improve health and well-being. Its name, the Root Cause Coalition, demonstrates the effect of societal factors such as hunger, the need for safe and affordable housing, poor education, lack of transportation, and isolation on the health and well-being of individuals and communities.

Outreach: With ProMedica’s many touch points in the community, including physicians, the system is “meeting people in their lives” to improve their health. Part of the strategy is to destigmatize receiving assistance — even middle class people can have trouble with food security, behavioral issues or employment.

Leadership commitment: Oostra (pictured) is a strong leader who is passionate about social determinants and sees addressing them not as a sideline but as a key strategic imperative. As he told me: “This isn’t a dabble thing.”

Well said. We will watch your progress with interest and deep appreciation for leading the way.

Ian Morrison, Ph.D. (contact@ianmorrison.com), is an author, consultant and futurist based in Menlo Park, Calif.