The implementation cost of a safety-net hospital program addressing social needs in Atlanta

Characteristics of hospital and health system initiatives to address social determinants of health in the United States: a scoping review of the peer-reviewed literature

Background

Despite the incentives and provisions created for hospitals by the US Affordable Care Act related to value-based payment and community health needs assessments, concerns remain regarding the adequacy and distribution of hospital efforts to address SDOH. This scoping review of the peer-reviewed literature identifies the key characteristics of hospital/health system initiatives to address SDOH in the US, to gain insight into the progress and gaps.

Methods

PRISMA-ScR criteria were used to inform a scoping review of the literature. The article search was guided by an integrated framework of Healthy People SDOH domains and industry recommended SDOH types for hospitals. Three academic databases were searched for eligible articles from 1 January 2018 to 30 June 2023. Database searches yielded 3,027 articles, of which 70 peer-reviewed articles met the eligibility criteria for the review.

Results

Most articles (73%) were published during or after 2020 and 37% were based in Northeast US. More initiatives were undertaken by academic health centers (34%) compared to safety-net facilities (16%). Most (79%) were research initiatives, including clinical trials (40%). Only 34% of all initiatives used the EHR to collect SDOH data. Most initiatives (73%) addressed two or more types of SDOH, e.g., food and housing. A majority (74%) were downstream initiatives to address individual health-related social needs (HRSNs). Only 9% were upstream efforts to address community-level structural SDOH, e.g., housing investments. Most initiatives (74%) involved hot spotting to target HRSNs of high-risk patients, while 26% relied on screening and referral. Most initiatives (60%) relied on internal capacity vs. community partnerships (4%). Health disparities received limited attention (11%). Challenges included implementation issues and limited evidence on the systemic impact and cost savings from interventions.

Conclusion

Hospital/health system initiatives have predominantly taken the form of downstream initiatives to address HRSNs through hot-spotting or screening-and-referral. The emphasis on clinical trials coupled with lower use of EHR to collect SDOH data, limits transferability to safety-net facilities. Policymakers must create incentives for hospitals to invest in integrating SDOH data into EHR systems and harnessing community partnerships to address SDOH. Future research is needed on the systemic impact of hospital initiatives to address SDOH.

Resilience and Value: Pediatric Trauma Care in Safety Net Hospitals

Background: In the setting of limited funding and high expectations for quality care, safety net hospitals play a crucial role in treating pediatric trauma patients. This study aimed to compare outcomes and hospitalization costs of pediatric trauma patients in safety net hospitals across the United States. Methods: The Nationwide Readmissions Database for 2016-2020 was queried for all patients under the age of 18 years hospitalized for traumatic injury. Patients admitted to safety net hospitals were propensity matched 1:1 to all other patients. The primary outcome was mortality. The secondary outcomes were readmission within 1-year, mean length of stay (LOS), total charges, and total hospitalization costs including readmissions. Results: There were 176,325 patients meeting inclusion criteria, and 30,869 were admitted to safety net hospitals. All safety net patients were successfully matched across predictors, and 61,738 patients were included. The overall mortality rate was 1.4% (n = 834), and the mortality risk was similar in safety net hospitals (OR 1.11 [.96-1.27] P = .15). The overall readmission rate, mean LOS, and mean total cost were similar for safety net hospitals when compared to all hospitals. However, the overall mean total charge was $78,724 (±$224,884) and was lower in safety net hospitals ($76,575 [±$198,342], P = .02). Discussion: Safety net hospitals deliver comparable outcomes as other health care facilities when caring for pediatric trauma patients. Notably, these hospitals appear to undercharge for their services, despite incurring similar costs in the process. These results shed light on the resilience of safety net hospitals in delivering quality and cost-effective care.

A National Approach to Promoting Health Equity in Cardiovascular Disease Prevention: Implementation Science Strengths, Opportunities, and a Changing Chronic Disease Context

In the USA, structural racism contributes to higher rates of cardiovascular disease (CVD) including hypertension, heart disease, and stroke among African American persons. Evidence-based interventions (EBIs), which include programs, policies, and practices, can help mitigate health inequities, but have historically been underutilized or misapplied among communities experiencing discrimination and exclusion. This commentary on the special issue of Prevention Science, "Advancing the Adaptability of Chronic Disease Prevention and Management Through Implementation Science," describes the Centers for Disease Control and Prevention, Division for Heart Disease and Stroke Prevention's (DHDSP's) efforts to support implementation practice and highlights several studies in the issue that align with DHDSP's methods and mission. This work includes EBI identification, scale, and spread as well as health services and policy research. We conclude that implementation practice to enhance CVD health equity will require greater coordination with diverse implementation science partners as well as continued innovation and capacity building to ensure meaningful community engagement throughout EBI development, translation, dissemination, and implementation.

Remote Monitoring for Heart Failure Management at Home

Early telemonitoring of weights and symptoms did not decrease heart failure hospitalizations but helped identify steps toward effective monitoring programs. A signal that is accurate and actionable with response kinetics for early re-assessment is required for the treatment of patients at high risk, while signal specifications differ for surveillance of low-risk patients. Tracking of congestion with cardiac filling pressures or lung water content has shown most impact to decrease hospitalizations, while multiparameter scores from implanted rhythm devices have identified patients at increased risk. Algorithms require better personalization of signal thresholds and interventions. The COVID-19 epidemic accelerated transition to remote care away from clinics, preparing for new digital health care platforms to accommodate multiple technologies and empower patients. Addressing inequities will require bridging the digital divide and the deep gap in access to HF care teams, who will not be replaced by technology but by care teams who can embrace it.

COMPASS II—Coordination of Medical Professions Aiming at Sustainable Support Protocol for a feasibility study of cooperation between general practitioner practices and community care points

Introduction

General practitioners (GP) increasingly face the challenge of meeting the complex care needs of multi-morbid patients. Previous studies show that GP practices would like support from other institutions in advising on social aspects of care for multi-morbid patients. Already existing counselling services, like community care points, are not sufficiently known by both GPs and patients. The aim of COMPASS II is to investigate the feasibility of cooperation between GP practices and community care points.

Methods and analysis

During the intervention, GPs send eligible multi-morbid patients with social care needs to a community care point. The community care points report the consultation results back to the GPs. In preparation for the intervention, in a moderated process, GP practices meet with the community care points to agree on information exchange. The primary outcome is the feasibility of the cooperation: Questionnaires will be sent to GPs, medical practice assistances and community care point personnel (focus: practicality, acceptability). Data will be collected on frequency and reasons for GP-initiated consultations at community care points (focus: demand). Qualitative interviews will be conducted with all participating groups (focus: acceptability, satisfaction). The secondary outcome is the assessment of changes in health-related quality of life, social support and satisfaction with care: participating patients complete a questionnaire before and three to six months after their counselling. The results of the study will be incorporated into a manual in which the experiences of the cooperation will be made available to other GP practices and community care points.

Discussion

In COMPASS II, GP practices establish cooperation with community care points. The latter are already existing institutions that provide independent and free advice on social matters. By using an existing institution, the established cooperation and experiences from the study can be used beyond the end of the study.

Trial registration

The trial is registered with DRKS-ID: DRKS00023798, Coordination of Medical Professions Aiming at Sustainable Support II.

Global developments in social prescribing

Social prescribing is an approach that aims to improve health and well-being. It connects individuals to non-clinical services and supports that address social needs, such as those related to loneliness, housing instability and mental health. At the person level, social prescribing can give individuals the knowledge, skills, motivation and confidence to manage their own health and well-being. At the society level, it can facilitate greater collaboration across health, social, and community sectors to promote integrated care and move beyond the traditional biomedical model of health. While the term social prescribing was first popularised in the UK, this practice has become more prevalent and widely publicised internationally over the last decade. This paper aims to illuminate the ways social prescribing has been conceptualised and implemented across 17 countries in Europe, Asia, Australia and North America. We draw from the 'Beyond the Building Blocks' framework to describe the essential inputs for adopting social prescribing into policy and practice, related to service delivery; social determinants and household production of health; workforce; leadership and governance; financing, community organisations and societal partnerships; health technology; and information, learning and accountability. Cross-cutting lessons can inform country and regional efforts to tailor social prescribing models to best support local needs.

The implementation cost of a safety-net hospital program addressing social needs in Atlanta

OBJECTIVE

To describe the cost of integrating social needs activities into a health care program that works toward health equity by addressing socioeconomic barriers.

DATA SOURCES/STUDY SETTING

Costs for a heart failure health care program based in a safety-net hospital were reported by program staff for the program year May 2018-April 2019. Additional data sources included hospital records, invoices, and staff survey.

STUDY DESIGN

We conducted a retrospective, cross-sectional, case study of a program that includes health education, outpatient care, financial counseling and free medication; transportation and home services for those most in need; and connections to other social services. Program costs were summarized overall and for mutually exclusive categories: health care program (fixed and variable) and social needs activities.

DATA COLLECTION

Program cost data were collected using a activity-based, micro-costing approach. In addition, we conducted a survey that was completed by key staff to understand time allocation.

PRINCIPAL FINDINGS

Program costs were approximately $1.33 million, and the annual per patient cost was $1455. Thirty percent of the program costs was for social needs activities: 18% for 30-day supply of medications and addressing socioeconomic barriers to medication adherence, 18% for mobile health services (outpatient home visits), 53% for navigating services through a financial counselor and community health worker, and 12% for transportation to visits and addressing transportation barriers. Most of the program costs were for personnel: 92% of the health care program fixed, 95% of the health care program variable, and 78% of social needs activities.

DISCUSSION

Historically, social and health care services are funded by different systems and have not been integrated. We estimate the cost of implementing social needs activities into a health care program. This work can inform implementation for hospitals attempting to address social determinants of health and social needs in their patient population.