A parable used in public health goes, if there is a group of people who’ve fallen into a river that need saving, the traditional treatment method would be to rescue them from drowning downstream. However, going upstream to find the cause of why these people were falling into the river in the first place would follow the preventative method.
The story is used to illustrate how addressing social determinants of health (SDOH) and preventing people from getting sick can be a more effective strategy than simply treating them afterward.
Recently, this idea has been thrust into focus as the coronavirus continues to impact virtually every aspect of life. In fact, during the pandemic, Black, Native American Indian, and Latinx communities faced the highest rates of severe illness, according to the CDC. Socioeconomic status also played a role in risk factors. A study by the Kaiser Family Foundation found that adults at risk of serious illness if infected with the virus was highest among those with a household income of less than $15,000 a year.
“COVID-19 has shed a light on disparities in general, especially racial disparities,” Rene Cabral-Daniels, the CEO of Cenevia, told MobiHealthNews. “I do think that if we’re going to be serious, if we’re really going to make a difference, we’ve got to be impactful and meaningful in terms of anything we do with social determinants of health.”
The government’s health initiative known as Healthy People 2020 lists factors like economic stability, education, social and community context, healthcare, and environment as key areas of SDOH.
The idea that these determinants affect people’s health outcomes predates COVID-19. One of the earliest studies on the issue took place over a century ago and examined the relationship between housing, nutrition and economic level during pregnancy and infant mortality.
However, despite the fact that genetics and clinical care amount to only 30% of a person’s overall health, a survey from Welltok found that people overestimate the role that it plays in their health, believing that it accounts for 49% of how healthy they are.
Knowing that social factors can play a major role in a population’s health, many organizations have been trying to address SDOH for years.
Most programs are created to help their communities reach a place of health equity, which is defined by the CDC as “when everyone has the opportunity to ‘attain their full health potential’ and no one is ‘disadvantaged from achieving this potential because of their social position or other socially determined circumstance.’”
Despite the effort, health disparities do exist, and one of the biggest disparities comes from racial and ethnic differences.
In the U.S., health disparities related to race take on many forms, including higher rates of chronic disease and premature death compared to whites.
In 2010, African Americans were 30% more likely to die prematurely from heart disease, and African American men were twice as likely to die prematurely from stroke compared to their white counterparts, according to the National Center for Biotechnology Information.
In 2017, American Indian and Alaska Native adults were almost three times more likely to have diabetes than non-Hispanic white adults. They were also 2.5 times more likely to die from diabetes, according to the U.S. Department of Health and Human Services Office of Minority Health.
In 2018, Hispanic Americans were 1.2 times more likely to be obese than non-Hispanic whites, according to the OMH.
Organizations addressing SDOH pre-pandemic
One such company that has been focusing on SDOH is NowPow, a community-based organization-referral company.
“Our approach is a whole-person approach,” Dr. Stacy Lindau, the founder of NowPow, told MobiHealthNews. “We’ve developed a technology solution that envisions that all people do better if we are all connected to the resources of our communities. Our solution recognizes that most of health happens outside the doctor’s office. It happens outside the four walls of the hospital or the medical center.”
NowPow’s platform works by connecting health systems, health providers and health plans to community resources in their area that they can refer to patients.
With over 200 different types of services available on its platform, NowPow can address a variety of needs, according to Rachel Kohler, the CEO of NowPow.
“The biggest need, usually, across our customers, is food,” she said. “We’re also moving into areas that support social isolation, a lot of cancer support groups [and] any services related to diabetes or hypertension, depression. We have a large mental health set of services in our taxonomies. But then, we also support unemployment services, whether it’s job training or job-search assistance.”
ChristianaCare has a similar platform for connecting people with resources in their community. The system gathers data on a patient and can then recommend them to a service targeted specifically to their needs, according to Dr. Janice Nevin, the president and CEO of ChristianaCare.
“We have a data platform that gets real-time data that then uses AI [artificial intelligence] and ML [machine learning] to create that patient story,” Nevin said during the 2019 Annual Thought Leadership on Access Symposium. “It feeds to a data analytics engine, and we have risk-score set so we can decide what level of risk you want to set. So, in real-time, our virtual care team is getting information from our patients.”
The health system has connected its patients to a wide variety of services, including those of behavioral health specialists, nutritionists, diabetes managers and social workers.
“We even had loneliness counselors; we had volunteers come and talk to people who are lonely,” Nevin said.
The impact of COVID-19 on health disparities
During the pandemic, these disparities were only made more apparent.
“Long-standing systemic health and social inequities have put some members of racial and ethnic minority groups at increased risk of getting COVID-19 or experiencing severe illness, regardless of age,” the CDC said on its website.
As of June 12, the age-adjusted hospitalization rates were highest among non-Hispanic American Indian or Alaska Native and non-Hispanic black persons and followed by Hispanic or Latino persons, the CDC reported.
In the age of COVID-19, NowPow had to adjust its services for customers located in the heart of the pandemic. Some of its largest networks were in New York, New Jersey and Illinois.
“We were in the thick of it, and we immediately, because we’re supporting these larger organizations, understood the magnitude of what was happening,” Kohler said.
As a result, NowPow began integrating “COVID status tags” in the platform to keep users up to date on what was opening and in what capacity.
“As you can imagine, that’s a huge challenge because what’s open and operating is changing daily,” Lindau said. “It is hard to know, even if you’re a knowledgeable person in your own community what’s open and operating.”
The company also created a rapid sign-on system where a link could be sent out by text to a potential user to immediately get them registered on the platform.
Through its rapid resource verification process, emergency services that were popping up in the areas covered by NowPow could also get added to the registry.
“NowPow has made it our business to know more than 65,000 community and emergency-relief services which are open and operating,” Lindau said. “So when we send people to places – people who have a real need and who find it hard to get to places under the current circumstances – those [services] are there to help them.”
Other companies, like Unite Us, which was featured in a recent HIMSS20 Digital session, have also been addressing SDOH during the pandemic.
“What COVID-19 put a big magnifying glass on is our lack of public health infrastructure," Taylor Justice, cofounder and president of Unite Us, said during the session. "I think cities and states, once they started to transition away from just a pure clinical response, started to realize, with the increased unemployment numbers, there's this unprecedented stress about to hit their human and social service systems."
That stress comes from low-income families who rely on those services to meet their basic needs, according to a report from Johns Hopkins.
When many of those people lost their jobs and were forced to stay home in often overcrowded living situations, it only created “more ideal conditions for transmission than might otherwise exist,” the report said.
However, when many social service centers closed due to the pandemic, the needs of those who rely on them became unmet.
To help its local organizations address those unmet needs, Unite Us plans to double its nearly 200-person team by the end of the year.
"City governments and state governments are looking for solutions, looking for answers, and historically their knee-jerk reaction during COVID-19 hasn't been human and social services," Justice said. "But I think we've been pretty successful at having their ear, giving them a game plan of how we can implement our solutions, and that we've done this before. This isn't a brand-new concept that we're bringing to them and saying, 'Hey, we think we can execute.' We're saying 'No, we know we can execute. Here are the KPIs, here's when we are going live.'"
Cenevia is an organization based in Virginia that provides integrated, network-based services and programs to healthcare clients. Many of the clients that it serves are in rural areas and don’t have access to the same kinds of community services that urban organizations do, according to Cabral-Daniels.
In one health facility that Cenevia works with, five employees were diagnosed with COVID-19, which caused it to stop operating.
“It’s not just that a center was affected. The entire community was affected,” Cabral-Daniels said.
In response to these times, many organizations are turning to technology to help address the needs of their communities.
“The best tool to integrate health and social needs is health IT,” Cabral-Daniels said. “I think that is like the magic wand that could bring these two together in a way that would seriously lower healthcare costs. That has potential like no other action or activity that I’ve seen.”
NowPow was also able to use its technology during the pandemic to increase its reach into communities.
“We’ve given out tens of thousands of referrals in this time period. We actually had a three-fold increase of care professionals coming on to technologies,” Kohler said. “This idea of quickly extending care across a community during a time of crisis has really been profound in terms of demonstrating the need for this kind of solution, and we feel it’s not just going to be just this moment in time, but it will be something that extends beyond the crisis.”
Tackling health disparities post-pandemic
As people begin to look past the pandemic, the need to change the way the U.S. treats healthcare has become evident.
Cabral-Daniels called on the government to put more money into social issues.
“It will have a ripple effect and have a positive effect on healthcare,” she said. “Then we can just take care of people who really need tertiary care.”
If passed, the bill would help set up grants from the Centers for Medicare and Medicaid Services, increase coordination between health and social service programs, and set up program-evaluation criteria.
“The Federal Government should prioritize and proactively assist State and local governments to strengthen the capacity of State and local governments to improve health and social outcomes for individuals, thereby improving cost-effectiveness and return on investment,” the bill says.
The bill was introduced in July 2019, but has yet to make it past the House or Senate.
NowPow has also begun working on creating lasting change after the pandemic and following the recent protests regarding police brutality and systemic racism in the U.S.
In an effort to show policymakers how community-based organizations improve individuals' health and well-being, it has been compiling data on the outcomes of the platform.
“One of the things that we had started working on before these two crises, and which we think is now even more important, is this idea of creating evidence to have policymakers understand that they need to increase money spent on community resources or reimburse for them,” Kohler said.
By doing so, the NowPow team hopes to make lasting change on two fronts.
“These two back-to-back crises have really validated the work that we’re doing in a way that I think we could have never imagined,’ Kohler said. “They have laid the groundwork for this to be ongoing work in our communities.”