Why this simple change could revolutionize primary care for the better

The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document.

By: Dr. David J. Priscal, Chief Medical Officer

Our healthcare system is sick. Patients suffer from chronic diseases that burden their quality of life, challenge providers’ impact and raise costs. Three of the most common chronic diseases for Medicare beneficiaries—heart disease, diabetes and arthritis—are also the most expensive for payers.

Our reactive rather than proactive approach to healthcare in America further exacerbates these problems. Medical and nursing schools haven’t taught our providers to think about the underlying causes of disease or the social determinants of health (SDoH) that impact a person’s health outcomes. When it comes to seeing patients day-to-day, many providers just try to get through the day, especially in the wake of a global pandemic.

On top of this, providers face more challenges to not only providing quality care but also keeping their practice afloat with increasing administrative burdens, falling payment rates, data and IT adoption and professional isolation as written about here. A staggering 40% of primary care providers are worried about the future of primary care and 21% expect to leave primary care practice in the next three years. All this even though primary care is the foundation of the healthcare system.

We need a new way of practicing medicine. The new ACO REACH model can help providers achieve better health outcomes for patients while also improving the practice and business of medicine. Here’s how.

Focus on SDoH

Many chronic diseases are caused and/or exacerbated by SDoH, which are environmental and lifestyle factors that affect how we live, work and play. Food insecurity, defined as not having access to sufficient or quality food, contributes to diabetes, while both food and housing insecurity, defined as not having stable or adequate living arrangements, contribute to cardiovascular disease. The more SDoH a patient faces, the higher the risk of exacerbating their chronic disease states. . If primary care providers don’t start integrating SDoH into their practice, they’ll never achieve the outcomes they want for their patients.

Let’s say a patient is struggling with skin lesions or ulcers. They’re taking their medication as prescribed, but the condition persists or worsens. If you don’t ask about food insecurity to find out if this patient can afford to buy protein-rich foods, you’ll never be able to truly treat the underlying cause of the condition.

Take chronic obstructive pulmonary disease (COPD) as another example. COPD can be triggered by changes in temperature. If a patient can’t keep their home at a certain temperature, whether that’s with air conditioning in the summer or heating in the winter, no amount of medicine or oxygen is going to permanently resolve the issue. Without addressing SDoH, providers and patients are trapped in a never-ending cycle of “Band-Aiding” their condition rather than resolving it.

Start with food insecurity, housing insecurity and transportation

There are numerous SDoH; however, I recommend providers start with three:

Food insecurity: as the old saying goes, we are what we eat. As providers, we need to make sure our patients have the reliable nutrition they need to get and stay healthy with the right level of vitamins, minerals and proteins.

Housing insecurity: providers need to ensure patients have reliable and safe housing. I’ve already mentioned how temperature can affect health. Pests, mold, lack of electricity or running water, broken appliances and more can negatively impact a patient’s health.

Transportation: Providers need to have patient transportation on their radar, especially when it comes to Medicare beneficiaries. As patients age, their worlds often become smaller due to changes in their vision, hearing and/or cognition. They may need rely on others and/or public transit more to complete basic errands like visiting the doctor or the pharmacy. If they don’t have reliable transportation, they may skip appointments or filling prescriptions they need.

Weave SDoH into care delivery

As I explained earlier, many providers aren’t taught about SDoH or how to integrate it into their clinical practice. At ilumed, we’ve spent decades developing the tools and resources to address SDoH even before there was a term for it.

We help providers take a multifactor approach to SDoH:

1.We help transform practices for the better.

2.We explain why SDoH remains important to providers and patients alike.

3.We integrate SDoH into care delivery through a Health Risk Assessment as part of our health data platform, BrainStream.

-With this tool, we can ask the necessary questions to find out if someone struggles with SDoH or if they are at risk for SDoH.

-So far, we’ve collected almost 6,000 patient assessments and we’ll be tracking these patients to confirm our thesis that addressing those underlying SDoH barriers leads to better outcomes.

4.Our beneficiary benefits include programs designed to mitigate SDoH, including:

-Transportation to and from doctor’s appointments and the pharmacy plus assistance with scheduling those appointments.

-A pilot food insecurity program that provides qualifying beneficiaries with two meals a day, seven days a week.

5.Our disease and case managers along with our concierge outreach team provides additional support to provider staff and patients, helping to connect them to the appropriate community resources and being a compassionate ear.

6.We ensure everything works together—the assessment, our data and analytics, the doctor, ilumed case managers, ilumed outreach staff—giving providers, their staff and their patients the essential wrap-around support they need to improve outcomes through proactive rather than reactive care.

SDoH: the future of healthcare

The Centers for Medicare & Medicaid Services see the value of tracking SDoH, which is why tracking SDoH data is required for ACO REACH organizations and providers. They’ve seen how this approach can make a difference at the individual level and want to help scale this approach.

I’m glad SDoH is getting the light of day within the government. That’s the first step. Our second step is proving better outcomes with data, and we’re on the right path for that. The third step will be standardizing education about SDoH in medical schools nationwide. I firmly believe that by making these changes today, we’ll see radically improved patient outcomes two or three decades from now.

Imagine a world without food or housing insecurity, where patients don’t have to choose between paying their utilities or filling their prescriptions, where getting to and from the doctor is as simple as making a phone call. That’s the world ilumed works day in and day out to build. I hope you’ll join us.

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