Can Hospitals and Clinics Spread Social Health Integration Faster and Better? Results of an 18-Month Collaborative Says They Can.

When it comes to addressing the social determinants of health in our healthcare system, no one can argue that a lot has changed in the past five years. But even as little as two years ago, most of the healthcare’s efforts to address their patients’ essential resource needs consist of small, pilot programs with enormous potential, but little sustainability. That’s why my Health Leads colleagues and I set out to explore and understand how to both improve and spread these existing pilots – operationally and financially.

To say we learned a lot is an understatement. Two years later, we’ve reached the end of the Collaborative to Advance Social Health Integration (CASHI), a community of 21 innovative primary care teams and community partners across the country committed to increasing the number of people who have the essential resources they need to be healthy.

In many ways, this work is only beginning – but in reviewing our learnings and findings, launched today in this report, CASHI brought several key successes:

  • Teams dramatically accelerated quality improvement; 90% of teams tested and implemented changes in three or more areas key to social health integration like bolstering effective staffing, training, technology, and screening/assessment approaches.
  • By testing patient-reported outcome measures, we both explored new ways of measuring meaningful impact, and we generated evidence of a relationship between resource navigation and health confidence, and therefore health and health equity.
  • Collectively, 15 teams spread their social health approach to over 70 new clinics in just 18 months, demonstrating an unprecedented level of spread over a short time period.
  • Teams applied a practical framework to build a business case, demonstrating value with multiple lenses – not only cost reduction, but also areas like more appropriate use of primary care, increased new patient referrals from community partners, improved provider satisfaction and mission alignment. Rigorous cost analysis also pushed thinking on more efficient ways of operating to support sustainability and expansion.

But most importantly, the work undertaken by the participating health systems laid the foundation for critical practices to move beyond “addressing social needs” to supporting health equity more directly. Here are some of the most promising outcomes on that front:

More robust shared decision-making. Social health integration can only be done well if it is actively shaped by those served. Given the systemic inequities that exist in our society, designing solutions is not simple and assumptions cannot and should not be made. Those who face barriers to health must be engaged to define their priorities and develop solutions. Trusting relationships are critical, but building this level of trust takes significant time and investment. Over the course of CASHI, 70% of teams formalized approaches such as patient advisory councils to gather patient input. They are now better positioned to hear and act on the priorities of the actual “consumers” of their social health work.

Measures that require direct patient feedback. Rather than evaluating impact solely based on measures that matter to healthcare organizations, teams invested in measures that rely on direct feedback from patients (patient-reported outcome measures, or PROMs). Patients were asked about the degree to which they had the resources they needed to be healthy, and how confident they were that they could manage their health. In addition to contributing to a need to find better ways to measure this work, what I love about this is that care teams have reported this is driving better conversations with their patients. It is helping to build the caring relationships that are so important to health.

More integration of and sustainability for community health workers. CHWs, because of their high level of cultural competence and the level of trust they can build, are uniquely positioned to bridge between healthcare and the community to help people access what they need to be healthy. During CASHI, teams collected robust qualitative and quantitative data on how valued CHWs and navigators were. For example, one team’s results from patient focus groups made it clear that they wanted CHWs to assess their resource needs because of the time they could spend and how they spent this time. And when over 1.3K patients among CASHI teams were asked to rate their experience working with their CHW or navigator the average rating was a 9.7/10! The increasing value placed on these critical staff members allowed teams in CASHI to grow their CHW staff from a few, usually funded by short term grants, to many, more often salaried and with benefits paid for via operating funds.

Increase in place-based approaches grounded in cross-sector collaboration. While much of CASHI focused on ways to integrate social health into primary care, teams are now thinking more about how to integrate primary care into their communities. As one team noted, they are now working to avoid being a “gatekeeper” of social services. They are actively investing in their community partners’ capacity, including funding CBO staff and training. Teams are also participating in cross-sector collaboratives to address the gaps in the resource landscape we so often see, such as affordable housing, healthy food or employment opportunities.

Given all that these teams accomplished, CASHI is certainly a testament to the power of a supportive community of innovators in this work. Together we are working to change the systems that are contributing to poor and inequitable health. This is ridiculously hard work, but it is what’s required to truly move the needle on increasing the number of people whose essential resource needs are met, and who can, therefore, realize improved health. Teams in CASHI saw peers implement a range of innovations, from a “no wrong door” approach to building a cross-sector care coordination network, to integrating an empathic inquiry approach to assessing clients’ resource priorities, to developing a trauma-informed racial equity supervision toolkit, and seeing the range of possible approaches to making a business case for this work. This committed community of learners and do-ers helped individual teams be resilient and keep “fighting the fight” – a long one with the potential to make health more equitable in our country.

Download the Report

CASHI was made possible through the generous support and partnership from The Commonwealth Fund.