Bob Atlas Discusses “Ways That Purchasers and Providers Can Improve Upon Leveraging Patient Social Determinants of Health Information in Pursuit of the Triple Aim” in MCOL ThoughtLeadersMCOL ThoughtLeaders August/September 2017
Bob Atlas, a Strategic Advisor and President of EBG Advisors, Inc., in the firm’s Washington, DC, office, was featured in MCOL ThoughtLeaders and discussed the question: “What are some ways that purchasers and providers can improve upon leveraging patient social determinants of health information in pursuit of the triple aim?”
Following is an excerpt:
Managing population health costs over the long term and elevating health outcomes requires payers and providers alike to widen the lens to view the whole person. The medical model, even when viewed across the continuum – prevention, acute care, post-acute care and chronic care management – often ignores factors that can make or break health care interventions.
Suppose we’re given this information about two seemingly identical patients, John and James, both members of the same Medicare Advantage plan: 82 year old male admitted to acute hospital after fall at home resulting in hip fracture, transferred to skilled nursing facility for rehab, now ready to be discharged back to home. Now, add this information: John is a federal government retiree living with his wife in a continuing care retirement community where there is an on-site dining facility and a medical practice that offers outpatient physical therapy. James, who left school after seventh grade and never earned a pension, lives alone in a regular apartment building where the elevators often break down.
Absent recognition of social factors – family supports, literacy, nutrition and access to health care – we might expect John and James to receive the same plan of care and have the same outcomes. But when taking these factors into account, the health plan and the providers involved will see plainly that James needs a more holistic plan of care if he can hope to avoid downstream exacerbations that lead to recurrent acute care episodes and poorer health outcomes.
Now, multiply John and James by tens of thousands. To be successfully accountable for population health in the right way, health plans and providers must identify the social factors of each person for whom they are responsible and be prepared to act on that knowledge. Sometimes this will translate to enhancing services offered within the available revenue; at minimum it ought to entail connecting enrollees/patients to appropriate community resources.