Episode 12 of “The THCB Gang” was live-streamed on Friday, June 5th from 1PM PT to 4PM ET. If you didn’t have a chance to tune in, you can watch it below or on our YouTube Channel.

Editor-in-Chief, Zoya Khan (@zoyak1594), ran the show! She spoke to economist Jane Sarasohn-Kahn (@healthythinker), executive & mentor Andre Blackman (@mindofandre), writer Kim Bellard (@kimbbellard), MD-turned entrepreneur Jean-Luc Neptune (@jeanlucneptune), and patient advocate Grace Cordovano (@GraceCordovano). The conversation focused on health disparities seen in POC communities across the nation and ideas on how the system can make impactful changes across the industry, starting with executive leadership and new hires. It was an informative and action-oriented conversation packed with bursts of great facts and figures.

If you’d rather listen, the “audio only” version it is preserved as a weekly podcast available on our iTunes & Spotify channels a day or so after the episode — Matthew Holt

By ALYA AHMAD, MD

Call it what you want, white privilege and health disparity appear to be two sides of the same coin. We used to consider ethnic or genetic variants as risk factors, prognostic to health conditions. However, the social determinants of health (SDOH) have increasingly become more relevant as causes of disease prevalence and complexity in health care.

As a pediatric hospitalist in the San Joaquin Valley region, I encounter these social determinants daily. They were particularly evident as I treated a 12-year old Hispanic boy who was admitted with a ruptured appendix and developed a complicated abscess, requiring an extensive hospitalization due to his complication. Why? Did he have the genetic propensity for this adverse outcome? Was it because he was non-compliant with his antibiotic regimen? No.

Rather, circumstances due to his social context presented major hurdles to his care. He had trouble getting to a hospital or clinic. He did not want to burden his parents—migrant workers with erratic long hours—further delaying his evaluation. And his Spanish-speaking mother never wondered why, despite surgery and drainage, he was not healing per the usual expectation.

When he was first hospitalized, his mother bounced around in silent desperation from their rural clinic to the emergency room more than 20 miles from their home and back to the clinic, only to be referred again to that same emergency room. By the time he was admitted 2 days later, he was profoundly ill. The surgeon had to be called in the middle of the night for an emergency open surgical appendectomy and drainage. Even after post-operative care, while he was on broad-spectrum intravenous antibiotics, his fevers, chills and pain persisted. To avoid worrying his mother, he continued to deny his symptoms. Five days after his operation, he required another procedure for complex abscess drainage.

In a 2007 study published in The New England Journal of Medicine, “We Can Do Better—Improving the Health of the American People,” Steven Schroeder describes the proportional contributors to premature death. Behavioral patterns & social circumstances dominate:

More recently, there appears to be a paradigm shift in how access to care and health care systems are viewed. As Schroeder demonstrated, health care delivery plays a relatively minor role in its impact on premature death. What governs the individual behavior of patients are the SDOH, which are a product of:

1. Barriers to appropriate health care
2. Economic instability
3. Unsafe environment
4. Poor health literacy and education
5. Limited social and community support
6. Food scarcity
7. Social discrimination and language barriers

These are just a few of the factors that contribute to challenges in patient care and health inequities. Interestingly enough, genetics actually plays a relatively minimal risk factor for disease conditions & diagnosis. We cannot just say that Black people have a greater risk of heart disease, diabetes, hypertension, etc. We need to ascertain the social context of our diverse populations in order to address the incidences of chronic disease and its effects. The issue cannot simply be blamed on the genetics of the immigrant, the refugee, the homeless, or impoverished populations that lead to greater morbidity and mortality.

As a pediatrician practicing in the Central Valley, I see the consequence of social complexity in pediatric care delivery every day. In a recent 2017 report by the Center for Regional Change and Pan Valley Institute, California San Joaquin Valley, children in the area are “living under stress.” They are not only born under duress but face lifelong barriers to better physical and mental health. The occurrence of child poverty levels in counties of the San Joaquin Valley (SJV) are profound. The graph below shows poverty levels of 28% to 38% in the valley:  

Additionally, California has a large Gross Domestic Product in terms of agriculture production in the country. When you break it down by county, crop value in the valley ranks high. Yet, the valley with the largest crop production also paradoxically has the highest child poverty in the state. Even with economic stability, poverty remains rampant in the central valley.  The rates of concentrated poverty, where more than 30% of the population are below the Federal Poverty Level (FPL), are greatest in SJV areas and are increasing over time:

Percentage of children under 18 living in areas of concentrated poverty

Furthermore, poverty rates are highest among children of color. The ethnic gap in poverty is 10-35%.

Percentage of San Joaquin Valley Children under 6 in Poverty, by Race/Ethnicity

Despite the economic potential, health care access and resources also operate at crisis levels. Rural communities with geographic obstacles face shortages in provider availability and health care systems. The same fertile communities of SJV, producing the food source of the nation, ironically have the largest limitations of access to food. Food scarcity, where food and especially healthy food is either limited or uncertain, remains above 26 to 29% when compared to a food shortage for the whole of California, which is at 23%. 

Estimated Percentage of Children under 18 living in Households with Limited or Uncertain Access to Adequate Food, 2014

The overall pollution burden, which represents the potential exposures to pollutants and adverse environmental conditions caused by pollutants, is greater than 8 to 10% in the Valley. Not surprisingly, asthma and lung diseases in SJV districts are highest in central California.  

Percentage of children diagnosed with asthma

Scientific literature now highlights Adverse Childhood Experience (ACE) in which the number of exposures of toxic stress and trauma: child abuse, neglect, domestic violence, parental drug/ alcohol exposure, incarceration, separation, and or stress, is scored.  The greater number of ACE’s, the greater degree of maladaptive physiological, neuro-architectural, immunological, and epigenetic effects on the fetal and developing children. The effect of ACE’s on mental health and chronic medical conditions, (asthma, diabetes, cancer, heart disease, obesity, etc.) correlates exponentially with the number of ACE exposures. Such that, if a child has more than 4 ACE exposures, the risk of developing COPD (Chronic Obstructive Pulmonary disease) as an adult increased by 260%; for depression, it increased by 460%. In California, the prevalence of the number of ACEs with 2 or more toxic level stress exposures early in the child’s life is at 16.7%. Per kidsdata.org, a Population Reference Bureau, analysis of data from the National Survey of Children’s Health and the American Community Survey (Mar. 2018) the incidence of parent-reported ACE scores >2 for the SJV counties is even higher: Fresno, Tulare, Madera, and Merced cities range from 17.9 to 19.3% of the population. Such that 1 out of 5 children are exposed to toxic level stress.  The consequences of that same child becoming an adult with a chronic medical and or mental condition cannot be discounted.

Health vulnerabilities in the valley are extreme and burden the limited health care systems servicing the community in SJV. The current California governor’s administration has acknowledged this fact.  Support to implement and maintain medical education and training programs with retention of providers in SJV is necessary. Specific funding allotments for improving mental health, air quality, homelessness among many other SDoH’s in the region is vital. 

Dr. Nadine Burke-Harris, California’s first female Surgeon General, who recently visited the Valley, announced an ACEs Aware campaign. The ACEs Aware initiative is a first-in-the-nation statewide effort to screen for childhood trauma and treats the impact of toxic stress. The bold goal of this state-wide initiative is to reduce Adverse Childhood Experiences and toxic stress by half in a single generation . and to launch a national movement to ensure everyone is ACEs Aware. ACEs Aware is not only a complete program with training and readily available tools to implement screening, it is also a fully reimbursed program in a preventative pediatric care setting.  

Starting early, as pediatricians, we can identify kids exposed to ACEs through routine screenings and establish prevention programs in health care, schools and youth-serving organizations. In their critical and early developmental stages, resource allocation of health services can be provided. It is also imperative to know and stay engaged with our region’s leaders, telling our stories in health care, enlist our community partners, schools, regulatory agencies, and empower our patients and families to advocate for social and health equity.

Alya Ahmad MD FAAP is a pediatric hospitalist who has worked in both private and academic centers as a professor and faculty and blogs at The Context of Care.

By KIM BELLARD

We’ve been spending a lot of time these past few years debating healthcare reform.  First the Affordable Care Act was debated, passed, implemented, and almost continuously litigated since.  Lately the concept of Medicare For All, or variations on it, has been the hot policy debate.  Other smaller but still important issues like high prescription drug prices or surprise billing have also received significant attention.

As worthy as these all are, a new study suggests that focusing on them may be missing the point.  If we’re not addressing wealth disparities, we’re unlikely to address health disparities.  

It has been well documented that there are considerable health disparities in the U.S., attributable to socioeconomic status, race/ethnicity, gender, even geography, among other factors.  Few would deny that they exist.  Many policy experts and politicians seem to believe that if we could simply increase health insurance coverage, we could go a long way to addressing these disparities, since coverage should reduce financial burdens that may be serving as barriers to care that may be contributing to them.

Universal coverage may well be a good goal for many reasons, but we should temper our expectations about what it might achieve in terms of leveling the health playing field.

The new study, by Paola Zaninotto, PhD, et. alia, in The Journals of Gerontology “examined socioeconomic inequalities in disability-free life expectancy.”  It compared cohorts from England and the U.S., looking not just at life expectancy but also how healthy those lives were, as measured by presence of disability — the “disability-free” life expectancy.  Long study short:

people in the poorest group could expect to live seven to nine fewer years without disability than those in the richest group at the age of 50.  

The study looked at men versus women, at different ages, by disability level and wealth status.  Most importantly, it compared results for those in England versus the U.S.  The authors found that: “we showed that within each country, there was a consistent advantage for people in high socioeconomic groups, particularly for wealth and education, so that they could expect to live a higher number of years without disability.”  

Dr. Zaninotto told Yahoo: 

We were not surprised.  In fact, the reason for looking at wealth and not income is that we know how important a socioeconomic indicator it is. This measure of wealth is based on housing, savings, investments — something that takes a long time to accumulate. It’s a measure of past and present circumstances.

Still, when it came to the similarities between the two countries, Dr. Zaninotto admitted: “It was surprising to find that the inequalities are exactly the same.”  

It was surprising because, unlike the U.S., England does have universal coverage.  The National Health Service provides access to care to everyone, without financial burdens.  There may (or may not) be access issues with the NHS, but they are not, for the most part, financially-driven.  And yet the differences of the impact of wealth on health between the two countries are similar.

One could speculate that the wealthy in England are somehow buying their way into better care — perhaps jetting off to Switzerland or even the U.S. — but that is unlikely to account for those seven to nine extra years of disability-free life they are getting.  

It’s about the money.  

There has been much furor about the obesity crisis in the U.S., with the childhood obesity crisis presenting a ticking time bomb for future health care problems.  Same for diabetes.  But what we’re not paying enough attention to is that a wealth crisis is looming for younger people as well, which the new findings suggest will result in major health implications.  

Economist Gary Kimbrough has been studying the upcoming wealth gap, with some alarming results:

Millennials are way poorer than previous generations at their age, burdened by student debt and stagnant wages.  Christopher Ingraham, writing in the Washington Post, warns:

It’s a hole they’ll never truly be able to dig out of, given the way that money draws other money to itself via the gravitational pull of compound interest: The less money you start out with, the less you’ll make during the rest of your life.

 Some argue that it will all be OK, they’ll eventually inherit significant wealth from their parents –“the Great Wealth Transfer” — but that assumes that those parents won’t end up spending that inheritance on their own health care and other financial needs. 

Equally as worrisome, it ignores the adverse health impacts that the reduced wealth is already having on their health.  Lack of wealth is not the only hole that you may never be able to dig out of; poor health is at least as hard.  

Dr. Zaninotto thinks the results should be a call to action, telling Yahoo: 

We really think this inequality should be addressed much earlier in life.  When people are older, you can’t give them an education — it really should start much earlier in life. It’s looking at improving opportunities across community and education much earlier and trying to help younger people to buy a house. It seems it is quite important.  

The U.S. could, and should, move to universal coverage.  It is the right thing to do.  We could, and should, find ways to lower costs, both for coverage and for care.  It is the right thing to do.  But we shouldn’t expect that those actions would level the unequal playing field that wealth creates.  

We need to address affordable housing.  We need to reduce student debt burdens.  We need to ensure people are paid living wages.  We need to provide parents with affordable child care options, such as  day care, preschool, after-school programs.  

Arguably, these are more important than universal coverage, or at least their long-term impacts on health will be greater.  

We can’t, and shouldn’t, try to equalize wealth.  That’s not what America is about, and not what most Americans want.  But there are some aspects of life where wealth should make less of a difference.  It shouldn’t dictate opportunity, and, as these findings suggest it does, it shouldn’t determine health.  

Kim Bellard is editor of Tincture and thoughtfully challenges the status quo, with a constant focus on what would be best for people’s health.

By PHUOC LE, MD, CONNIE CHAN, and BROOKE WARREN

I recently took care of Rosaria[1], a cheerful 60-year-old woman who came in for chronic joint pain. She grew up in rural Mexico, but came to the US thirty years ago to work in the strawberry fields of California. After examining her, I recommended a few blood tests and x-rays as next steps. “Lo siento pero no voy a tener seguro hasta el primavera — Sorry but I won’t have insurance again until the Spring.” Rosaria, who is a seasonal farmworker, told me she only gets access to health care during the strawberry season. Her medical care will have to wait, and in the meantime, her joints continue to deteriorate.

Migrant and seasonal agricultural workers (MSAW) are people who work “temporarily or seasonally in farm fields, orchards, canneries, plant nurseries, fish/seafood packing plants, and more.”[2] MSAW are more than temporary laborers, though— they are individuals and families who have time and time again helped the US in its greatest time of need. During WWI, Congress passed the Immigration and Nationality Act of 1917^[3] because of the extreme shortage of US workers. This allowed farmers to bring about 73,000 Mexican workers into the US. During WWII, the US once again called upon Mexican laborers to fill the vacancies in the US workforce under the Bracero Program in 1943. Over the 23 years the Bracero Program was in place, the US employed 4.6 million Mexican laborers. Despite the US being indebted to the Mexican laborers, who helped the economy from collapsing in the gravest of times, the US deported 400,000 Mexican immigrants and Mexican-American citizens during the Great Depression.

Today, there are about who live and work throughout the US, providing crucial labor for the US economy. Unfortunately, as with other exploited minority communities, MSAW have had to withstand from the effects of structural determinants which have ultimately led to poor health outcomes. In fact, 11.4% of MSAW infants versus 8.9% of non-MSAW infants are found to have perinatal medical conditions. This means MSAW infants are almost 30x more likely to experience perinatal medical conditions.

At the forefront of these structural determinants that determine health and wellness is economic stability. The average annual income of MSAW is between $15,000 to $17,499 per person and $20,000 to $24,99 per family. Workers are not paid per hour like many temporary jobs. Instead, they are “… often paid by the bucket; in some states they earn as little as 40 cents for a bucket of tomatoes or sweet potatoes.”[4] To earn $50, farmworkers need to pick about two tons of produce.

How can we tell patients to make their health a first priority when they are doing painstaking work that does not allow them to attain enough economic stability to provide for themselves and their families?

Although their livelihoods are dependent on the cultivation of food, many farmworkers, ironically, are food insecure. The reality that 59% of Indigenous farmworkers in Ventura, CA who said they did not have enough food for their families should give us pause.

Another structural determinant of health is dangerous work conditions. For example, pesticide drift exposure is hazardous for MSAW and their families. The relationship between exposure to pesticides on health outcomes in agricultural communities has been the focus of the Center for the Health Assessment of Mothers and Children of Salinas study, a longitudinal cohort study run by the UC Berkeley School of Public Health.^[5]  The CHAMACOS found that “mothers who lived in close proximity to agricultural operations using the highest percentage of pesticides – the top 1 percent – had an 11 percent increased probability of preterm delivery and a 20 percent increased probability of having a low birthweight baby.”[6] The CHAMACOS study also found that living near farms is associated with respiratory problems in children. The youth who live in Salinas Valley’s agricultural community (a half-mile or less from pesticide application) have “…reduced lung function, more asthma-related symptoms, and higher asthma medication use…”[7] compared to unexposed children. This was found to be the direct result of organic farms using elemental sulfur to control fungal growth of crops and pests.^[8]

Finally, access to healthcare is severely lacking for MSAW. . Twenty-two percent of farmworkers have an H2A visa (47% are unauthorized, 31% are US citizens)^[9]Employers are not required to provide health insurance under the ACA for H2A because of their temporary status. The ACA only requires that employers let H2A recipients know of the health insurance options they can purchase themselves. California actually expanded federal Medicaid, allowing H2A workers who fall below 138% poverty level to qualify for Medicaid.

Many of these structural determinants impact MSAW patients well before they even step into the examination room. Even so, providers should assist in offering necessary care and advocacy for MSAW patients as well as make it a point to understand these structures in order to have context for conversations about care plans. Clinicians can help MSAW by supporting organizations like Farmworker Justice, Migrant Clinicians Network, and the National Center for Farmworker Health, Inc (NCFH) who work with, by, and for the MSAW community. Providers can join arms with organizations like these to advocate for migrant and seasonal agricultural workers who have been systematically oppressed by structural forces outside of their control. If we don’t, we will be jeopardizing the health of our patients, like Rosaria, whose health and livelihood are dependent on the current system that fails them.

[1] Name changed for patient confidentiality

[2] https://www.migrantclinician.org/issues/migrant-info/migrant.html

^[3] Mexico was not included in migration restrictions that the Immigration and Nationality Act of 1917 set in place for Eastern European, Southern European, and Asian immigrants.

[4] https://saf-unite.org/content/united-states-farmworker-factsheet

^[5] The cohort participants were primarily born into families of immigrant farmworkers.

[6] https://www.reuters.com/article/us-health-preemies-pesticides/moms-most-exposed-to-pesticides-more-likely-to-have-preterm-babies-idUSKCN1BN2YC

[7] https://www.futurity.org/elemental-sulfur-children-1515012/

^[8] Although elemental sulfur is found in our everyday food, when inhaled, it is results in poor respiratory outcomes.

^[9] An H2A Visa given by agricultural employers who anticipate a shortage of domestic workers to bring non-immigrant foreign workers to the US to perform agricultural labor or services of a temporary or seasonal nature

Internist, Pediatrician, and Associate Professor at UCSF, Dr. Le is also the co-founder of two health equity organizations, the HEAL Initiative and Arc Health.

Connie Chan and Brooke Warren are currently interns at Arc Health. Chan is an Economics and Public Health double major and graduate of UC Berkeley. Warren is a Native American Studies major and recent graduate of UC Davis.

This post originally appeared on Arc Health here.

By CATALYST @ HEALTH 2.0

Three finalists for the Robert Wood Johnson Foundation Home and Community Based Care and Social Determinants of Health Innovation Challenges competed live at the Health 2.0 Conference on Monday, September 16th! They demoed their technology in front of a captivated audience of health care professionals, investors, provider organizations, and members of the media. Catalyst is proud to announce the first, second and third place winners.

Home and Community Based Care Innovation Challenge Winners

First Place: Ooney 

Second Place: Wizeview

Third Place: Heal 

Social Determinants of Health Innovation Challenge Winners

First Place: Social Impact AI Lab New York

Second Place: Community Resource Network 

Third Place: Open City Labs

For the SDoH Challenge, innovators were asked to develop novel digital solutions that can help providers and/or patients connect to health services related to SDoH. Over 110 applications were submitted. For the Home and Community Based Care Challenge, applicants were asked to create technologies that support the advancement of at-home or community-based health care. Nearly 100 applications for Home and Community Based Care Challenge were received. After the submission period ended, an expert of over 50 judges evaluated the entries. Five semi-finalists from each challenge were selected to advance to the next round and further develop their solutions. The semi-finalists were evaluated again and the three finalists chosen. 

To learn more about the Home and Community Based Care Innovation Challenge, click here. 

To learn more about the Social Determinants of Health Innovation Challenge, click here.

For further updates on the finalists of the RWJF SDoH and Home and Community Based Care Innovation Challenge and other programs, please subscribe to the Catalyst @ Health 2.0 Newsletter, and follow us on Twitter @catalyst_h20.

Catalyst @ Health 2.0 (“Catalyst”) is the industry leader in digital health strategic partnering, hosting competitive innovation “challenge” events and developing programs for piloting and commercializing novel healthcare technologies.

By CATALYST @ HEALTH 2.0

Catalyst is excited to announce the finalists for Robert Wood Johnson Foundation’s Home and Community Based Care and Social Determinants of Health Innovation Challenges! The three finalists from each Challenge will compete in an exciting Live Pitch on September 16th, from 2:30-4:30pm, at this year’s Health 2.0 Conference in Santa Clara. They will demo their technology in front of a captivated audience of health care professionals, investors, provider organizations, and members of the media. The first place winners will be featured on the Conference Main Stage, September 17th at 3:15pm. Winners will be awarded $40,000 for first place, $25,000 for second place, and $10,000 for third place.

If you are attending the Health 2.0 Conference, join us to see the finalists showcase their innovative solutions. 

Home & Community Based Care Innovation Challenge Finalists

• Heal – Heal doctor house calls paired with Heal Hub remote patient monitoring and telemedicine offer a complete connected care solution for patients with chronic conditions.  
• Ooney – PrehabPal, a home-based web-app for older adults, delivers individualized prehabilitation to accelerate postoperative functional recovery and return to independence after surgery.
• Wizeview – A company that uses artificial intelligence to automate and organize information collected during home visits, supporting the management of medically complex populations at the lowest cost per encounter. 

Social Determinants of Health Innovation Challenge Finalists

• Community Resource Network – The Social Determinants of Health Client Profile, a part of the Community Resource Network, creates a whole-person picture across physical, behavioral, and social domains to expedite help for those most at risk, fill in the gaps in care, and optimize well-being.
• Open City Labs – A company that matches patients with community services and government benefits that address SDoH seamlessly. The platform will integrate with HIEs to automate referrals, eligibility screening & benefits enrollment.
• Social Impact AI Lab – New York – A consortium of nonprofit social services agencies and technology providers with artificial intelligence solutions to address social disconnection in child welfare.

For the SDoH Challenge, innovators were asked to develop novel digital solutions that can help providers and/or patients connect to health services related to SDoH. Over 110 applications were submitted to the SDoH Challenge. For the Home and Community Based Care Challenge, applicants were asked to create technologies that support the advancement of at-home or community-based health care. Nearly 100 applications for Home and Community Based Care Challenge were received. After the submission period ended, an expert panel comprised of subject matter experts, venture capitalists, as well as designers evaluated the entries. Five semi-finalists from each challenge were selected to advance to the next round and further develop their solutions. The semi-finalists were evaluated again and the three finalists chosen. 

For further updates on the finalists of the RWJF SDoH and Home and Community Based Care Innovation Challenge and other programs, please subscribe to the Catalyst @ Health 2.0 Newsletter, and follow us on Twitter @catalyst_h20.

Catalyst @ Health 2.0 (“Catalyst”) is the industry leader in digital health strategic partnering, hosting competitive innovation “challenge” events, as well as developing and implementing programs for piloting and commercializing novel healthcare technologies.

By HILARY HATCH, PhD

The growing movement to include the patient voice in medicine through Motivational Interviewing, patient-reported outcomes, social determinants of health and shared decision-making

One day in 2011, as a part of my research on ways to improve patient-provider communication about health behaviors, I was shadowing Dr. G., a talented young internist with a cheerleader demeanor. He marched through 12 afternoon patient appointments with confidence and purpose. But when he saw the name of the last patient on his schedule, he turned pale, faced me and said, “I apologize for what you are about to see.”

I must have looked confused. He repeated, “I apologize for what you are about to see.”

We walked into the exam room. I’m not sure either one of us knew what to expect. The patient, a white, obese man, was seated, doubled over. He had a wad of paper towels jammed in his mouth. He threatened to pull out his own, presumably abscessed, tooth. He refused to see a dentist because he had no dental coverage, no money and no one to borrow money from. He said he would use pliers to pull his tooth, but stayed put, rocking in his seat. At the computer, the young doctor’s white-knuckled hand gripped his mouse. Click. Click. Click. He searched the patient’s chart aimlessly for help. Alerts kept popping up about the patient’s missing A1C results. It took two minutes, but it felt like 20.

Dr. G. left the room and came back a few minutes later. He gave the patient the name of a dentist who would see him at no cost. I suspected Dr. G. had called the dentist and said he would pay for the appointment out of his own pocket. The patient hugged Dr. G. He only wanted help, and Dr. G. wanted to help. The tension was resolved for the moment.

The visit note looked like nice and neat, bearing no resemblance to the interaction of human need I had just witnessed.

Problem list:

• Diabetes Type 2
• Major depression
• Acute toothache

Note: “Patient complaining of tooth pain. Referred to dental for eval of abscess.”

No mention of the patient’s many major stressors. Lack of dental insurance. Poverty. Pain. Trauma. Anxiety. Possible addiction. Obesity. Social isolation. The patient’s record said he was 39. He looked 59. Not a single box in the patient’s EHR reflected those issues, despite the evidence that behavioral health problems and poverty cost people 20 years in life expectancy. There were years of A1C test results in the man’s record. A lot of quality alerts related to his uncontrolled diabetes and missed blood, eye and kidney exams. “Tsk, tsk, Dr. G.,” the patient’s chart said. No wonder he dreaded this patient. When I returned to the practice a month later, Dr. G. was gone, “promoted to an administrative role.”

The patient’s non-medical self has not historically had a place in the medical record. Dr. G., like many physicians, managed his patients with complex behavioral health and unmet social needs by sticking them on his schedule at the end of the day. Dr. G. felt he had to apologize for what I saw. He seemed to feel I would judge him as harshly as his quality report would for this patient. On the contrary, Dr. G reminded me of how many years of training it took me as a psychologist to learn how to be at ease with the incredibly uncomfortable feelings that come up in an interaction like the one I witnessed.

Dr. G.’s practice, like many others, had yet to reflect the 40 years of accumulated evidence that supports incorporating the patient’s voice and “the whole person” into medicine. Ideas such as:

• Integrating behavioral health and social determinants of health (SDOH) into medicine
• Motivational Interviewing to understand individual patient goals and barriers to care
• Shared decision-making
• Health literacy
• Patient-reported outcomes

Each of these efforts inserts the patient’s voice and social context into care. None of these ideas are new, but somehow it feels like these evidence-based threads have finally woven themselves into a sail that has recently caught wind.

This is a movement whose time has come. Listening to the patient’s voice and story, understanding the patient’s needs and priorities, and capturing that information in data reportable to the provider in the workflow—are becoming more common. In fact, we are seeing an unprecedented surge of practices integrating patient-reported outcomes data (PROs) into their workflows. Primary care practices increasingly are screening for behavioral health and substance use, SDOH, environmental triggers for asthma, fall risk, cognitive and functional decline, health literacy and hereditary cancer risk. Providers want to activate patients around their individual barriers to care and medication adherence. Specialists are incorporating PROs and considering that data alongside clinical outcomes. They want to know which patients lack social support and might therefore be readmitted.

Every day, my team is helping organizations around the country implement patient-reported data and programs to increase patients’ participation in their care. The goal is to improve not only the patient experience, but also the provider experience with data that is actionable and consumable, and that allows physicians to collaborate with a broader care team. We are asked to find ways to maximize and extend the reach of the provider-patient interaction beyond the 15-minute visit.

This is not a movement without ambivalence. As a psychologist, I am keenly aware that most physicians didn’t sign up to be psychologists and social workers. They are overwhelmed. Dr. G.’s patient is not terribly uncommon.

I often wonder why this movement is taking off now. I worked in an integrated adolescent primary care setting at Bellevue Hospital in the 1990s, where I learned about Motivational Interviewing for substance abuse interventions and shared decision-making for talking to adolescents about birth control and HIV testing. These ideas have been around a long time, especially in community health centers and public hospitals. Why the sudden explosion in interest and broader adoption across medicine? Here are some of the major influences.

• Consumerism: Healthcare organizations lose money and payer contracts if they cannot attract consumers and keep their patient satisfaction scores up.
• Value-based care, government and health-plan incentive programs: Shared decision-making, PROs, Motivational Interviewing and the integration of behavioral health and SDOH into primary care delivery have all been proven to improve outcomes and reduce the total cost of care.
• A downward trend in life expectancy, notably among white males
• Physician burnout: Practices are looking for ways to improve and humanize patient-provider communication.

Clearly, the movement to include patient-reported data is here, and the patient’s non-medical self needs a place in their healthcare record.

I apologize for what you are about to see. It is going to be extremely human.

Hilary Hatch is a clinical psychologist, the founder and CEO of VitalScore, and the VP of Clinical Engagement at Phreesia.

By CATALYST @ HEALTH 2.0

Health disparities domestically and globally can often be attributed to social determinants of health (SDoH). According to Healthy People 2020, SDoH are conditions and resources in the environments in which “people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” Examples of these include: resources to meet daily needs (e.g. access to and quality of housing and food markets), educational opportunities, employment opportunities, and transportation. Despite well-established literature on the importance of SDoH, these factors are often overlooked and excluded in health care frameworks. 

Concurrently, health services provided in traditional settings such as hospitals and clinics can be expensive and inaccessible. There are a large number of communities, from rural areas to major cities, that are in need of high-quality care. Innovative technologies can mitigate these challenges. Home and community-based care models coupled with digital tools provide the opportunity to serve patients where they feel most comfortable in a cost-effective manner. 

In an effort to spur creativity in the SDoH tech environment and improve the landscape of home based care, the Robert Wood Johnson Foundation and Catalyst partnered to launch two Innovation Challenges on Social Determinants of Health and Home and Community Based Care. 

For the SDoH Challenge, innovators were asked to develop novel digital solutions that can help providers and/or patients connect to health services related to SDoH. Over 110 applications were submitted to the SDoH Challenge. For the Home and Community Based Care Challenge, applicants were asked to create technologies that support the advancement of at-home or community-based health care. Nearly 100 applications for Home and Community Based Care Challenge were received. 

After the submission period ended, an expert panel comprised of subject matter experts, venture capitalists, as well as designers evaluated the entries. Five semi-finalists from each challenge have been selected to advance to the next round:

Social Determinants of Health Semi-Finalists

• Community Resource Network – The Social Determinants of Health Client Profile, a part of the Community Resource Network, creates a whole-person picture across physical, behavioral, and social domains to expedite help for those most at risk, fill in the gaps in care, and optimize well-being.
  
• Open City Labs – A company that matches patients with community services and government benefits that address SDoH seamlessly. The platform will integrate with HIEs to automate referral, eligibility screening & benefits enrollment.
• Project Well – A company that personalizes food and social dining interventions to address food insecurity, social isolation, and strained household budgets for health plan members with chronic disease.
• Smart Community Health – A team from the University of Minnesota with a full service community resource recommendation system that uses PRISM mobile app technology integrated with MyStrengths+MyHealth to provide personalized community resources.
• Social Impact AI Lab New York – A consortium of nonprofit social services agencies and technology providers with artificial intelligence solutions to address social disconnection in child welfare.

Home & Community Based Care Semi-Finalists

• CareTree – A company with “HIPAA-compliant Facebook” that guides families to manage a loved one’s care.
• Epharmix – A company that scales remote patient monitoring for 24 conditions using accessible SMS & IVR to collect real-time patient health data. Provider alerts enable proactive care for patients worsening.
• Heal – Heal doctor house calls paired with Heal Hub remote patient monitoring and telemedicine offer a complete connected care solution for patients with chronic conditions.
• Ooney – PrehabPal, a home-based web-app for older adults, delivers individualized prehabilitation to accelerate postoperative functional recovery and return to independence after surgery.
• WizeView – A company that uses artificial intelligence to automate and organize information collected during home visits, supporting the management of medically complex populations at the lowest cost per encounter.

The semi-finalists for the Challenges will be awarded $5,000 each to further develop their application or tool. After a second application round, three finalists from each Challenge will be chosen to compete at a live pitch event during the Health 2.0 Conference (September 16th-18th). They will demo their technology in front of a captivated audience of health care professionals, investors, provider organizations, and members of the media. Judges will select the first, second, and third place winners live after a series of short demos from the finalists. The winners will be awarded $40,000 for first place, $25,000 for second place, and $10,000 for third place.

For further updates on the semi-finalists of the RWJF SDoH and Home and Community Based Care Innovation Challenge and other programs, subscribe to the Catalyst @ Health 2.0 Newsletter, and follow on Twitter @catalyst_h20.

Catalyst @ Health 2.0 (“Catalyst”) is the industry leader in digital health strategic partnering, hosting competitive innovation “challenge” events, as well as developing and implementing programs for piloting and commercializing novel healthcare technologies.