As health care CEOs and executives consider how to address the mental health crisis and social determinants of health, some are finding significant overlap between the two.
“Social determinants and behavioral health can be very difficult to separate,” said Gaurov Dayal, MD, President & COO, Everside Health during a meeting at the 2022 Health Evolution Summit. “When it comes to integrating those into primary care, we’ve seen there are so many cracks in our care delivery system, many of which disproportionately impact folks who are underprivileged, who are minorities, who don’t have resources.”
To that end, Health Evolution convened Fellows of the Work Group on Reinventing Primary Care and Preventative Care Models and the Work Group on Building Scalable Models and Community Partnerships to Address Social Determinants of Health.
In the convening Dayal led the Primary Care & Beyond: Moving Meaningfully Upstream & Integrating Behavioral Health session. The discussion also included Mandy Cohen, MD, EVP & CEO, Aledade Care Solutions and former Secretary, North Carolina Department of Health and Human Services; Patrice Harris, MD, Co-Founder and CEO, eMed and a former President of the American Medical Association; Sachin Jain, MD, President & CEO, SCAN Group & Health Plan; and Steppe Mette, MD, CEO, University of Arkansas for Medical Sciences Medical Center.
According to a poll taken at the invitation-only meeting, the majority of CEOs who responded believe that health care organizations should expand beyond traditional roles to address drivers of health, but only about 20 percent indicated that they have actually made a significant impact at this point.
How can CEOs lead their organizations forward in terms of addressing both issues? During the meeting, Fellows shared what their organization has learned about mental health and social determinants.
Critical elements of working with the community
While Cohen served as Secretary, the NC DHHS created NC 360, a scalable statewide platform that connects the health care system with community organizations.
Cohen said there are three key elements to the program’s success. First, the department had to create a payment and incentive context that made sense. Second, NC DHHS needed appropriate data to identify the best ways to pair specific populations to the right interventions. Third was to invest in and create infrastructure necessary to support new workflows.
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“I don’t think that you’re ever going to get a really good integration with people thinking collaboratively about health unless you get the incentives and the payments right,” Cohen said. “If you can get the data and really targeted interventions to the right population, that’s how you make progress.”
Cohen added that it’s important for leaders to be intentional about which populations need which types of interventions to move the needle toward health. As the industry recovers from the COVID crisis, Cohen also urged CEOs to embrace the opportunity to leverage federal and state dollars being used to make investments in public health and build on that infrastructure accordingly.
“This is possible for folks to do elsewhere. You need a champion across sectors to do this work and think creatively about using COVID dollars as you’re doing it,” Cohen said. In the case of North Carolina, the funding came from payers, philanthropy and state government.
Bringing care to the streets
When Jain joined SCAN as its chief executive, one of his priorities was to create a solution for people experiencing homelessness in Los Angeles County.
“Their total cost of care is often comprised of avoidable hospitalizations, avoidable ICU stays, avoidable costs from complications of poorly managed chronic diseases or behavioral health issues,” Jain said.
From a risk adjustment perspective, those patients cost $25,000 to $35,000 per year each, creating what Jain said is “a tremendous opportunity to reallocate dollars away from acute care services to primary care services.”
To leverage that opportunity, SCAN established Healthcare in Action to serve vulnerable individuals experiencing homelessness.
“Healthcare in Action is essentially a street-based medical group focused on providing intensive outpatient care to people who don’t otherwise have access to it,” Jain said. “Industrywide, we’re talking a lot about bringing care to the home. For people whose home is the streets, we are trying to bring care to the streets.”
Sometimes SCAN clinicians first meet patients when they come into a hospital, other times they work with an individual’s case manager or identify people in need via partners, such as Molina Healthcare.
“We’re now thinking about technology solutions to be able to, with consent, know where patients are so we can come to them and provide care,” Jain said. “We are trying to innovate and understand ways in which we can stay closer to patients.”
When Dayal asked whether SCAN considered the program a pilot or something that could be scaled outside of Southern California, Jain said that he has been heartened by the amount of interest it has received and he has had conversations about bringing the program to Washington, DC, and Northern California.
“These are specifically the people we need to embrace as a society. We spend a lot on this population,” Jain said. “It’s just that we’re spending a lot on the wrong things.”
Building housing — and trust — in the community
UAMS is adjacent to one of the wealthiest zip codes in Arkansas but 500 yards away is a zip code among the poorest. Mette explained that the underserved community lacks a grocery store, pharmacy and a bank. What it does have are hundreds of abandoned houses and empty lots not generating taxes for the city of Little Rock.
To address that issue, UAMS partnered with the city, other health care organizations, minority-owned banks and building contractors to convert the abandoned houses and lots into single family homes that are available at low-interest rate mortgages. The organizations are also establishing financial literacy and cooking classes for community members, Mette said.
“Everybody benefits from this. People who never owned a home now have the ability to do so. The community loves it because that blight of dangerous homes will be removed and we’re being asked by the community to put a grocery store in the space immediately adjacent to the same building as the police department.”
UAMS’ work began in 2018 by closing the gap between a minimum wage for its employees and what is considered to be a living wage. Beyond being the right thing to do, Mette said that it established new levels of trust between the health system and its workforce as well as the community it serves.
“In the communities where we demonstrated that we were able and willing to recognize fundamental needs, the work cemented for us the trust needed to do all these other projects,” Mette said. “I don’t think we would’ve been invited into that zip code with safe and healthy foods if we had not demonstrated our commitment otherwise.”
‘A moment for behavioral and mental health’
Health Evolution convened the two Work Groups because mental health was figuring into the conversations taking place in the Work Group on Building Scalable Models and Community Partnerships to Address Social Determinants of Health.
“There’s a moment here with behavioral health and mental health,” Harris said.
Many social determinants, in fact, negatively contribute to the 80 percent no-show rates in child psychiatry and 75 percent of those patients who do not comply with prescriptions, Harris added, whether that is due to transportation challenges, difficulty accessing childcare or an inability to afford time off from work to bring children into appointments.
That is just one example of where social determinants and behavioral health intersect and it’s the reason Health Evolution is establishing the new Roundtable on Mental and Behavioral Health. “The point is to have focused conversations about actionable solutions from cross-sector leaders in health care, and then put those solutions into action and coordinate with our other Work Groups,” Harris said. “One of the key pieces of this work will be looking at evidence.”
