Taking QI upstream to address social needs
A patient comes into the emergency department with a diabetes-related infection that will lead to an amputation unless properly cared for. The patient does not have a place to live and therefore has nowhere to store medication or consistent access to healthy food. Despite wanting to do more, healthcare workers discharge the patient back to the street, knowing they’ll return within the next three months and require a below-the-knee amputation.
This, says Snehal Patel, is an example of how the existing healthcare system doesn’t always allow providers to make the best decisions for patients’ health.
“Our hospital system is really a disease-care system, not a healthcare system,” Patel, an EQUIP grad and physician, said. “It’s focused on this idea of treatment of acute disease when someone is ill but misses the opportunity to leverage the power of the hospital to improve not just individual and family health but community and population health.”
Patel’s ideal solution? Buy the patient an apartment – it will ultimately cost the health system a lot less than paying the thousands of dollars for their surgery and repeat visits to the emergency department.
But hospitals are not in the business of buying apartments. However, they can implement the next best thing: connect patients with community resources that can put them on the right track to addressing their unmet healthcare-related social needs (HRSNs) like housing and food insecurity, domestic violence and unemployment.
That was the idea behind an initiative by Patel and his team at Dell Medical School at the University of Texas at Austin. In fall 2019, Patel helped implement a QI program to ask patients about – and address – HRSNs. When the pandemic began, his team quickly shifted to expand the program to all patients with COVID at Dell Seton Medical Center, a “safety net” hospital where the majority of patients are uninsured. They encouraged the use of a screening tool to identify HRSNs and then helped connect patients with community, public and private resources based on their needs.
“Of the first ten COVID patients at our hospital, nine identified as Black or Latino and eight spoke Spanish as their primary or preferred language,” Patel said, adding that four out of the ten also had concerns about losing their housing. “It was immediately clear there was a disproportionate effect of how the pandemic was playing out. We didn’t have a perfect model but we knew our patients were the ones hit the most significantly by the pandemic and we needed to connect them with resources.”
Fifty-six of the first 100 patients with COVID were screened and, of those, 64 per cent had relevant HRSNs. They all received targeted information and assistance for support.
In Toronto, a recent research study showed patients are not only comfortable with this data collection but appreciative – as long as the hospital can act on it. Victoria Davis, a master’s student at the University of Toronto working with The Upstream Lab at St. Michael’s Hospital, Unity Health Toronto, led a qualitative research project talking to general internal medicine (GIM) patients about their experiences and attitudes about being asked social determinants of health information. Many patients were 60 or older, typical of GIM units, and represented a range of race, gender and social needs.
“It was a very interesting finding – patients identified resource constraints as a barrier,” Davis said. “We talked to patients during COVID when they could see the burden hospitalizations were having on providers, so they naturally weren’t sure whether or not the hospital was capable of meaningfully and appropriately collecting this information and helping to address their needs.”
Other barriers were identified, including whether this data collection could lead to discrimination.
“There was a fear that patients would be judged or perceived differently by their provider if they find out they have difficulty making ends meet or couldn’t feed their children,” Davis said. “They were also really worried about staff gossiping about them. As part of this, they identified it’s essential to have a trusting relationship with their provider who would be asking these questions.”
Even patients who did not have unmet social needs recognized the importance of data collection if the hospital could follow through to help address concerns. Many patients suggested they wanted support navigating things like community resources – not just a list of places they could call, but someone to follow up with them and confirm they received access or provide support or alternate options if there was a significant wait time for recommended resources.
This is aligned with an increasing number of studies showing that patients recognize the role of their living circumstances on their health and medical care.
“The patients we talked to were able to identify that social needs were connected to their health and thought it could be important for their provider to understand their social and living circumstances and try to incorporate that into their care,” Davis said.
There’s a benefit for providers as well. When Patel and his team originally pitched the idea of introducing HRSN screening, they connected it to helping providers find more joy in their work.
“Many folks, regardless of what kind of work they do in the healthcare field, go into healthcare because they want to improve health and social conditions,” he said, “and so much of what we’re taught through medical, nursing and social work school is those sorts of things are not possible. When you send that patient with diabetes back to the street because you’re told that’s the only action you can take, that contributes to moral injury – when you know it’s a setup for disaster but you can’t help it. One of the things that came out of this is that having a community health worker on the case with a patient helps providers feel like they’re making a difference, not just putting Band-Aids on and hoping they don’t fall off.”
Moral injury can negatively impact patient outcomes and readmission rates, as well as lead to provider burnout.
“The solution has to be systemic – it’s not just about individual resilience,” Patel said. “If you’ve been through years of training and you worked through the pandemic, you’ve got resiliency. It’s not just telling folks to do yoga or meditate – we need to change our systems and structures and, unless we do that, we’re not addressing what causes moral injury.”
Both Patel and Davis are continuing this work, looking at various aspects of how to implement social needs screening, the best way to provide ongoing support and what it takes to build stronger, more trusting relationships both between providers and patients and between hospitals and community resources. Their work stems from an understanding that this is transformational – and necessary – change.
“We know that there are many different health inequities, and social determinants of health have the greatest impact on people’s health outcomes, on their morbidity and early mortality,” Davis said. “We also know many patients and individuals are struggling in society and don’t have the proper resources, knowledge or skills to help with that, so hospitals can bridge this gap to help improve public health, population health goals, more equitable healthcare and health outcomes.”
“We know we can help someone who is unhoused when they’re leaving the hospital, which is different from 2019 when we said that’s just not possible. We know it’s possible because we’ve done it and not only did cities not collapse but we prevented hundreds of thousands of cases of COVID and saved lives because of it. Now that we’re on this side of the pandemic, not only do we know this is the right thing to do and we know we can do it, how do we continue to build political movement to say our health system needs to put money and push towards this?” Patel said. “We need to transform the work we do to actually build a different model of healthcare so it’s not just improving the quality of what we’re doing – it’s shifting and transforming the model and changing the conversation about what is possible.”