New report: Improving Care for Socially-Disadvantaged Populations

Anthony Shih, MD, MPH is Executive Vice President of The New York Academy of Medicine and a member of the committee of the National Academies of Sciences, Engineering and Medicine that just issued a new report on approaches to improving care for at-risk populations.

Imagine that you’re working with a patient with multiple chronic diseases and clinical risk factors—perhaps heart failure, diabetes, high blood pressure, and obesity. This is not uncommon, and these alone would be challenging for providers and health systems to effectively manage. Imagine now that in addition to these clinical issues, the patient had a host of social risk factors as well—such as poverty, unstable housing and limited literacy. The challenges of caring for this patient have just become dramatically more complex and difficult. Will the patient be able to afford the medications, never mind the healthy food that you’re recommending? Can he understand the instructions about monitoring his blood sugar and blood pressure? Does he have a safe home where he can rest in a relatively stress-free environment? Unfortunately, for many of the nation’s safety net hospitals, community clinics, and similar institutions, facing patients with these social risk factors is a routine occurrence.

Systems Practices for the Care of Socially At-Risk Populations, a new report from the National Academies of Sciences, Engineering and Medicine’s Committee on Accounting for Socioeconomic Status in Medicare Payment Programs, addresses the issue of caring for disadvantaged populations. Based on a review of both the peer-reviewed literature and case studies from the gray literature, the committee identified six practices, when implemented by a system of collaborating partners, which show promise for improving care and health outcomes for patients with social risk factors. Of import, the committee noted that these practices should be grounded in patient-centered and community-informed care.

Although the term “patient-centered” is likely familiar to you, the term “community-informed” is probably new. It essentially expands on the notion of patient-centered care to include the community-context in which the patient is embedded. This community-context, including understanding the community assets and resources, conditions, and needs, are particularly important since interventions for patients with social risk factors will require partnerships outside the traditional health care system.

The six systems practices, when taken together, constitute a general approach to identifying and developing interventions for a specific community context to improve care for socially at-risk populations, and they begin with a commitment to health equity. The full list of the practices identified are:

1. Commitment to health equity: Value and promote health equity and hold yourself accountable.
2. Data and measurement: Understand your population’s health, risk factors, and patterns of care.
3. Comprehensive needs assessment: Identify, anticipate, and respond to clinical and social needs.
4. Collaborative partnerships: Collaborate within and across provider teams and service sectors to deliver care.
5. Care continuity: Plan care and care transitions to prepare for patients’ changing clinical and social needs.
6. Engaging patients in their care: Design individualized care to promote the health of individuals in the community setting.

Each of these practices, as well as specific examples of strategies and interventions within those practices, are described in detail in the report. I hope that these provide useful guidance to those systems seeking to improve care for disadvantaged populations.

Disadvantaged populations need not suffer from sub-optimal care. In fact, the committee found that across different quality measures, there were examples of providers serving disadvantaged populations who performed at high levels, compared not only to their peer institutions, but also to institutions who served the general population. However, it was also clear that both the availability of resources and the alignment of incentives to improve quality of care and promote health in disadvantaged populations were required to adopt and sustain these practices.