In this weeks podcast we talk with Kirsten Bibbins-Domingo, general internist, Professor of Medicine and Epi/Biostats at UCSF, and chair of a National Academies of Sciences task force on Integrating Social Care into the Delivery of Health Care. See Kirsten’s JAMA paper summary here, and the full report here.
This podcast spans the gamut from the individual clinician’s responsibility to be aware of the social needs of their patients and impacts on health (think homeless person with no place to store their insulin), and adjustment to meet these needs (such as keeping on oral medications), to larger health policy issues including the need to integrate health and social policy.
This was a fun podcast, as you’ll hear. This is a topic that lends itself well to discussion. Eric really pushes this issue: to what extent are meeting the our patient’s needs for housing, transportation, and food a health issue? Are these issues that a doctor should care about, and why?
And our rendition of “Waiting on the World to Change” was perfect in every possible way!!!
by: Alex Smith, @AlexSmithMD
GeriPal is funded by Archstone Foundation. Archstone Foundation is a private grantmaking foundation whose mission is to prepare society in meeting the needs of an aging population.
Eric: Welcome to the GeriPal Podcast this is Eric Widera.
Alex: This is Alex Smith.
Eric: Alex, we have a couple of people in our studio audience today.
Alex: We have a couple people here in our studio audience. We have Kirsten Bibbins-Domingo who is a professor of medicine. She was the chair of the committee of The National Academy of Sciences, Engineering and Medicine which provide recommendations about integrating social care into the delivery of healthcare. She’s a general internist and we’re so delighted that you could be here today.
Kirsten: I’m thrilled to be here.
Alex: We also have Anne Kelly who’s a frequent guest and host on our podcast welcome back Anne.
Anne: Thanks guys.
Eric: We’re going to be talking about this, Kirsten, you just published a paper in JAMA on this topic. But before we jump into this we always start off with a song request. Do you have a request for Alex?
Kirsten: Well, I’ve requested Waiting on the World to Change.
Alex: Why this song request?
Kirsten: Well, I really loved the song and it sort of puts me in mind when we want to do things to change the world and we’re sort of stuck in the way the world is – we’re sometimes waiting. So it just resonated with me for this theme too.
Alex: Mm-hmm (affirmative). Great.
Alex: Perfect in every way – as always with the GeriPal Podcast [laughter].
Eric: Fascinating. That was great. So we’re going to jump right into this topic. So Kirsten, you just had a paper published in November in JAMA titled Integrating Social Care Into The Delivery Of Healthcare, giving five activities in healthcare settings that address social needs. We’ll talk about each one of those five. But before we do, how’d you get interested in this topic? Why?
Kirsten: Great. So the paper that we published was actually about a larger report that we were involved with in the national academies. I think everyone knows that in healthcare we’re not quite achieving everything we want to achieve in healthcare. A lot of that is because there are many things related to the social context that our patients are living in that really affect what happens to them and their health outcomes. The Robert Wood Johnson Foundation calls this the blind spot of medicine, right? That in fact our most socially complex patients are also those patients who have the most health needs often. And physicians feel particularly ill equipped to deal with the social needs of their patients.
Kirsten: So that’s how this group came together funded by lots of funders, including the Archstone Foundation and many other funders who said it would be great for the academies to say how could healthcare more effectively integrate social care into the delivery of healthcare? We had a group that came together and met for a number of months. We had a lot of speakers come in from the outside to talk about how different organizations are doing this. Then we basically said what we wanted to do was understand the literature and then not give people a one size fits all for how to do this. But rather to say, here’s the framework for how we in healthcare could be doing this better and how we should be thinking about it.
Alex: That’s terrific. I wonder if there are some clinical examples, that we could come up with that speak to this issue in the dire need to integrate the social aspects of care into traditional health care. I’m just thinking of the one of the last podcast we did with Joanne Lynn who said, I can prescribe a medication that costs tens of thousands of dollars or more, but I can’t buy my patients supper. Just put it so starkly. Other examples from our own practices of the need to integrate the social determinants of health into traditional healthcare.
Kirsten: So the one I think about, I’m a general internist and I take care of patients with diabetes. When I think about is I can do all that I can and prescribing medicines to get them their best diabetes outcomes. If I don’t understand whether they have a refrigerator to refrigerate their insulin or if that there are times of the month when they cannot get the food that they need to get, or if they don’t have a stable place to live. All of those things are ultimately going to affect the outcome so I can prescribe the best medications the patient can come to all their visits and still not achieve what we both want to achieve if I don’t understand and figure out the ways in which I can address that context.
Alex: Terrific. Anne you’re a social worker, you see this all the time, I suspect.
Anne: Certainly. One thing that comes to my mind readily is even just the very practical nature of getting people to and from their appointments. I know your article touches on transportation as one example and I would add to that also people who might have some functional decline and have stairs to get in and out of the house and how we really often don’t have a system that’s readily equipped to even help people get up or down their stairs to get up to appointments.
Kirsten: Thanks for saying that. We make this point that we think about social needs sometimes as the most vulnerable or most marginalized patient or community, but in reality all of us may have social needs at some point in our lives. Certainly as we age it might be as we’re discharged from the hospital and thinking about them across different needs in different communities. Then the problem is when the mismatch between a need and the resources to address that need is really great. I think that’s when we have to figure out structures to do this.
Eric: Can I ask you a really probably stupid question. What do we mean by social needs or social care? What does that encompass?
Kirsten: Great. So people often talk about social determinants of health. It’s just saying the social context matters. Some of the basic things food, a place to live, transportation, those are things that are part of the general factors that certainly influence your health and needs are when we are not addressing those, when there’s a need that needs to be addressed in order to achieve that outcome. So there can be a lot of ways to think about more specifics under these, but those are sort of the go-tos, housing, transportation, food, shelter, things like that. How would you think about them?
Anne: Totally. I’m wondering this group that got together, this community that you were chair for, was it largely physicians that are in that committee or who made up that group that wanted to come together to think about this?
Kirsten: I like to tell the story how the group came together because there were 20 funders and 64 different organizations across the country that came together to say we need this type of report. They were actually largely driven by social workers who sort of see this need, but there’s a lot of interest in health care also because we’re not quite achieving these outcomes. So our committee was made up of physicians, social workers, people in government organizations, people in the private sector, people who think about healthcare financing and people who think about community health workers gerontologist. Other types of the workforce that might be doing some of this work. We had a lawyer on the committee as well who thought about that sort of nontraditional.
Kirsten: That was great to have all those perspectives because I don’t think there is a one model for how to do this and it’s certainly one of the points we emphasize in the report is the importance of multidisciplinary teams to really do this well. I think in the end, this is the type of thing that every doctor needs to know that this is important and important to understand for the health of their patients, but we need to know how to work with teams in order to do this better.
Eric: This reminds me of a patient that several of us cared for recently whose primary concern, number one concern is this guy who has metastatic cancer. We actually couldn’t get a tissue biopsy, we should probably pancreatic. He’s number one concern was if he’s cared for at home, they would have to pay out of pocket for care and that would deplete the family’s resources and his wife has dementia and he wants to make sure that those resources are preserved for his wife and her care needs in the future. Just sort of starkly illustrate does his primary goal was a social concern about his family’s limited resources.
Kirsten: I think you’re bringing up how this … it’s not just for the individual patients and when we think about social needs and social context, it’s oftentimes this family context and the community context that is also both sort of can magnify the need and also is it has to be considered in order to understand how you’re going to care for that individual patient, right?
Eric: Right. So we have these social needs and social determinants of health they should address … they include a lot of things it sounds like including transportation, access to food. Whose responsibility is that? I am I as a physician, is that my responsibility to do that?
Kirsten: Yeah, it’s a super question. This is like, are we waiting for the world to change? We want this world to be a better place and in the better place it would probably be not healthcare taking on all of these roles, right? One of the things that the committee struggled with was to say, if we imagine a better world, we would not be as fragmented a system as we are. There wouldn’t be fragmented between social service agencies and healthcare agencies and different types of providers doing all of these things. I think the reason that there’s an interest in healthcare right now, we can either take the optimistic or the pessimistic view. The reason in part is because healthcare has a lot of money, right? So healthcare has more money than the social care sectors and the social service sectors.
Kirsten: So that some of the push to say healthcare needs to take this on and some of the pull is says your patient that you’re describing Alex, our patients like we’re not getting there. And so if we’re not meeting our own outcomes that we’re responsible for, we have to step up and sort of do something.
Eric: I can imagine like the concern is, from the pessimistic standpoint is healthcare is a medical industrial complex and it’s becoming more and more about profit and profit driven motives rather than potential mission. Is this mission creep for health care? Now we’re in charge of food and transportation and all of these other things that are indirectly related to maybe directly related to people’s health.
Kirsten: So it’s not only mission creep, but we do some things well and we do some things not so well, right? By what metric are you going to hold us accountable for identifying whether people have food, right? The metric we usually hold ourselves accountable for is like I met my hemoglobin A1c target, right? But there’s a lot of steps between here and there and it’s really complicated, right? So I think that concern is a very valid concern. On the other hand, I think we’re sort of at that we’re a country where we are having shorter life expectancies and not meeting goals that we have because we invested a lot of money here and we’re not getting what we paid for. Then the question is, well, what else could we do?
Kirsten: It’s interesting to see that there are organizations that are trying to take this on. So if you look, Kaiser launched their thrive local, so up in Portland. They’re thriving local, they’re screening all their members for social needs and they have a platform that does sort of referrals to social service agencies and actually does a lot of tracking of this, right? That’s one experiment of people trying to do this in North Carolina. One of the women on our committee at the department of public health has basically taken all the social service agencies and really integrated them on a single platform so that some of these referrals can take place more seamlessly. I think people are trying to do different things and I think one of the goals and the committee was not to say there was one way in which health care could take this on. I think it’s to say this is a problem. Healthcare probably needs to be part of the solution and there are many ways in which different organizations are trying to figure out how to do this.
Eric: That sounds it really is about that first recommendation or goals that you actually talked about in your JAMA piece. Design, Healthcare Delivery to Integrate Social Care into Health Care.
Kirsten: Right. So we have five recommendations and I hope you’ll let me talk about my five A’s also. But we have five recommendations and the first one is that is to say if we’re going to do this, you have to actually not just do this haphazardly. A healthcare organization has to sort of take this on. It says we have to do this. Well, we have to figure out the workforce to do this. We have to work ideally with … Are the people we’re trying to serve, patients and communities we’re trying to serve to design this in the right way. That it’s hard to do this. We have a really excellent chapter in this report on implementation and the implementation, the steps to do this is hard. You can’t just screen people not having enough food to eat without understanding how are we going to address that? What are we going to do with that information? That all requires both leadership at the top to say we’re going to do it. Then lots of steps below to really figure out how to do it.
Anne: That sort of speaks to your first A. Doesn’t that? Which is before we know what needs to happen we need … it sounds like we first seem to ask the right questions and assess the need, is that?
Kirsten: Yeah, so we coined this term for the five A’s. It says mostly because we realized that a lot of people were saying, Oh, we should consider social determinants of health. Then we realized people were talking about a billion different things and we said, well let’s try to categorize the activities you could do in the healthcare setting that would address somebody’s social needs. Awareness is the first A, that’s everyone should be aware. Aware that this is important, aware that we might need to do this to take care of patients. Then we have two A’s that are related to how you take care of an individual patient. That is make adjustments, or provide assistance.
Kirsten: The transportation example of the make adjustments says, well let’s do some of our visits remotely so that you don’t always have to drive to see me. Let’s do tele-health. If we’re working in a rural community. Assistance means, for the transportation example, let’s give you a taxi voucher so that you can get home so that that barrier is not one that prevents you from coming to see me. Then we said there are two other As that really speak to the fact that healthcare organizations are organizations that have money, have political clout. They shouldn’t just be doing things one patient at a time, but maybe they should be aligning with community organizations and actually advocating for changes in policy that might help this whole transportation conundrum be better for communities and not just individual patients. So five As, everyone’s aware. Two ways we help patients assist and adjust and then two ways we work at the community or policy level align and advocate.
Eric: All right. Maybe we can talk about a couple of examples. So housing, we have a fair amount of patients that we care for where they’re marginally housed or not housed at all, which is an issue for things like diabetes care, know where to put their insulin, all of those things. How do we use five A’s for housing if that’s the issue?
Kirsten: You want me to jump in? Right, so housing. So that might be for an individual patient that I would be aware that they might be marginally housed. So I’m aware as I’m having the visit with them. I might be working with you to figure out how I provide assistance for them in terms of getting them into housing.
Eric: … about housing as an example. I want to jump to the advocacy piece.
Alex: Inspired by that podcast with Joanne Lynn, Ken Kavinsky, Eric and I are going to set up a meeting with Nancy Pelosi because she’s not doing anything else at this point in time [laughter].
Kirsten: Yes, I don’t know. I’ve heard of her.
Alex: She’s pretty free. I think. So how should we advocate? Because one of the key things we also want to advocate is the integration of social care into healthcare. We met, we like how do we start this conversation? What do we tell her?
Kirsten: You mean specifically? So in any type of advocacy.
Alex: Well we’re first focused on geriatrics and palliative care-
Kirsten: Of course.
Alex: … more, but how do we change the system so that … because she’s involved in legislation. In order to improve care for our older adults and those living with serious illness so that their housing needs are met, their transportation needs are met, they don’t experience food insecurity.
Kirsten: Right. So that’s a really good question. I think so we actually met with Nancy Pelosi’s office-
Alex: Oh, great.
Kirsten: … with this report and other things. There are recommendations that we have in that report about how health care should be financed. There are a lot of ways in these alternative payment models for healthcare. As we say, moving from just providing more and more care to providing value in care. Usually those models are more compatible with thinking through incentivizing things that don’t traditionally look like healthcare to addressing social needs as a part of healthcare and being actually reimbursed for that. I have to say when we’ve talked with her office, one of the things that became clear is that there’s a lot that’s actually allowed currently under our current financing structures. So, some of the take home messages is that more healthcare organizations should just try to do something. They should take on and try to think in more innovative ways about the ways they might organize themselves in partnership with social service agencies to actually deliver sort of care for their patients.
Kirsten: But some of this does need some advocacy in terms of how health and human services agencies might align and continue on the federal government to do this. I have to say health care compared to the social sector agencies, there’s more investment in health care, right? So some of this needs investment in the social sector itself, which is will come from the federal and state level. And so there’s some advocacy on that side. One of the things that we talk about in the report is the need for digital infrastructure to help connect social sector agencies. That’s the type of thing that has been recommended at the federal level for a long time but hasn’t really been funded. We don’t just want to say this is more for healthcare. We need to say that we’re under investing in this really important sector and that needs more money and that will come from the federal state and local level.
Kirsten: With specifically to housing, I mean affordable housing is that the lack of affordable housing is in the end the underlying problem behind homelessness. So we can’t really solve that one patient at a time, right? We can try to provide assistance, we can provide adjustments, but ultimately there are aspects of housing policy that need to be addressed at the federal state and local level that really are important. I think that healthcare organizations who see this and see this in the health needs for their patients need to be part of the advocacy solution to those issues as well.
Eric: I noticed that as you were talking about examples of where this integration of social care into health care is happening are largely in systems that are designed to meet the needs of populations of patients. Kaiser for example, I think of the patients that we care for in the VA and I think that we have a rather robust investment in social workers and other systems that support-
Kirsten: And programs.
Eric: … and programs that support the social needs of our veterans. Including at the end of life when we have a hospice benefit that provides for room and board in a facility for patients who are enrolled in hospice for free, for veterans. I’m reminded of the podcast we did with Vince Moore who suggested we need Medicare advantage for all. That we need a greater investment in health systems that take care of populations of patients and that aren’t motivated by fee for service. The more you bill for the more money you get paid.
Kirsten: It’s interesting that you say that. I think that’s exactly right. And so I think the reason why the time is ripe now for this is because we have more and more examples of either fully integrated systems or for plans that really emphasize alternative payment models, volume not moving from volume to value. And that’s going to create opportunities within Medicaid and Medicaid waivers to design more innovative systems that look more integrated. It’s interesting though, because across the country there’s of course a range of ways we practice, right? Some are in fee for service. Some of the recommendations in this report are simple things the care that a social worker provides should be reimbursed. That is something that if you’re in a fully fee for service model, you have to figure out how to actually build a healthcare team that includes people who can address social needs.
Kirsten: But in the ideal world, I think we’re moving towards what you said is this more integrated because those types of organizations have those built in incentives to think across a range of strategies to actually provide the best care of patients, including addressing their social needs.
Alex: Right. The other reports from national Academy of sciences was about the end care at the end of life. In that report, one of the key recommendations was that Medicare should provide greater support to meet the daily needs of patients in terms of assistance with activities of daily living and potentially in terms of housing support. Because Medicaid of course supports housing for the very poorest individuals and that there’s tremendous variation in Medicaid by state level. But Medicare doesn’t pay for it at all. Should we be pushing for Medicare in particular because it’s at the federal level to fund more of these social programs and are there some that are there low hanging fruit that we might pick off first?
Kirsten: Yeah, it’s really interesting that you say that because I think that Medicaid … they have been designs in Medicaid to actually with these waivers that have allowed organizations to look at different models. I think one of our recommendations was to encourage Medicare to allow more flexibility to think about what could be reimbursed. There are some legal obstacles to this, like what is the actual definition of healthcare, right? That actually doesn’t allow for there to be reimbursement for certain types of things. I think what you want is a flexibility within those structures in Medicaid and Medicare to allow for a greater set of things to be considered part of the delivery of healthcare. I mean it gets back to Eric’s point though how much do you want us to be in the housing business?
Kirsten: Like does that make sense? If you look across the country, there are different ways in which we do that. There are healthcare systems that actually have invested in housing, right? They’ve actually bought up housing because it impacted their ability to discharge patients effectively to care for patients with chronic illness and complex patients more effectively. So sometimes that’s going to be the right answer. I think in other cases it won’t be because it won’t be right for a healthcare organization to be in the housing business. That is why we sort of have those five A’s because it isn’t a one size fits all. But I do think in some situations the ability of the healthcare organization to invest in the community is a better option than the one patient at a time providing a voucher or whatever.
Anne: When I could imagine that if people had to less frequently divert their finances to other social services, the more likely they would be able to maintain their housing or achieve housing.
Kirsten: Well, I think the interesting thing to me, what I’ve been reading about most recently in terms of housing is how many people who end up homeless. The margin that makes them end up homeless is really something that is relatively small and could be invested in if we knew that they were going to. And so you can see if people are teetering on the a few hundred dollars is the difference between remaining housed or not remaining housed. Then if you’re trying to make the decision of … I don’t know, invest paying the co-pay for your medicines or those types of things, it’s all of a sudden … these things are very tied together, right? The number of people who are chronically and homeless over long periods of time is small compared to the large numbers of people. Certainly in our environment who are homeless or marginally housed and for whom considerations at the margins could actually might prevent them from actually becoming homeless.
Eric: So it makes me think hearing Alex’s comment about another report and recommendations, what’s next after these reports? Because it sounds we didn’t have much movement in what Alex was talking about.
Alex: On that particular record.
Eric: On that particular record – what’s next with this report? Does it just get filed away and we kind of move on or is there kind of thoughts on where do we go?
Kirsten: Yeah, super good question. The Academies does a lot of these reports and some of our dissemination strategies is to do briefings on the hill to do briefings with policymakers.
Eric: And to do podcasts.
Kirsten: And to go on GeriPal Podcast. Exactly right [laughter].
Anne: The primary forum, we’re national.
Alex: A national copy of sciences report it’s a dissemination strategy.
Eric: It’s one thing to talk to Pelosi.
Kirsten: Exactly right. But I do think for this particular thing, to me when I’ve gone around to talk to different organizations, it’s pretty clear that there’s a real hunger for this topic that people are struggling with this particular topic and again speaks to the number of organizations that came together and said please do this topic. I think the challenge is that it’s not a one size fits all, people are going to try different things. I think the question now and one of our recommendations is it’d be great to learn from what other organizations are doing. My hope is that especially the organizations that invested in funding this report or other organizations that are trying things that we will learn from what each other are doing and figure out how we can do that in the context of our own clinical environment.
Eric: It just makes me think even like within the VA, like around housing, there’s so many different initiatives. Even here we’ve got to have a podcast on it. There’s a housing development for frail older adults who are marginally housed or not housed at all. Like bringing all these different kind of pieces together to learn from each other, sounds an absolutely fabulous idea.
Kirsten: I think it’s really necessary and I just say you brought up the VA. The VA is a great example of … because it’s an integrated system and because of the commitment to the populations thinking across social needs and health needs.
Alex: Great. Were there any other of these recommendations that you particularly wanted to highlight on the podcast?
Anne: Well, I would say, I mean we talked a little bit about financing and how financing is important. We talked a little bit about healthcare leadership, the workforce. This is something that everybody on a workforce should know and be aware of. But that there are experts in addressing social needs, social workers importantly. But other community health workers, including people like lawyers and other that might be important in a particular practice or people who are family caregivers and who are really outside the healthcare sector and figuring out models for integrating all those. Digital platforms are the ways in which we could potentially link healthcare sectors to social care sectors.
Anne: We don’t have a lot of great models for doing this, but people are trying to do this, and the Kaiser example of sort of having that seamless referral is one example. I think that other organizations are trying to think this out and I think I’m here at digital infrastructure that connects the social sector to those agencies to themselves and to the healthcare sector is one of the things many people would like to see. Then the last recommendation is really what I just talked about is that we have the capacity to learn from each other to learn what works. That there should be a clearing house for best practices, best ways that which we can understand how people are trying to do this. Certainly if Medicare or Medicaid incentivize these models that could be the form for them to learn what’s working the best and to figure out how to provide additional incentives to sustain models that are working.
Alex: I think about that digital, boy that would be revolutionary if we had one health record that we could access reports from adult protective services from there, like the social worker that was seeing them that the county sent out and that we could see the housing support folks could access their medical record to see some sort of abstracted version of their health record that adequately protected confidential information. That’d be fantastic.
Kirsten: That would be fantastic. If you’re the pessimist, you say, well how well are you doing with like your Epic rollout for your healthcare set. Not that great [laugher].
Eric: I just want a social worker in my clinic. Like can we just start off with that?
Kirsten: Exactly. I think you’re right and I think we would all like to get there, but the challenge of getting from here to there. Then I would be remissive not to comment on the fact that once you gather all this data in one place, you have to make sure that you are protecting the most vulnerable groups that you are actually wanting to help with this type of information because information that’s all gathered in the same place that has information about social needs also is information that can be used in ways that would not be helpful to patients or communities.
Eric: All right. My last question, do you have a magic wand? You can use it once. What one thing would you change big or small.
Kirsten: One thing …
Eric: One thing, right now. I gave you the magic. I should have prepped you for that question.
Kirsten: One thing … I don’t know if I could do one thing. I don’t know if I could do one thing.
Eric: It sounds it’s pretty common. There’s so many different facets of this that it actually may be hard, like one thing in something where you’re dealing with multiple social determinants of health would be very challenging.
Kirsten: I think in my clinic environment, I care for patients at public hospitals, Zuckerberg, San Francisco General Hospital. I would love for those referrals to take place more seamlessly. So I as a physician, somebody who worked on this report, I know about the importance, but it’s still hard for me to be the one doing all of that screening, right? I would love for those things to happen in the context of our social work team to happen very seamlessly for my patients and for the systems to work around that. For that to happen. The optimist in me says that when systems invest in saying that we’re going to put everything in place for that to happen, they will also then realize sort of the broader context that they also have to advocate for.
Kirsten: So I think that’s why in some ways it does require sort of that commitment at the top level to say, we’re just going to make sure that every patient who has this need, we’re going to figure out what we can do to address it and get all of our bells and whistles and everything else in a … put that all together to do that. Then I think healthcare will realize where it also has to advocate in partner.
Eric: Wonderful. Well with that, maybe instead of waiting for the world change, note to all our listeners, listened also to the Joanne Lynn podcast because she’s really telling us, don’t wait for that world to change.
Alex: We’re not actually going to change the lyrics to the song.
Eric: Another time. All right. How about …
Kirsten: Send a letter to John Mayer.
Eric: Right? Everybody joined in.
Eric: Perfect again. You like those pauses as I scroll up the lyrics. I forgot to hit the auto scroll button, but see, it makes it more – [laughter]
Kirsten: It just sound like your own personal take.
Anne: I know, exactly.
Eric: Dramatic pause.
Alex: Waiting for the next lyric. Kirsten, thank you so much for joining our podcast.
Kirsten: This was super fun.
Eric: Thank you to all of our listeners for joining us as well. Anne thank you for always coming back onto our podcast. If you have a moment, please take a second and rate us on your favorite podcasting app. Spreading the word really does help our podcast reach other listeners. So thank you for that.
Alex: Thank you to Archstone Foundation for funding this podcast. We will look forward to talking to you next week. Thanks folks. Bye.