Two Portland-based healthcare research organizations are collaborating to understand how social determinants of health impact measures of health care quality.
Why is this important?
Research suggests that the social determinants of health – the conditions in which people are born, grow, live, work and age – may contribute more to health outcomes than medical care. These determinants include a wide range of social, economic and environmental factors such as availability of resources to meet daily needs (e.g., safe and affordable housing, healthy food), access to educational, economic, and job opportunities, social support, neighborhood and community safety and clean air and water. Differences in these factors help to explain why some people experience better health than others and why there continue to be such profound disparities in health outcomes in the United States. As part of its Healthy People 2020 initiative, the U.S. Department of Health and Human Services highlighted the importance of creating “social and physical environments that promote good health for all” through action in five key areas, including health care, education, neighborhood, economic stability and social and community context.
Insurers are increasingly implementing policies that tie the amount of reimbursement that health care providers receive to measures of health care quality. These measures of health care quality are typically based on clinical outcomes of patients, such as the number of patients who have uncontrolled diabetes or who go to the emergency room. Reimbursement amounts do not take into account the social determinants that impact health. Failure to incorporate these determinants into health quality measures may explain why health care organizations that serve low-income patients often appear to perform poorly on quality measures relative to those serving patients with higher incomes. There are concerns that ignoring patients’ social determinants in quality measures may unfairly penalize providers that serve patients with complex needs and further compound the burden of health disparities on vulnerable populations. Therefore, fuller understanding of the impact of these determinants on patient outcomes may have important implications for reducing disparities in health systems.
Local researchers from OCHIN Inc. and the Kaiser Permanente Center for Health Research-Northwest (CHR-NW) are partnering to study these important issues. OCHIN is a nonprofit health care innovation center that provides health information technology support and services to more than 500 clinical sites across 15 states. OCHIN works with community health centers that serve vulnerable populations across the country. Community health centers provide care regardless of a patient’s ability to pay, and their patients are largely low-income, often on Medicaid or uninsured, and are more often from racial and ethnic minority groups.
The Center for Health Research – Northwest conducts independent research within Kaiser Permanente Northwest’s integrated health care system, which serves 606,000 medical members and 280,000 dental members in Northwest Oregon and Southwest Washington. Research areas at CHR-NW include health services, public health, tobacco cessation, obesity and weight loss, mental health, maternal health, cost-effectiveness, cancer screening and many others.
Researchers from OCHIN and CHR-NW are using information on social needs from patients’ electronic health records (for example, a patient’s insurance status or household income) and data from the US Census and American Community Survey about the social conditions of the neighborhoods where patients live (for example, the percentage of individuals in the patient’s neighborhood who have an income below the federal poverty level) to understand how these factors impact specific outcomes like diabetes control and emergency department utilization. This study focuses on patients, communities and providers in Oregon and Washington.
In previous work on this topic, the study team found that social determinants did indeed affect health outcomes in patients seen at community health centers from OCHIN and the OneFlorida health network. As expected, patients receiving care in these community health centers lived in more socially vulnerable communities than average U.S. populations. We found that social determinants of health and clinical factors explained more of the variation in clinic-level care quality – such as diabetes control or emergency department utilization – than accounting for clinical factors alone.
One limitation of previous work was that it focused only on clinics serving vulnerable populations and that the results may not apply in other patient populations. The study team at OCHIN and CHR-NW recently received additional funding from the Patient-Centered Outcomes Research Institute to expand this research beyond safety net clinics to a less vulnerable patient population (e.g., where a large percentage holds private health insurance). The collaboration between OCHIN and Kaiser Permanente CHR-NW enables us to look at patients from a broad mix of social circumstances and levels of social deprivation. Increasing the types of patients included in our study will give us a better understanding of the impact on health outcomes and health care utilization.
The study team wants to ensure that findings can help health care leaders improve delivery and policy. We are committed to engaging stakeholder advisers (patients, clinicians, communities, health systems leaders, policymakers/payers and other researchers) who understand those experiences best. These stakeholders provide regular and unique voices to help the study team evaluate the implications and utility of their findings, especially for clinical decision-making, system improvement and health care payment and policy. Stakeholder advisers will help the study team interpret the results of the study, provide context to vast amount of data, and communicate findings to the public and research groups. The study team includes over 20 researchers and stakeholder advisers. The study is led by Erika Cottrell, Ph.D., and Abby Sears, MBA, MHA, at OCHIN and Stephanie Fitzpatrick, Ph.D., and Mary Ann McBurnie, Ph.D., at the Kaiser Permanente CHR-NW.
This research is critical because it considers a larger context of factors that may affect a person’s or population’s health. What we learn from this study has the potential to impact how policymakers influence change within health systems and improve patient-centered health care. The study team will report back to Street Roots with our updated findings.
Erika Cottrell, Ph.D., MPP, is an OCHIN Investigator. Jean Baker, is the patient adviser for the Health Systems Demonstration III project.
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