September 4, 2016

“Upstreamist” reduces healthcare utilization by providing a lawyer!

In an effort to reduce demand for healthcare services among high utilizing homeless vets,  Rishi Manchanda, MD did NOT ask to hire more health care professionals.  Instead, he successfully persuaded the West LA Veterans Administration Medical Center to bring in a public interest lawyer once a week.

The purpose was to identify vets with unmet legal needs that were in turn creating / driving demand for health care services.   That bet paid off.  Healthcare utilization decreased by 24% among the 139 homeless vets who participated.   The pilot program cost an average of $525 per person, and the vets gained access to more than a half million dollars in increased disability and other cash benefits.    Helping the vets resolve stressful legal, administrative, or financial barriers to housing, for example, made a big difference.

Manchanda is an advocate for moving “upstream” in order to achieve the so-called “quadruple aim” of healthcare:   better care, lower total medical costs, as well as increased patient and physician satisfaction.   [The Institute for Healthcare Improvement uses the term “triple aim” which ignores the issue of professional satisfaction.]  In Manchanda’s view, the KEY to achieving the quadruple aim is the integration of “social determinants” in health care.

Manchanda asserts that physicians are forced to work  with one hand behind their backs unless social determinants are addressed.  “Unlike all of our peer nations, we have more spending on health care than social services.  That actually creates a scenario where you have DOCTORS talking about moving upstream.”  In fact, he now calls himself an “upstreamist.”    You can read more about his remarks which were made at an AMA conference on radical redesign in health education.

Public health researchers have been intently studying what is called health inequalities or health inequities.  The country of Ireland has a particularly straight-forward definition:  “Health inequalities are preventable and unjust differences in health status experienced by certain population groups. People in lower socio-economic groups are more likely to experience chronic ill-health and die earlier than those who are more advantaged.”  In the U.S., health status varies with race and culture as well as with socio-economic status.

In the US, the phrase “social determinants of health” refers to the EXTERNAL CONTEXT in which a person lives such as safe housing, local food markets, access to educational, economic and job opportunities, access to healthcare services, public safety, cultural and social norms and attitudes, exposure to crime and violence; housing and community design, natural environment, etc.. All of these things have been shown to have an impact on health status.  (See more below).

Social determinants do not include INTERNAL PERSONAL FACTORS like a person’s life philosophy, the things they or don’t know, their past life experiences, preferences, attitudes, motivations, intentions, values, beliefs, emotions, or other psychological dynamics.  Obviously, both internal personal and external factors influence people’s behavior and what happens (outcomes).  Thus, our more comprehensive BPSE model of sickness and disability includes the ENTIRE context:  BOTH external AND internal personal factors.  (BPSE = bio-psycho-socio-economic)

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From the U. S. Government’s Healthy People 20/20 website:

Understanding Social Determinants of Health

Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Conditions (e.g., social, economic, and physical) in these various environments and settings (e.g., school, church, workplace, and neighborhood) have been referred to as “place.”5   In addition to the more material attributes of “place,” the patterns of social engagement and sense of security and well-being are also affected by where people live. Resources that enhance quality of life can have a significant influence on population health outcomes. Examples of these resources include safe and affordable housing, access to education, public safety, availability of healthy foods, local emergency/health services, and environments free of life-threatening toxins.

Understanding the relationship between how population groups experience “place” and the impact of “place” on health is fundamental to the social determinants of health—including both social and physical determinants.

Examples of social determinants include:
•    Availability of resources to meet daily needs (e.g., safe housing and local food markets)
•    Access to educational, economic, and job opportunities
•    Access to health care services
•    Quality of education and job training
•    Availability of community-based resources in support of community living and opportunities for recreational and leisure-time activities
•    Transportation options
•    Public safety
•    Social support
•    Social norms and attitudes (e.g., discrimination, racism, and distrust of government)
•    Exposure to crime, violence, and social disorder (e.g., presence of trash and lack of cooperation in a community)
•    Socioeconomic conditions (e.g., concentrated poverty and the stressful conditions that accompany it)
•    Residential segregation
•    Language/Literacy
•    Access to mass media and emerging technologies (e.g., cell phones, the Internet, and social media)
•    Culture

Examples of physical determinants include:
•    Natural environment, such as green space (e.g., trees and grass) or weather (e.g., climate change)
•    Built environment, such as buildings, sidewalks, bike lanes, and roads
•    Worksites, schools, and recreational settings
•    Housing and community design
•    Exposure to toxic substances and other physical hazards
•    Physical barriers, especially for people with disabilities
•    Aesthetic elements (e.g., good lighting, trees, and benches)

By working to establish policies that positively influence social and economic conditions and those that support changes in individual behavior, we can improve health for large numbers of people in ways that can be sustained over time. Improving the conditions in which we live, learn, work, and play and the quality of our relationships will create a healthier population, society, and workforce.

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