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Thompson L, Munyikwa M, Aysola J. ‘We Are Only as Safe as Our Most Vulnerable Citizens’: Healthcare systems’ role in reducing exacerbating social and economic inequities before, during, and beyond the COVID-19 pandemic. HPHR. 2021; 30.
DOI:10.54111/0001/DD31
The link between individual social and economic needs and health outcomes is well-known and investigated in the field of public health (Braveman et al., 2011; Evans et al., 1994; Galea et al., 2011; Link & Phelan, 1995; Marmot, 2004; Marmot & Wilkinson, 2005)). As a result, screening for social needs and implementing interventions are becoming a mainstay value-based strategy among many US health systems (L. M. Gottlieb et al., 2017; Horwitz et al., 2020). However, in the year-long presence of the novel coronavirus disease (COVID-19) pandemic, recent studies have suggested that social risk factors, such as financial, housing, and food insecurity, may have worsened, leading to a burgeoning social and economic crisis in the United States (Bartsch et al., 2020; Dunn et al., 2020; Sharma et al., 2020). Especially among vulnerable populations, these consequences have had a critical impact on national rates of COVID-19 morbidity and mortality (Van Dyke et al., 2021).
Health care systems must universalize social needs screening and response programming in order to meet the complex social and health needs of patients, during and beyond this public health emergency. This editorial aims to highlight the essential role of healthcare systems in mitigating unmet social needs during and beyond the COVID-19 pandemic. Here, we will describe how the COVID-19 pandemic exacerbates existing social and economic inequities, highlight the current role of the health-care system in responding to individual and population-level health outcomes, and examine two large health-care systems’ social needs referral and response programs piloted before and during the current public health emergency. Lastly, we will conclude with possible implications and future directions for public health, and other stakeholders, in addressing these dual crises during and beyond the pandemic.
Unmet social needs were a practice, research and policy imperative prior to the current public health crisis. In June 2019, Kaiser Permanente distributed a nationally representative survey, Social Needs in America, which included over 1,000 American adults in households that earn an income of less than 138% of the federal poverty line. The results were damning. About a third of Americans experience frequent or occasional stress over their basic needs – housing, food, transportation and social support (Kaiser Permanente Research, 2019). An even closer look revealed Americans’ food and housing expenses represent nearly 50% of their budget with healthcare spending accounting for 9%. Prevalent across income and age categories, food insecurity and social isolation were the most commonly reported social needs. Notably, more than a third (35%) of these respondents lacked confidence in their ability to find the resources to meet their own needs and more than a quarter (28%) have experienced a barrier to their health as a result of unmet social needs. With such a considerable prevalence and impact on the burden of disease in the US, it is no wonder there has been a widespread call to focus on the social determinants of health in public health practice, research and policy (Abrams & Szefler, 2020; Braveman et al., 2011; Kuh & Ben Shlomo, 2004; Lynch et al., 2000; Thompson et al., 2019). These adverse social and economic conditions produce constraints on people’s self-efficacy and capacity to maintain health and wellbeing and have only been exacerbated by the advent of the COVID-19 pandemic.
In the United States, susceptibility to severe COVID-19 morbidity and mortality has fallen along socioeconomic and racial lines, with the African American, Latinx, and Native American communities disproportionately impacted (Dalsania et al., 2021; Phillips et al., 2020; Van Dyke et al., 2021). Often by the mere phonetics of a name or arbitrary phenotypic features, these groups face overwhelming structural vulnerability where historical stigmatization have led to a contemporary exclusion from adequate living, learning, and working conditions further health disparities we see today (Amutah et al., 2021; Aysola et al., 2011; Bailey et al., 2017; Holmes et al., 2020; Metzl & Roberts, 2014; David R. Williams et al., 2019; D. R. Williams & Collins, 2001). Unlike white-collar workers who can often work from home, many of these workers, commonly receiving low-wages in industries such as grocery or home health, are unable to work from home despite lockdowns (Larochelle, 2020; McClure et al., 2020; The Lancet, 2020). Economic barriers have resulted in challenges with isolation and quarantine, and school closures have created burdens on parents and caregivers (Kantamneni, 2020; Karpman et al., 2020; McClure et al., 2020; Russell et al., 2020).
The volume of daily requests for food, housing-related and transportation assistance surged as a result of stay-at-home orders, loss of employment, and crowded homes (M. Kreuter et al., 2020). Most importantly, in-person visits are also scarce forcing some chronically and terminally ill folks, including those with underlying chronic respiratory conditions, to defer necessary treatment to reduce their risk of contracting the deadly virus (Baum et al., 2021; Lam et al., 2020; Nouri et al., 2020; Wosik et al., 2021). In this evolving context, we see even more clearly structural forces shape and produce inequitable downstream outcomes in the lives of our most vulnerable populations. Thus, unmet social needs are an urgent site of intervention.
Healthcare systems play an important role in addressing social risk factors to improve individual and population level health outcomes (L. M. Gottlieb et al., 2017). They are often located in neighborhoods addressing the acute needs of the homeless through emergency services to the preventative care of mothers and their families to the long-term needs of the chronically-ill. Laura Gottlieb and colleagues have offered critical strategies for healthcare systems to address patient social needs and reduce health care costs with a dual focus on patient care and community health (L. Gottlieb et al., 2019).
The patient care strategies involve two levels of investment: social risk informed care and social risk targeted care. The prior involves the healthcare system’s adaptation of care delivery based on an awareness of the patient’s environmental (social, behavioral, or economic) circumstances. This entails healthcare systems utilizing rigorous, validated tools to collect social risk data that informs clinical decision-making. Commonly seen examples may include the provision of patient transportation for outpatient visits or the offering of a translator to patients with limited English proficiency. Yet, these strategies are insufficient, and somewhat unethical, without the use of the latter – social risk targeted care – which demands activities that directly address and impact patient social needs. Here, the incorporation of social workers, community health workers and other useful navigators is essential in facilitating and coordinating referrals to internal and external resources to meet specific patient needs.
While acknowledging healthcare systems’ need to cut costs, the authors also offer broader community health strategies that implores use of financial investments and cross-sectoral coalitions for the intended consequence of population health improvement. These strategies require social risk data for the system’s larger geographical domain or reach. As a fiat of the Affordable Care Act, the community benefit has been allotted to tax-exempt health systems intended to promote wider community health spending – yet, it has often gone to reimbursed patient care (Young et al., 2018). Instead, eligible health systems should shift these resources towards building workforce capacity and meaningful investments in community health initiatives that produce tangible social returns, such as affordable housing, economic development, and food banks. The Centers for Medicare and Medicaid Services’ (CMS) Accountable Communities for Health (ACH) Model also supports health systems’ engagement with community partners to not only mitigate and intervene population social risk, but also reduce healthcare cost and utilization (Hsu, 2017; Hughes & Mann, 2020). These broad coalitions allow synergistic decision-making warranted by value-based payment models and sustainable effects on population-level social risk factors (Horwitz et al., 2020).
Social needs interventions are an important component of the health system response to health disparities in their communities. In fact, four in ten (42%) Americans want medical providers to assess their social needs and connect them to resources that can help, and a majority (51%) would also feel supported by these inquiries (Kaiser Permanente Research, 2019). While there is a growing multi-stakeholder interest in responding to social needs, models for doing so – particularly in the context of a pandemic – are scarce (Gurewich et al., 2020; Parrill, 2020). However, recent examples of innovative solutions suggest that such interventions are both feasible and acceptable in their communities.
Of the many health systems developing and implementing social needs screening and response programs, one had instituted a social needs referral and response program prior to the pandemic and featured its utility during the pandemic: New York City Health + Hospitals (NYC H+H). This public health system is the largest of its kind in the US, providing accessible care to over 1 million low-income, minority, immigrant and other vulnerable populations across the city’s five boroughs. These populations are disportionately uninsured, beneficiaries of Medicaid or Medicare, and at increased risk of food, housing, and overall economic insecurity. Based on the CMS’ACH screening tool, in 2017, their staff administered self-reported surveys to their patients to screen for eight social needs domains – food insecurity, insurance coverage, housing insecurity, domestic violence, welfare benefits, adult education, legal assistance, and caregiver services – to inform the vital connections for effective workflow and referral for implementation within the health system (Billioux et al., 2017).
Berry and colleagues conducted a qualitative study on two of their adult outpatient clinics and one pediatric clinic, querying staff and providers to find barriers, facilitators, and recommendations of their social determinants of health (SDOH) screening pilot intervention (Berry et al., 2020). Use of non-clinicians for screening, streamlined data tracking, an emphasis on patient-related factors, and the presence of community-based partnerships were found to be crucial to the establishment and growth of the screening and referral program at their facilities. These translated into useful best practices to respond to their patient’s burgeoning social needs from the start of the pandemic – the creation of a data-tracking system of social needs screening and results, a volunteer program (Health Advocate), a electronic closed-loop referral system (NowPow), and an intensive case management team? for patients with high acuity.
In a Health Affairs commentary, Jennifer Clapp and colleagues described the necessity of this existing foundational program to address the “shadow” of the pandemic – the compounding effects of structural inequities during the COVID19 pandemic (Clapp et al., 2020). With social workers at the helm, this health system was able to adapt their approach and expand their operations to address unmet social needs of their patients and families. Their outreach team, in partnership with local community based organizations, was able to reach more than 500 households and provided about a quarter of those with assistance in receiving food stamps, identifying nearby food pantries, or registering for city-approved meal delivery programs for improved patient access to food. A pre-existing relationship with the city’s Department of Homeless Services and the New York Legal Assistance Group allowed this health system to also develop quarantine and isolation sites for the city’s 55,000 shelter dwellers, as well as telephone-based legal counsel, to residents facing housing insecurity. Lastly, care coordinators and social workers connected up to 500 low-income patients to cash assistance grants with priority towards the undocumented who are traditonally barred federally-sourced assistance.
Some health systems also witnessed and understood this “shadow” pandemic but did not have a centralized social needs response instituted. At one such institution, the University of Pennsylvania Health System, the Social Needs Response Team emerged to respond rapidly to the growing need in the Philadelphia region. Rapid-cycle innovation was employed to urgently screen patients for social risk and quickly connect them to resources. The sites of the Hospital of the University of Pennsylvania (HUP) and the Penn Presebyterian Hospital (Presby) are located in some of most under-resourced neighborhoods not only in the city, but also in the nation. With the city’s poverty rate nearly at 25%, West and Southwest Philadelphia communities face high burdens of unmet social needs, as revealed by the city’s past Community Health Needs Assessments (CHNA). Nearly half of all West Philadelphia adults face housing insecurity, and the city’s households also account for nearly half of the state’s utility assistance. Philadelphians face higher food insecurity rates than neighboring counties, and 1 in 9 of the city’s older adults are without access to transportation (Philadelphia Department of Public Health, 2017). Thus, clinicians, faculty, and students are presented with a unique opportunity to improve population health and promote health equity within these communities.
In direct response to the pandemic, this health system formed a clinical social worker-supervised interdisciplinary team of graduate-level health professionals (medicine, nursing, social work) who sought to address patient safety, distress, and a myriad of other unmet social needs in order to effectively mitigate their compounding negative effects of the dual crisis. There are a few features of this program that provide novel consideration and direction for prospective social needs referral and response programs. Firstly, this initiative is entirely remote, consisting of a coordinated call center of virtual teams using scripted screening questions and protocols to assess distress and social needs and to connect patients to needed resources- which may, upon evaluation, prove replicable for optimal cost-effectiveness. Secondly, the program addresses the documented challenge of burden on existing staff (especially during a public health emergency) by leveraging the commitment and flexibility of graduate health professionals to address ongoing social needs while providing the practical fieldwork experience vital to the promotion of health equity (Berry et al., 2020). Thirdly, the program’s approach is grounded in tenets of crisis intervention theory, where student volunteers are trained to provide a safe and empathic space for joint prioritization, navigation, and resolution of patients’ identified social needs (Roberts, 2000).
Since its inception, the SNRT has received over 1,000 referrals. Food assistance (37%), housing (17.2%) and employment (15.8%) among the most commonly identified social needs. Majority of participants (51%) are referred to a community based organization and/or primary clinics for coordination of care. In reference to demographics, the average age of the patients referred is 45 years of age, Black (64.9%) and female (59%). The program is yet another demonstration of the value in strategic collaboration across a health system and, most importantly, with community-based resource organizations. Notably, among community partners, this health system serves as a referral source and resource for addressing the social needs of locally-residing patients and, also, their on-campus students, staff, and faculty.
Echoing Dr. Mary T. Bassett’s commentary, the COVID-19 pandemic has ravished the poorest and most marginalized Americans. The inadequacies of our health, social and economic systems are well-known; thus, the dismal impact on American adults and their families could have been prevented with actionable preparation and intervention (Dr. Mary T. Bassett’s Statement on COVID-19 for the Poor People’s Campaign, 2020). Responding to social needs means ensuring health care, housing, and employment for all Americans, which requires innovative solutions and synergistic health system interventions. At many institutions, multi-pronged approaches are emerging to tackle these needs. First, decision support tools and references built into the Electronic Medical Record, such as Aunt Bertha and NowPow, offer an opportunity to screen individuals at point of care, funneling patients into social needs interventions with greater frequency (Lindau, 2019; Schulman & Thomas-Henkel, 2019). Multi-disciplinary, technological approaches like those described here – from first-pass screening to intensive case management – are the future of social needs response and will become a mainstay in health-system community health engagement (Gurewich et al., 2020; Parrill, 2020).
Further questions remain, however. Firstly, how do we harness the role of direct patient navigators and community health workers, whose positive impact and cost-effectiveness has been documented in the literature (Chaiyachati et al., 2016; Kangovi et al., 2014, 2017, 2018, 2020); but still work towards structural solutions. Before and during this pandemic, we have had to face a hard reality about our health system: it is needlessly complex, extrinsically biasing a vast majority of US adult patients, and often proliferates inequities among the populations. Future public health researchers and practitioners must reorient programmatic interventions away from an approach that is population-deficit focused and instead look inward to correct the deficiencies within our health system and upstream to address structural determinants of health. (Hansen & Metzl, 2016; Metzl & Roberts, 2014; Paradies et al., 2015). Secondly, what role do health systems have in broader interventions into the structural roots of the social determinants of health, for example through interventions in housing and educational policy (Chaiyachati et al., 2016; Fichtenberg et al., 2020; L. M. Gottlieb et al., 2019; Katch, 2020; M. W. Kreuter et al., 2021)? Thirdly, how can health systems sustainably partner with community organizations and ensure their longevity in creating equitable change (Agonafer et al., 2021; Chaiyachati et al., 2016; Park et al., 2019))? As we seek the answers to these questions, there is one thing that we do know – healthcare systems are bound to play a pivotal role in the actionable impact on the decimation of social and economic inequity in the United States now and beyond the COVID-19 pandemic.
Latisha D. Thompson MSW, LSW currently practices as a medical social worker serving home-bound populations in Philadelphia. This spring, Latisha will complete her Master of Public Health (MPH) program at the University of Pennsylvania Perelman School of Medicine. She is also a member of the evaluation team for Penn Medicine’s Social Needs Response Team (SNRT).
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