The Aunt Bertha Blog

Is Social Service Coordination included in your Treatment Plans?

It’s been well documented that social factors play a significant role in people’s health.  In fact, studies show that up to 40% of a person’s overall health outcome can be attributed to things like food stability, transportation, housing, and employment.  



It’s becoming increasingly clear to providers that achieving the triple aim of better patient care, improved health outcomes and lower costs, will require more focus and better coordination around patient needs that fall outside of the healthcare setting.  New payer models are contributing to the rapid acceleration toward more patient-centered care but many are asking, is enough emphasis being placed on social determinants impacting people’s health?

Under the Affordable Care Act's Hospital Readmissions Reduction Program, hospitals are fined significant penalties for repeated admissions that are deemed preventable.  The reality is that multiple readmissions are not always due to of a lack of quality care but rather social factors that are not controllable by hospitals and are not taken into consideration in penalty calculations.  Consider the diabetic who doesn’t have access to healthier foods, lacks adequate transportation to follow up appointments, or is forced to choose between basic needs; healthier food or medication?  Medication or rent?

Health care organizations that implement a standardized process for social service coordination and make it a consistent part of the patient journey will not only create direct economic benefits, it will positively affect patient engagement and satisfaction, as well.  In addition, creating a standardized process of addressing social factors hindering patient wellness allows providers to better track and report trends which ultimately leads to better business decisions.     

Aurora Sinai Medical Center in Milwaukee went a step further in their efforts to address outside social factors impacting patient health by placing social workers in the ER department full time.  They realized that among their patient population, the highest utilizers of emergency room services were constantly in crisis.  They weren’t thinking about scheduling appointments and planning ahead but rather where they were going to sleep or whether they could get groceries. Over a monitored period of time, the social workers began helping patients schedule appointments to see a doctor and coordinated services such as transportation and child care services for the appointment. The results were measurable. Visits by the selected targeted group to the Aurora Sinai emergency room fell by 68 percent, from 487 to 155. Compared to four months before the program was implemented, costs fell from $1.5 million to $440,000. (Kodjak 2015). 

Equipping healthcare staff with the tools and processes to facilitate social service coordination is a win-win-win for both patients and providers, as well as, health care plans covering the costs.  It’s also a great step in shift toward patient-centered care.    

Topics: social determinants of health health care patient care