Sarah Ridout, MBA, SPHR
Communications and Development Director
There is amazing work taking place in our communities. Even before COVID, I have continued to be uplifted by stories of health care workers looking for ways to better serve patients, meeting the healthcare challenges within our region, and exploring ways to provide greater access to health care. Within southeastern North Carolina, we see the tremendous outreach by Human Service Organizations (HSOs) to support underserved populations and those facing adversity, inequity, inequality, or all of the above.
Working for a non-profit that specializes in population health, we hear stories from our Care Teams about the barriers to better health. While some may revolve around a lack of understanding about navigating the healthcare system or needing support to manage chronic conditions, a substantial barrier for our members is basic physiological and safety needs such as food, shelter, resources, and personal security—all of the areas in which our HSOs work so hard.
So how can we open the door to these relationships? How can we get practices and providers into the same “rooms” as HSOs to form an effortless and trusted relationship—one where the patient talks openly with a doctor about how putting food on the table took precedence over buying diabetes test strips or the challenges of getting to the pharmacy without transportation?
What would happen if doctors knew how to refer patients to resources in real-time or, on the flip side, what if an HSO could screen for basic health needs and know who to send that person to? How can we create a bridge that influences health disparities and access to whole health care?
Currently, 90% of health care spending in the United States is on medical care. National health spending is projected to grow at an annual average rate of 5.4% and reach $6.2 trillion by 2028. Research suggests that social determinants of health—these physiological and safety needs such as food insecurity, housing, transportation issues, and interpersonal violence—and health behaviors drive about 80% of health outcomes for patients.
To reiterate that point, 80% of health outcomes (and the associated healthcare costs) could potentially be impacted by simply connecting those in need with the right resources! That is reason alone to consider building our bridge—or at least one lane of it.
But what about the other lane–the one going from the HSO to the provider? Getting preventive care reduces the risk for diseases, disabilities, and death, yet millions of people in the United States don’t get recommended preventive health care services. Many vulnerable men, women, and children may visit the food bank before going to an annual wellness visit.
In fact, the work that CCLCF is currently doing at the Harrelson Center shows us just that. A client will come into the Harrelson Center’s Help Hub for emergency services, only for the intake coordinator to discover that the client also hasn’t been able to fill a much-needed prescription, may need medical equipment, or would benefit from behavioral health services.
North Carolina is fortunate, as experts are already recognizing these healthcare barriers and are working to address them. As part of NC Medicaid Transformation, the federal Centers for Medicare and Medicaid Services (CMS) approved a groundbreaking pilot program called Healthy Opportunities. Over the next five years, NC Department of Health and Human Services (NC DHHS) will provide three selected Healthy Opportunities pilot regions with up to $650 million in Medicaid funding to pilot services related to housing, food, transportation, and interpersonal safety in an effort to directly impact the health outcomes and healthcare costs of Medicaid beneficiaries. NCCARE360, a platform uniting health care and HSOs, is the first statewide coordinated care network to better connect individuals to local services and resources. New Hanover Regional Medical Center, in partnership with the Community Partners Coalition, allows residents to search for free or reduced-cost services like medical care, food, or job training on Our Community Link.
What we’re saying is, the resources are available, so how can we optimize their use?
Adding a health care navigation channel to HSOs providing non-health care-related services is an option to consider.
What if… there was a standard set of health-related questions that HSOs could add to their intake process form? We know that many HSOs already hear challenges from an individual or their family that go beyond the reason they are there in the first place.
What if…we were to educate HSOs on how to ask those basic health-related questions and then have a Healthcare Navigator onsite or on the phone in real-time? Community Care of the Lower Cape Fear and The Harrelson Center are currently piloting this program with great success. Could we scale this to other HSOs in our region in order to increase preventative health services and the use of a primary care physician instead of the Emergency Department for non-emergencies?
What if…practices and providers had access to a Healthcare Navigator that was located within our communities and knew our local resources to improve food security, address housing concerns, link to transportation, and help guide someone to interpersonal safety?
What if…we could use platforms like NCCARE360 to create a whole health care concept?
The good news is that some of this work is already taking place. We need to ensure that we do it in a way that the goal is the citizen, working across organizations to build consistency and sustainability in the process. We must work together to transform our community and equip our practices, providers, and HSOs with the tools they need to increase access to health care and health-driven support services.