Integrating Health-Related Social Needs as a Standard of Care

The Opportunity

The environments where children live, learn, and grow, along with health-related behaviors, consistently drive their health. Health care systems that can seamlessly integrate these “social factors” into care delivery and reimbursement strategies will be far more effective at managing health, improving experience, and creating value for their customers. A large pediatric health system sought to address these factors in ways that were effective, feasible, and sustainable.

Approach

Genesis led the development of an integrated, scalable, pediatric social health approach to systematically screen for and address essential human needs (e.g., healthy food, stable housing) as a standard part of clinical care.

Outcomes

Model implementation produced measurable improvements in:

• Patient health outcomes – 17.2% reduction in abnormal asthma scores; 17.4% decrease in abnormal depression screens
• Family experience – 91% I prefer to come to a clinic that asks about things I need outside of the doctor’s office, like resources for jobs, housing, food, childcare, etc.
• Provider satisfaction – 92% I value having this service available in my clinic
• ED utilization – significant decline in visits/1,000, p=0.006
• Total annual spending on healthcare – significant decline in PMPM, p=0.024

Key Success Factor

Design, implementation, and evaluation of this model were approached as a learning exercise, with active engagement of stakeholders across the care continuum (e.g., clinicians, operational staff, system leadership, and patient families), which enabled rapid process adjustments and facilitated behavior change among clinic staff.