SDOH Center of Excellence to support providers in addressing social determinants of health

Date: 06/25/19

New Orleans, LA (June 25, 2019) – When an intensive surgery to repair an infected metal plate in her arm left New Orleans resident Terthia* without a home or a job, she wasn't sure where to turn. With no family nearby and no income, Terthia had no choice but to put her possessions in a storage unit and move into her 2001 Buick LeSabre.

Just like that, Terthia joined the ranks of Louisiana's homeless population. "I've worked my whole life. I always had money - not a lot, but enough. I couldn't believe I was one of the people on the streets," she said.

For months, she slept in her car in parking lots and beneath bridges. She was sometimes forced to move along by security guards, and she was often frightened away from favored parking places by homeless men. After nearly a year of living in her car, she was contacted by a social worker with her Healthy Louisiana Medicaid health plan. And when Jasmine Harkless-Thomas, a Louisiana Healthcare Connections Licensed Clinical Social Worker, discovered Terthia’s living situation, she began coordinating local resources to help her find safe housing.

Within an hour of their initial meeting, Harkless-Thomas established that Terthia qualified for low-income housing, located an apartment vacancy and helped her apply. Three weeks later, Terthia moved out of her car and into a safe apartment.

“Jasmine rescued me. Without her, I really don’t know where I’d be today,” Terthia said. “When you’re in that shape, it’s hard to believe anything will get better. But with her help, things got a whole lot better.”

For Harkless-Thomas, however, helping people like Terthia is her job. “We all have the opportunity to make an impact by reducing stigmas, having those hard discussions and building relationships with our members,” she said. “Our team was built on the idea that improving health takes a coordinated, integrated approach, and an important part of that is helping our members overcome non-health factors that are negatively impacting their health, like homelessness and food insecurity.”

These factors, called social determinants of health, or SDOH, affect a wide range of health, functioning, and quality of life outcomes and risks, according to the Centers for Disease Control and Prevention (CDC). Examples include the availability of healthy foods, safe and affordable housing, access to education and health services, and public safety, among others.

“What we know is that healthcare really represents only about 10 percent of a person’s health,” said John Kight, DNP, RN, FNPC, NEA-BC, Senior Vice President of Population Health for Louisiana Healthcare Connections. “When basic needs like food, shelter and transportation are not met, families are forced to neglect their health needs. As a result, healthcare costs increase as health outcomes decline.”

Creating an integrated network of community-level resources and healthcare provider partnerships has long been the foundation of Louisiana Healthcare Connection’s approach to transforming health, Kight said.

“The unfortunate truth is that Louisiana has often fallen at the wrong end of the scale in terms of health and healthcare rankings. Our state has a significant number of healthcare provider shortage areas, geographic disparities in care, and poor performance in important predictors of health, like educational attainment, employment status, and income level,” Kight explained. “Reversing these issues won’t happen overnight, but it can happen. And we are committed to being part of the effort to make it happen.”

Over the past few years, the Healthy Louisiana Medicaid health plan has launched a number of SDOH-focused initiatives, including a community health grants program to fund community-level projects that address food insecurity and a physician education campaign to promote the use of Z-codes in medical claims.

“Every medical claim includes codes that indicate the types of services rendered by the physician, but many physicians are providing services that go beyond medical care,” explained Kight. “Z-codes are used by physicians to indicate non-health factors that influence outcomes. For example, if a patient isn’t taking his or her medication due to a financial problem, or not following an appropriate diet because of food insecurity in the home – these are issues that can be documented with Z-codes. And when we see those codes on the claim, we know we need to provide some targeted outreach to that patient to help them overcome those barriers to care.”

As this outreach has grown, so has the health plan’s need for a centralized SDOH strategy, leading to the creation of the Louisiana Healthcare Connections SDOH Center of Excellence. The center will be based in the company’s New Orleans office, and will focus on providing “comprehensive, whole-person care” to its 450,000 members across the state, Kight said.

“This team will coordinate resources and implementation to eliminate gaps in healthcare and social services,” he explained. “Their focus will be on providing our members with personalized assistance and helping them to better navigate what can be a very complex system of care.”

The team that will power the SDOH Center of Excellence is being built now, Kight said. “We are in the process of developing a team that will include population health experts, clinicians, social workers, community health workers and more. Together, they’ll work with our network providers and integrated care management team to make sure our members don’t fall through the cracks in the system.”

The SDOH Center of Excellence is expected to be fully operational before the end of the year, and will play an increasingly key role in the health plan’s mission to transform health in Louisiana, one person at a time, according to Kight.

“When families have access to the right combination of quality healthcare and appropriate community-level resources, health improves and healthcare costs go down,” Kight said. “To us, it’s not an innovative strategy. It’s a common sense solution for the health of our state.”

*Member’s last name withheld to protect privacy.