What happens when a bus company teams up with a senior center offering health promotion classes? Older people who want to attend are able arrive on time.
On the latest episode of The Dose, host Shanoor Seervai talks to Amanda Brewster, a health policy professor at the University of California, Berkeley, about how health care organizations can work with groups providing social services to get older people the care they need.
While most conversations about health care focus on medical issues, Brewster’s work is part of a growing body of research showing that social factors – like food, housing, and transportation – can have a big impact on our health as well.
AMANDA BREWSTER: In a community in California, a group of government agencies and organizations first joined forces to care for older adults two decades ago. They knew that a growing proportion of the people they served had interrelated needs that affected their health and well-being: medical needs, housing needs, transportation needs. And they knew that different agencies in the community specialized in helping people meet these different needs. But when each organization operated individually, certain needs were overlooked, while other efforts were duplicated.
SHANOOR SEERVAI: So what did they do?
AMANDA BREWSTER: A coalition got together, including the local government, community-based organizations, like the area agency on aging, nonprofit organizations, hospitals, adult protective services, long-term care specialists, mental health care providers — and the most unlikely partner of all — the bus company.
SHANOOR SEERVAI: That’s right — bus companies helped to figure out how to care for the older adults in this California community. I’m Shanoor Seervai, and you’re listening to The Dose. We just heard from Amanda Brewster, a professor at the University of California, Berkeley.
Most conversations about health care focus on the medical aspects of care people receive, like hospital procedures or prescription drugs. But Amanda’s research is about the social factors — like food, housing, transport — that go into whether someone is healthy or not. So on today’s show, we’re going to talk about how community organizations can work together to make sure residents get the services they need to stay healthy.
Amanda, thanks for joining us.
AMANDA BREWSTER: It’s great to be here.
SHANOOR SEERVAI: So let’s get back to the coalition you were describing. Why was it important to have the community’s bus company involved?
AMANDA BREWSTER: In most places, the bus schedule is something service care providers have to worry about — clients can’t get to important services because the bus route doesn’t stop at the right place, or at the right time, or it takes way too long to get there. But in this community, the head of the bus service was right there at the table to discuss how to make things easier for seniors who rely on public transit.
So when the senior center had a new set of health promotion classes or the hospital was offering low-cost, healthy meals for seniors and people didn’t have a way to get there, this was a problem that could be fixed.
SHANOOR SEERVAI: And because the head of the bus service was in the room, the organizations providing care services didn’t need to worry about transport.
AMANDA BREWSTER: Exactly. Decisions about running a transit system are not simple, so the other important thing in this coalition was that it was the head of the bus company participating in this coalition, the person who was in a position to actually set priorities and make changes.
SHANOOR SEERVAI: And you mentioned that several other local organizations were part of the coalition?
AMANDA BREWSTER: Really all of the key groups trying to support the well-being of older adults in the region. Coming together allowed them to raise concerns they were seeing with the clients or patients they served, which others in the room might be able to address.
SHANOOR SEERVAI: So mental health care providers could talk to, for example, a patient’s social worker.
AMANDA BREWSTER: Yes. And because there were so many different perspectives represented in the room, they were able to proactively discuss what needed to change in their community in terms of services available or services needed — with a special focus on lower-income adults and people who are falling through cracks in the existing system.
SHANOOR SEERVAI: Tell me more about why it’s important for different health and social care organizations to work together.
AMANDA BREWSTER: Well, when we look at what puts people at risk of premature death, medical care accounts for just a small fraction of the risk — about 10 percent. The bigger influences are social and environmental factors, and individual behaviors — together those account for about 60 percent of risk of premature death.
SHANOOR SEERVAI: The U.S. spends $3.3 trillion — more than $10,000 per person — on health care each year. But could at least a portion of this money go further if it were spent on social care?
AMANDA BREWSTER: There’s increasing evidence that points in that direction — evidence showing that U.S. states and different countries that tilt their spending a bit more toward social services do better on key health measures, like mortality, and rates of asthma and other health problems. We are also seeing more evidence that some investments in social services, like housing, can actually pay for themselves by reducing heath care spending. People get healthier, which is great in itself, and they don’t need to use as many health care services, which saves money. That is really a great investment to make — you are getting better health at lower cost.
SHANOOR SEERVAI: Take me back, Amanda, to how you got interested in this research in the first place.
AMANDA BREWSTER: It was about four years ago, when I was doing research on hospital efforts to reduce readmissions. I was talking to nurses and case managers who were trying to figure out why some of their patients kept having to come back to the hospital over and over. These frontline clinicians were consistently telling me that it was not just medical challenges, but social needs that made it difficult for people to recover at home. And so that got me wondering if some hospitals were doing a better job of addressing these social challenges.
SHANOOR SEERVAI: So that’s what prompted your most recent research.
AMANDA BREWSTER: Yes, to understand more about how health care and social care organizations work together. Given the importance of both medical and social determinants of health, we wanted to look at some communities that might be collaborating well and bridging the work of different organizations.
SHANOOR SEERVAI: How did you find those types of communities?
AMANDA BREWSTER: We looked for places with good performance on three outcomes for older adults that we thought would be sensitive to collaboration among health care and social services: hospital readmission rates, preventable hospitalizations — complications from conditions like diabetes or dehydrations which can generally be avoided — and Medicare spending per beneficiary. We also found a comparison group of communities that were not performing so well on these same outcomes.
SHANOOR SEERVAI: And what did you find in the communities that were achieving good outcomes?
AMANDA BREWSTER: We found that those high-performing communities did have better collaboration among health care and social service providers serving older adults, but it was specific types of collaboration. What was distinctive about high performers was collaboration on strategic planning and goal-setting, and work that required substantial commitment, like cosponsoring programs together. These relationships were not just about referring patients back and forth, but trying to make sure the services are complementary and meeting the population’s needs.
SHANOOR SEERVAI: That sounds like an important finding — collaboration in itself isn’t enough, it’s how organizations collaborate. Could you give me an example of how a cosponsored program would work?
AMANDA BREWSTER: One example we observed in a community that was performing well was that the area agency on aging actually had a staff member embedded in the local hospital so that that staff member, who was an expert in the social services and home-based services available for older adults, could work directly with patients who were getting ready to get discharged home. So they could help that person with services to get a ramp installed at their house if they needed to, or start Meals on Wheels to get home-delivered meals if they needed that.
SHANOOR SEERVAI: That makes so much sense.
AMANDA BREWSTER: And when we mapped out the collaboration networks in high-performing communities, we noticed that position of health care organizations was especially important.
SHANOOR SEERVAI: What exactly do you mean by position?
AMANDA BREWSTER: Health care organizations were much more engaged with social service organizations in high-performing communities — they had more collaborative links with social services than their counterparts in lower-performing communities. In high-performing communities, when you map out all of the collaborative links, you see tight, productive networks of collaboration linking organizations that provide food and housing and nutrition and other sorts of social services.
SHANOOR SEERVAI: So what you mean is that in these productive networks, the health care organization is actually deeply engaged in the work the social service organizations are doing.
AMANDA BREWSTER: Right. You also see health care organizations positioned much more towards the center of these networks: health care organizations working as active hubs, collaborating with different social service organizations. Whereas when you look at the low-performing communities, the health care providers tend to be more on their own, on the periphery of the network. Not so engaged.
SHANOOR SEERVAI: What does this culture of collaboration mean for patients who are facing a whole host of medical and other needs?
AMANDA BREWSTER: It makes it easier for patients to get the variety of services they need. It means patients don’t have to be on their own trying to find housing or transportation when they are also trying to recover from a complex medical condition. And if this coordination is happening effectively, it is happening behind the scenes.
SHANOOR SEERVAI: You mean the patient shouldn’t have to think about it?
AMANDA BREWSTER: Exactly. It needs to be something that a patient can just step into, without being responsible for wrangling all these moving parts by themselves. So I think that communities where organizations are already working together and thinking together about how to integrate their services make it much, much easier for patients who have a lot of complex needs to actually get their needs met.
SHANOOR SEERVAI: If that’s the case, why has the health care and social services link historically been overlooked?
AMANDA BREWSTER: Health care organizations have a lot on their plates as it is, and have not historically been incentivized to think about population health, and keeping patients out of the health care system.
SHANOOR SEERVAI: It seems counterintuitive — if the evidence is that spending money on food, housing, and transportation keeps people healthier, why do health care organizations tend to ignore this?
AMANDA BREWSTER: Some of this evidence is new, but also, in a fee-for-service health care system, health care organizations get paid more for providing more health care services. There are not a lot of forces pushing that sort of system toward prevention.
SHANOOR SEERVAI: And is this changing?
AMANDA BREWSTER: We are seeing some gradual shifts in how health care providers get paid, efforts to shift incentives so that health care organizations really want to think hard and think creatively about how they can keep patients healthy so they don’t need medical care.
SHANOOR SEERVAI: Could you give me an example of how the incentives have shifted?
AMANDA BREWSTER: One example is hospital readmissions penalties, where hospitals lose money if too many patients end up having to come back to the hospital soon after discharge. If investing in social services prevents the need for costly medical care, it may make sense for health care providers to do that.
SHANOOR SEERVAI: If incentives are shifting, are we actually seeing health care organizations, like hospitals, investing in social services?
AMANDA BREWSTER: Yes. It’s not necessarily a common practice yet, but in our research we saw multiple examples where hospitals recognized that there were certain patients that just were not going to be able to recover after a hospital stay if they got discharged to continue being homeless, or discharged to really poor housing situations. So these hospitals decided it was worth their while to contract with a housing agency to pay for a month, or two, or three months of stable housing for certain patients who didn’t have a safe place to recover.
SHANOOR SEERVAI: So hospitals are paying for housing, which falls outside what we think of as medical care — but the evidence shows housing is actually a critical part of health.
AMANDA BREWSTER: We’ve seen some hospitals making high-profile hospital investments in housing programs over the past couple of years as well — Portland Oregon’s Housing is Health program is a really interesting example, where not just one hospital but six health care systems got together to contribute over $20 million to create new housing and new services that integrate housing and preventative care for low-income residents of the city.
SHANOOR SEERVAI: We’ve talked about transport, and housing, but what about food? I’m thinking specifically of some low-income patients I interviewed some months ago. All of them brought up how difficult it was for them to access nutritious food, either because the grocery store in their neighborhood didn’t stock healthy options, or because they couldn’t afford fresh fruit and vegetables. And, of course, there’s plenty of research that shows how what we eat impacts our health.
AMANDA BREWSTER: I’ll give you an example: In one of the communities we looked at, the food pantry was linking up with a clinic in their area. So when people came in to pick up boxes of food, they could also get a flu shot, or blood pressure screening, or other connections to medical care. And then vice versa, for patients who were flagged by their physicians, nutrition support could be directed right over to this food agency.
SHANOOR SEERVAI: That sounds like another relatively simple fix, but it requires different people, who work at organizations responsible for different aspects of care, to work together. Tell me what you observed in communities where different organizations don’t work well together.
AMANDA BREWSTER: Unfortunately that is a pretty common scenario; it can take a lot of effort to change how an organization works, and collaborate across agencies. And it can sometimes feel risky. I’m thinking of one community where providers, not only in the health care sector but also in the social services sector had the sense that they were all competing, intensely, for a limited slice of pie. I remember there was a social service NGO head who told us, the hospitals don’t want to refer to us because they don’t want to risk losing a potential revenue source, even if it wasn’t for a health care service.
SHANOOR SEERVAI: That sort of competition sounds terrible, especially when patients’ health is on the line.
AMANDA BREWSTER: Yes. And we also learned that intense competition pervaded the way organizations worked together — NGOs not wanting to cooperate with each other because there was a sense of, “we are all competing for the same types of grants and the same types of funding opportunities.” So helping somebody else do better might mean you get less money for your organization.
SHANOOR SEERVAI: So it’s not just that health care is delivered through a fee-for-service system. There are also a whole set of incentives that prevent NGOs from working together.
AMANDA BREWSTER: Yeah, and this in turn prevents communities from doing well when it comes to health outcomes. When we looked at the communities that were doing well, we saw that it was the ones that were much more connected — and as I explained earlier, with the health care organization at the center of the network.
SHANOOR SEERVAI: Besides the financial incentives, why isn’t it the norm for health care organizations to be at the center of the network?
AMANDA BREWSTER: Well, another factor is this: If you go in the office of a typical health care provider, everybody is really working hard to address the medical needs of their patients. So we have very highly trained professionals in the health care sector, physicians, nurses. And what they get trained to do for many years is be experts in the biomedical dimensions of health. Those aren’t necessarily the people who have the right training or connections to help people with their housing.
SHANOOR SEERVAI: That’s true — doctors aren’t trained to solve all the problems that arise from social inequality.
AMANDA BREWSTER: Yes, we have an entirely different sector that has specialized in addressing social determinants. So organizations that specialize in addressing housing and food and transportation exist in pretty much every community. But they just haven’t been as integrated with health care organizations, and the funding for social services is more limited than the funding for health care. I think that also contributes to the challenge of addressing these nonmedical determinants of health.
SHANOOR SEERVAI: And when we think about what actually drives health outcomes, your research is uncovering that partnerships between health care and social service organizations really matter.
AMANDA BREWSTER: Yes, it’s hard work, but some organizations are managing to do it — and their patients seem to be staying healthier, making it seem worthwhile.
SHANOOR SEERVAI: That’s a good note to close on, thanks so much for joining me, Amanda.
AMANDA BREWSTER: My pleasure.
SHANOOR SEERVAI: That’s it for The Dose. If you’re enjoying the podcast, or have ideas for what we could do differently, we want to hear from you. Leave us a review on your podcast app, or send us an email at [email protected].