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Episode 73: Social Risk Factors and Health

by Aledade

Dr. Alisahah Cole is the Chief Community Impact Officer at Atrium Health (formally known as Carolinas HealthCare System), an integrated healthcare system based in Charlotte, North Carolina.

She joins Josh and Joe to talk about how health systems can help tackle Social Determinants of Health including; food insecurity, housing, and financial stability, and how providers should work to understand and address their patients’ needs outside of what has been traditionally defined as health care.

Episode Transcript

Alishah Cole  00:02

A system is perfectly designed to achieve the results it achieves. And so you know, we have broken systems in this country. And you know, that has been perpetuated for many, many years, and that has led to a lot of these issues that we are in, or we are facing right now.


Josh Israel  00:22

Welcome to The ACO Show. Many of the things that most affect patients health are things that are not typically addressed in a doctor's office — issues like poverty, access to healthy food, and safe home environments. These are called the social determinants of health. On today's episode, we talk with Dr. Alishah Cole, an expert in this field, about why social determinants of health matter, and how healthcare providers and healthcare systems can begin to address these challenges. 


Josh Israel  00:47

Welcome to The ACO Show. We are joined today by Dr. Alishah Cole of Atrium Health, where she is the Chief Community Impact Officer. I'm Josh Israel, a medical director here at Aledade.


Joe Shonkwiler  00:58

And I'm Joe Shonkwiler. I'm a physician, and I also lead adoption and training here at Aledade. Dr. Cole, thanks for joining us.


Alishah Cole  01:06

Thank you for having me.


Joe Shonkwiler  01:07

Now, you are the Chief Community Impact Officer — I love that title — at Atrium Health. Tell me a little bit more about what that is.


Alishah Cole  01:16

Yeah, so I will say I often am asked that question what I tell people what my title is. So I initially started out as the first vice president and System Medical Director for Community Health, with specific responsibilities over some of our community health initiatives out in the neighborhoods that we were serving back in 2016. As we did a community health improvement study and our community identified social determinants as an area that they would like for our system to become more engaged with, I started to then help drive conversations at the system level to focus on some of those social determinants — including things like food insecurity, housing, financial stability, et cetera. And so as that scope of work started to expand, the decision was made to, as I was promoted to have more responsibility to change my title to the Chief Community Impact Officer because ultimately, at the end of the day, we wanted our organization to be able to speak to the positive impact that we have in the communities that we serve beyond just the healthcare needs.


Joe Shonkwiler  02:35

I really think calling out that kind of role with a C-suite title says a lot about the organization. So it's clearly something that's important to Atrium Health.


Alishah Cole  02:45

It definitely is, and it completely aligns with our mission, which is to improve health, elevate hope, and advance healing for all. And so taking care of everyone has always been kind of in the fabric of our DNA. But I always tell people we were intentional about the improved health and not improved health care. Because again, as the largest employer in the region, as the largest Medicaid provider in the state of North Carolina, as the largest safety net provider in this region, we really are responsible for, you know, taking care of our patients and our communities beyond just providing them health care.


Josh Israel  03:23

For people who don't know Atrium Health, can you tell us a little bit about that? What kind of organization is it? Where is it? Who do you serve?


Alishah Cole  03:30

Yes, definitely. So Atrium Health, formerly Carolina HealthCare System, is a fully integrated full-spectrum health care system. We are based out of Charlotte, North Carolina, but we cover North Carolina, South Carolina, and Georgia. We have over 50 hospitals, about close to 70,000 teammates, and we provide full service from hospital care, outpatient care, nursing home care, home health, and rehab. So you know, anything that you can think of in the healthcare continuum, we pretty much provide those services. So very, very large organization, again, obviously located in the Southeast, which has significant social challenges, which is one other thing that I also think sets Atrium apart from some of our other healthcare systems across the country.


Joe Shonkwiler  04:30

It seems like social determinants of health is a topic that's really coming up more and more in journals and at conferences and just in general discussion in this area. Can you give our listeners your definition of what that entails, social determinants of health?


Alishah Cole  04:48

Yeah, so social determinants of health really encompass the things that impact health outside of healthcare services. So if you really think of where people live, where they work, where they play, where they worship, you know, all the things outside of the clinical care walls that really impact health. And if you look at what the research has told us, over 50 years of research, that what actually impacts health, about 80% of that, happens outside of the clinical care walls. So when you really think of things around education or employment, for example, or the ability to access healthy foods, you know, all of these different things actually have more of an impact on an individual's health, when compared to them coming in to see me as a family medicine doctor.


Josh Israel  05:48

And what can healthcare providers do about things outside their walls?


Alishah Cole  05:53

Yes, that's a great question. It's one that I'm often asked and, you know, I am still a practicing family medicine doctor, so I'm very familiar with sometimes the restraints that are put upon us in a very busy clinical practice. However, I will say there are things that we are often addressing as the physician or as the clinical care provider that have to do with things outside of their medical diagnosis. And so, for example, we are often dealing with behavioral health issues in the clinic environment. We now know that majority of people with mental health diagnoses are often coming in through their primary care offices first, and even oftentimes receiving those diagnoses from a primary care physician. We're often talking about barriers to people achieving good health. So if you think about even someone not taking medications, you know, why are people not taking medications? Though, I still teach medical residents and one of the things they know, one of my quirks as an attending, is don't use the word "non-compliant." I think that's one term that we should take out of our vocabulary in healthcare. I don't believe that people want to be unhealthy. I think people have barriers to achieving good health. And so it's our responsibility as the healthcare system, as healthcare providers, to figure out and help people identify what those barriers are, and then help them work on solutions to those things. So if it's around transportation, if it's around not having access to healthy food, you know, versus someone having a side effect to a medication, those are all things that we should be talking to our patients about. I'm really trying to get to the crux of what those issues are, and I think as we transition into a more value-based reimbursement model, that actually does set up the framework for us to be able to have those conversations more easily.


Joe Shonkwiler  08:00

Dr. Cole, as you described that I'm reminded of my own internal medicine rotation when I was in medical school, it seems like a million years ago now for me, but that with this particular case that I was discussing, I was a med student, I had several residents on it, we went through our whole treatment plan for a very sick patient at a very busy urban hospital in New York City. And the attending smartly asked, "That all makes sense, but how's that person going to get a meal to go with the prescription? How are they going to get to the store to get food to make that meal?" And it sounds intuitive now, and the way you laid it out sounds so straightforward, but we had spent so much time in a hospital setting worried about treating a very sick person and their diseases that we sort of lost track of that, and honestly we weren't set up in that health system to even address that. So I guess my question is, how do you think as you're tackling this, what is the role of a healthcare organization to tackle these challenges? Because it seems very daunting when you think about it that way.


Alishah Cole  09:12

Yeah. So I do think that as a healthcare system, and quite frankly, as the healthcare industry, we do have a responsibility to start to address some of these issues and at least ask our patients these questions. I don't think it's only the healthcare responsibility to fix all the problems that exist. One of my favorite Edwards Deming quotes is, "A system is perfectly designed to achieve the results it achieves." And so, you know, we have broken systems in this country. And, you know, that has been perpetuated for many, many years. And that has led to a lot of these issues that we are in, or we are facing right now. So I don't think it's our responsibility to necessarily fix those issues, but I do think it's our responsibility to really understand our patients in a more holistic way, and work very intentionally and strategically with our community partners to address those needs. And so given all of the solutions that are out there, from technology to just different community organizations, you know, there are resources that are available to our patients and to our community members, to really start to be more intentional about the social determinants of health. So it is a different way of thinking, to your point, and even today, even with social determinants being a way more recognized, if you will, issue, it's still very, very difficult sometimes to introduce that into a clinical workflow. Because you know, if you're used to just addressing someone's diabetes, hypertension, and heart disease, and now you add on food insecurity, well, that's just a different way of thinking. And so we had to be really intentional about how we introduced our social determinant questionnaire into our clinical workflows, and quite frankly, flexible enough to allow for there to be variability. So how this process works in the inpatient facility, may be different than how it works in the nursing home, or how it works in the outpatient family medicine office. So that was one of the things that we learned, as we, you know, embarked on this process. And then, you know, the thing that I heard from my colleagues, I made sure that the people who were the frontline, who were delivering the care every day, were a part of this process from the very beginning. And one of the things that we heard was "Okay, you now want me to question patients about food insecurity or financial stability our housing. I can do that, but then what do I do when they say, 'No, I don't have any food for tomorrow' or 'No, I don't have transportation'?" And so we wanted to make sure that we had a solution to at least be able to connect patients to resources before we launched our questionnaire across the system. And so for us, we did utilize Aunt Bertha, which is an electronic community resource platform that we're now able to refer our patients to community partners, they're able to talk back to me, you know, as a family medicine doctor to say, "Yes, we received that referral, the referral was closed, they receive services, or they did not, we referred them to another organization." So that's been really helpful in addressing some of these social determinants for our patients, and also for the community at large.


Josh Israel  12:48

I really liked your quote about systems being designed for certain things. I heard a speaker recently saying, "You think our healthcare system is broken but it isn't broken at all. It works fantastic. You just wish that it were designed for patient health outcomes. It is, in fact, designed for provider revenue." Is what we're discussing, filling in the gaps, that if we had a more kinder, gentler country or more comprehensive social services, are we talking about filling in those gaps? Or is it something else?


Alishah Cole  13:24

Well, I think I think that there continues to be in this country a lack of coordination, particularly between health care organizations and community-based organizations. And I think that's a big part of the conversation that is happening right now. And you see a lot of different collaboratives and partnerships that are popping up left and right, as people really start to think more strategically about how they work together to improve the overall health of the communities that they serve. So I think that's one of the critical elements, and often as a hospital or health system, we do have a unique opportunity to serve as a convener of those conversations. And I think that is a unique role that hospitals and health systems can provide, and something to think about.


Josh Israel  14:22

I'm struck by some of the parallels with other organizations, like churches and synagogues, and even schools where the teachers describe some of the same issues, where they're trying to educate kids, but the kids are hungry, you know, the kids are cold and the teachers often feel like, "I know these are issues I know they're not gonna learn math if they haven't had breakfast, but I'm under-equipped."


Alishah Cole  14:44

Yes, it's exactly the same. And I think that's part of the value of collaborating and convening because you often get into the room and you do realize that the same thing that we're seeing with our patients, teachers are seeing with their students, you know, pastors are seeing with their congregation. I mean, we are all struggling with some of the same issues, and yet we each bring unique skillsets and resources to the table that are often siloed. And so by working together is where you really start to create that more holistic model of care, that again, not only includes clinical care, but also includes the social aspect of it as well. So we have multiple partnerships currently with the faith community, we actually have a faith community health ministry that is very embedded in a lot of our congregations across the entire region. We also partner with a lot of different schools in different ways, again, just being mindful of what the needs are of those individual schools. So one of my favorite programs that we have been able to launch and we've had tremendous success around has been our school virtual health program, which we actually launched in one of our Title One elementary school in a rural county in North Carolina — Cleveland County. And that was based off of quite frankly, looking at our ER utilization, our emergency room utilization, of one of our hospital facilities in that county, and recognizing that we had a large, unnecessary emergency room utilization pattern in children with asthma. And as we started to look more in-depth at that data, started to notice that "Wait a minute, these kids seem to be coming from the same zip code." And they tended to be elementary school age and so, then we're able to go to that school nurse and that principal and start having conversations there, and that's where we found out that the school nurse was sending a child to the ER once every five days. So at least once a week, she was sending a child to the emergency room often by EMS because the parents often worked outside the county and couldn't get to the school in time for asthma exacerbations, and they weren't sick enough to be admitted. But the reason that she had to send them were things like they didn't have an albuterol inhaler at the school, or they didn't have a spacer, or they had run out of their controller medication. And so we were able to work with that school nurse to embed virtual school health, an electronic stethoscope, and a virtual otoscope and connect those children back to one of our pediatric practices in that community. So since launching that program, we've seen a 50% reduction in kids being dismissed from school, we've seen a 77% reduction in unnecessary ED utilization for that cohort of students who have participated in the school health program, and we have also seen an increase in the number of patients establishing in our pediatric practice because once they've become virtual patients through our school program, they end up coming to us for their routine, well-child checks, and other things. And I think one of the other things that we have seen with that program, we've seen grades start to go up because the absenteeism rates have gone down. And we've seen an increase in parent satisfaction, and also just an ability for them to stay at work. So it's just been an amazing program. We have now started to expand that program to other rural counties that we serve, because access is such an issue, particularly in our rural communities.


Joe Shonkwiler  18:53

I'm struck Dr. Cole by how many of the terms and descriptions are very similar to the language of value-based care in ACO's, or accountable care organizations, but other value-based health care contracts and entities where our whole mission is to reduce costs, but improve health and improve quality. Not just maintain, but improve, and it seems like social determinants of health would be a great way to get at that, although relatively few within the value-based care space have taken this on in a systematic way. I'd love to get your thoughts on that, like where do you see as the opportunity through these newer payment models to really go after some of these thornier challenges that we're facing?


Alishah Cole  19:44

Yes. Well, I think the first thing is just getting over the fear of addressing social determinants and not being afraid to ask. I think that has been one of the key barriers that we've worked through, even in our own organization. But you know, it's one of those things — if you don't know, you can't do better. So data is so critically important. And I think, you know, in an ACO model, you really do need to know your patient population, if you're trying to, to your point, improve health outcomes and reduce costs. And so, we have the opportunity now, to be able to ask patients these questions, and we should. Now, I think the other thing I would say is, however, there is recognition that we can't address the issues by ourselves. And I think that's, again, where partnerships are critically important. I think it's so necessary that people start to think about how they partner, who they partner with, and be really strategic and, again, intententional. Those are my two favorite words when it comes to partnerships, you know, moving beyond just, "Oh, well we served this community, or we provided this number of screenings at this church." We have to really move past that, and we have all of the tools necessary to be able to do that. So, you know, I think being willing to have different conversations with different partners — and some of those partners may be people that historically have been seen as competitors. One of the other areas that I'm most proud about is the One Charlotte Health Alliance, which is a new joint venture that we've launched at Atrium Health, along with what most people would view as our competitor Novant Health, along with the Mecklenburg County Public Health Department, to really focus on the six zip codes in Mecklenburg County that have significant social challenges, as well as significant medical issues and disease burden. So the things that we said with that work is we need to focus on the social determinants of health and really help connect our community members to resources that do exist. But often in communities that have been historically excluded, they don't know that these resources exist. So with that partnership, we've launched two medical mobile units, where we serve those six public health priority zip code areas providing medical, behavioral health, and dental services. And we also just recently launched two mobile food pharmacies a couple weeks ago because these areas sit in food deserts. And so now we're able to take healthy food to the community versus them having to travel, sometimes two or three bus transfers to get to a grocery store that serves healthy food. And so that, again, that was listening to our community members and our patients who live in those six public health priority zip code areas. And saying, you know, this is one area that both of our organizations are committed to improving, and we need to work together.


Josh Israel  23:17

Dr. Alishah Cole, Chief Community Impact Officer at Atrium Health. We appreciate your time and your insights.