This document discusses how addressing social determinants of health, like housing conditions, could improve patient care and lower costs. It provides the example of Mrs. M, who had chronic headaches and multiple ER visits without diagnosis. Only after a clinic screened for housing risks did they discover she lived in a damp, moldy home, correctly diagnose her issue, and treat her condition along with improving her housing. The document argues that routinely asking patients about living conditions could help doctors better diagnose and treat patients. It also discusses how Medicaid Health Home programs and 1115 waivers could allow states to use Medicaid funding to address social needs like housing that impact health outcomes.

1. Rishi Manchanda MD MPH
Founder, HealthBegins
Author, The Upstream Doctors
The question your doctor
is not asking you &
how everyone, including you,
could save money and live
healthier lives if she did

2. “Where do you live?
Tell me about it.”
“p.s. Where do you work, eat and play?”

3. What would your health look
like if doctors’ offices routinely
asked about and could help
address problems where you
live, work, eat, and play?

4. Photo taken with permission
Mrs. M

5. Photo taken with permission
Mrs. M had a chronic
headache. After exhausting
primary care options, she
visited 3 Emergency Rooms
(ER) in 1 month, but still had
neither a diagnosis nor a
treatment plan.
Overall, she had:
2 CAT scans of her head
1 Lumbar puncture
Blood tests
Pain medicines
Out-of-pocket charges
Missed work
Lost income
And she was still sick.
Good
Care?

6. Photo taken with permission
After 3 ER visits, a clinic noted
that Mrs. M lived in an area
endemic for unhealthy housing.
A medical assistant screened
her for housing risks.
Mrs. M lived in a damp, moldy
home.
With that key social data, the MD
correctly diagnosed her in 12
minutes with a housing-related
illness.
He treated her with meds and a
healthy housing program.
Mrs. M & her home got better.
Better
Care

7. The Social Determinants of Health
– The conditions in which people are born, grow,
live, work and age, including the health
system.
• These conditions are shaped by the distribution of
money, power and resources at global, national and
local levels, which are themselves influenced by
policy.
– Major contributor to health inequities
• “Health inequities are unfair and avoidable
differences in health status seen within and between
countries often over generations.”

8. At the Intersection of Health Care
and the Social Determinants of Health,
the Current Standard of Care
Isn’t Good Enough

9. Schroeder S. N Engl J Med 2007;357:1221-1228
Contribution
of Social
Factors to
Premature
Mortality
What’s the big deal about housing
& other ‘social determinants’?

10. The sickest, costliest patients
often have unmet needs
in social & built environment
• Cohen, S. The Concentration of Health Care Expenditures and Related Expenses for Costly Medical
Conditions, 2009. Statistical Brief #359. February 2012. Agency for Healthcare Research and Quality,
Rockville, MD. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st359/stat359.shtml
In 2009, 5% of the
population accounted for
nearly 50% of overall US
health care spending
Propietary/ Confidential

11. Addressing Social Factors
improves care

12. Addressing social factors
lowers costs

13. Glimpses
of this better standard
of care are out there

14. But 4 out of 5 physicians still
feel under-equipped to
address their patients’
social needs.
-RWJF “Health Care’s Blind Side” Dec 2011
Propietary/ Confidential

15. Smart medicine starts upstream

16. Stories of
Upstreamists
A new conceptual
model for the
health care
workforce in the
context of the
Affordable Care
Act

17. A new model for the
healthcare workforce
By 2020,
24,000
260,000
450,000
Population-
level Impact

18. Our Work:
Improve Care
Train & Equip Upstreamists
Our Goal:
2.5K Upstreamists by 2015
25K Upstreamists by 2020

19. Propietary/ Confidential
Courtesy: Community Scholars 2012, Ben Palmquist

20. Housing and Health
Housing is linked to:
– Asthma
– Allergies
– Lung Cancer
– Injuries
– Mental Health
– Brain Development
– Respiratory
Infections
Courtesy: Dr. Jim Krieger, Seattle Public Health

21. Housing Hazards
• Biological agents
– allergens, mold
• Toxics
– lead, secondhand smoke, carbon
monoxide, radon, asbestos, VOCs,
etc.
• Temperature extremes
• Injury hazards
• Crowding
• Conditions:
– Ventilation
– Energy efficiency
– Structural integrity
– Sanitation and plumbing
– Siting
– Building materials
Courtesy: Dr. Jim Krieger, Seattle Public Health

22. Can health care transformation help more clinics
help improve conditions where we live?
Community-Centered
Health Home
Community-Centered Health Home
• Coordinate with policymakers and
community stakeholders to address social
and environmental conditions
Medical Neighborhood
• Coordinate care for patients and
populations with clinical and community
“neighbors”
• Potential role for ACOs
Medical Neighborhood
PCMH
Ambulatory ICU
• Integrate and coordinate care for high-
need, +/- high-utilizer patients with clinical
and community partners
AICU
PCMH
• Coordinate care for patients and clinic
population, primarily within clinical system
R. Manchanda MD

23. Medicaid Health Homes
A “Medical Neighborhood”
• One of the coordinated care models that states can
pursue with funding from the Affordable Care Act
• For patients with:
– mental health condition,
– substance use disorder,
– asthma,
– diabetes,
– heart disease, AND/OR
– body mass index over 25 (overweight)
http://familiesusa2.org/assets/pdfs/health-system-reform/Health-Homes-in-Medicaid.pdf

24. Medicaid Health Home
• Includes:
– Comprehensive care management
– Care coordination
– Health promotion
– Comprehensive transitional care
– Individual and family support services
• Must coordinate with behavioral health providers
• Required to help enrollees obtain non-medical supports
and services, such as:
• public benefits, housing, transportation, legal services, and
social support services.
http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical-
Assistance/Approved-Health-Home-State-Plan-Amendments.html
http://familiesusa2.org/assets/pdfs/health-system-reform/Health-Homes-in-Medicaid.pdf
Propietary/ Confidential
Not found in
most PCMH

25. States with
Medicaid Health Homes

26. 1115 Waivers: A chance for housing
under ACA?
• Under section 1115 of the Social Security Act, the
federal government can allow states to develop
comprehensive demonstration, experimental projects
that modify (waive) federal Medicaid and State
Children’s Health Insurance Program (SCHIP)
requirements related to benefits, cost-sharing and
eligible populations.
• Any new waivers must be “budget neutral” to the
federal government.
• Several states have combined coverage expansions
with a new managed care delivery system and used
the anticipated managed care savings to offset the
cost of the coverage expansion.

27. Minnesota example: Reform 2020
• Reform 2020 is an initiative to reform Medical Assistance (MA)
Minnesota’s Medicaid program.
• On Nov. 21, 2012, DHS resubmitted the Reform 2020 waiver
proposal to the Centers for Medicare and Medicaid Services
(CMS). This proposal would have made the following housing
stabilization services as eligible for Medicaid reimbursement up
to $600 for each member per month:
– Service coordination
– Outreach/InReach
– Tenancy Support Services
– Community Living Assistance
• The target population included: (a) Medicaid recipient who
were receiving General Assistance and homeless; and (b)
Medicaid recipients who were eligible of Group Residential
Housing.

28. TO LEARN MORE
HealthBegins.org
Read the Upstream
Doctors
http://www.ted.com/pages/tedbooks
_library#RishiManchanda