The influential National Academies of Sciences, Engineering and Medicine (NAS) has called for a major initiative to better integrate heath care and social supports. The group, formerly known as the Institute of Medicine, has published a white paper on the subject that should encourage both policymakers and medical practitioners to pay more attention to the importance of social supports to the well-being of patients.
While the NAS study was not directly aimed at the care of older adults, its recommendations have important implications for seniors. For more than a decade, researchers have recognized the value of what have come to be known as social determinants of health to older adults and others with chronic medical conditions. But those insights have been adopted very slowly by physicians and health systems.
Jargon, not action
Doctors and hospital administrators have learned to say the words, “social determinants of health,” but all too often they have no idea what they mean. It is a little like the health system’s experience with “person-centered care.” Actual medical practice lags far beyond jargon and rhetoric.
NAS has done an important service. But it has achieved more than that. For example, the report describes several concrete steps that health system can take to improve the well-being of patients by better integrating social supports with medical care.
It outlines five steps health systems can take to achieve this goal: Awareness, adjustment, assistance, alignment, and advocacy. These five “A’s” are, I suppose, a memory device, though by themselves, they are quite ambiguous. But they make a lot more sense when attached to a specific problem.
Take, for example, the difficulty many people have getting to medical appointments. Patients often are readmitted to hospitals because they miss post-discharge visits with their doctors and thus fail to get important follow-up treatment. A frequent cause: A lack of transportation.
That’s where the NAS’s five common-sense steps come in. It recommends that health systems;
- Increase awareness by asking people about their access to transportation.
- Make adjustments by using telehealth or other tools to reduce the need for patients to travel to medical appointments.
- Provide transportation assistance through vouchers.
- Improve alignment with social service programs by investing in community ride-share or time-bank programs.
- Advocate for policies that improve their community’s transportation infrastructure.
More broadly, NAS also recommends that health systems better integrate social care “into” health care. Improving the links between medical care and coal supports is critically important but much easier said than done. And though it tries to avoid it, the NAS report still treats social care as a tool to support medical treatment rather than a clinical equal.
The value of social supports for seniors
In reality, for many older adults with chronic conditions the center of their care environment is their social supports not their medical care. For example, while there is no medical treatment for dementia, adult day programs and other social supports can vastly improve the quality of life of those with cognitive loss.
The changes NAS suggests require a fundamental redesign of the health and social support delivery and financing systems. And it will require the US to decide how to pay for these services. It is a special challenge in fee-for-service medicine, where payers, including Medicare and private insurance, rarely compensate doctors or health systems for, say, providing transportation vouchers.
Today, some health systems may fund these services in a limited way through their community benefit dollars—financial support that the IRS requires of tax-exempt hospitals. But hospitals often treat this more like charity than investment.
Easier said than done
Integrating social supports and health care is easier—at least in theory—in managed care. But except for some suggested reforms for Medicaid and for those dually eligible for both Medicare and Medicaid, the NAS report is very cautious about enhancing social supports within managed care.
It makes some important recommendations. For example, it urges government to create incentives for health systems to collaborate with the community-based organizations that deliver social supports. But I wish it had been more aggressive.
The report highlights a huge gap between the US and the rest of the developed world. The US spends about $0.90 on social care for every $1 is spends on medical treatment. Elsewhere, countries spend an average of $2 on social care for every $1 they spend on medical treatment. And for many people, outcomes are as good or better.
The NAS report might have been more ambitious in some respects. But merely by highlighting the importance of social care, the group will help health care providers realize that social supports are as important to many patients as medical treatment, and in some case, even more so.
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