This article, written by Hilary Hatch, Chief Clinical Officer at Phreesia, originally appeared on LinkedIn on April 2, 2024. It has been lightly edited and republished here.
At Phreesia, we take great pride in supporting patients’ ability to self-manage their health. We’re committed to helping healthcare organizations allocate their resources effectively, and we believe that measuring patient activation can help providers deliver the right level of care to the people who need it most.
An important trend in healthcare is that a growing number of organizations are screening patients to better understand how to address social drivers of health (SDOH). We know that non-medical factors—like nutrition needs, transportation, education and housing—have a direct impact on patients’ overall health. Screening for SDOH creates a holistic picture of the patient and their unique circumstances, and addressing those social drivers ultimately improves their health outcomes.
But in practice, even when healthcare providers have SDOH data and understand their patients’ unmet social needs, few have the resources to address them. It’s frustrating for patients and providers alike.
Even in cases where social-needs programs are successfully implemented, they often do not lead to the most efficient allocation of resources. Take, for example, this large-scale study of a social needs case management program in Contra Costa County, California.
Adult Medicaid patients in the top 15% of elevated risk for healthcare use were offered 12 months of social-needs case management, in which more intensive services were provided to people with higher demonstrated needs. Although emergency department and hospital admissions fell, savings from reduced healthcare use did not cover the program’s cost.
In other words, even in the best-case scenario—an effective social-needs intervention that decreased hospital use and potentially improved health—overall healthcare costs likely did not decrease.
When the study results were published in the Annals of Internal Medicine, the authors wrote: “More work is needed to identify ways to increase patient uptake and define characteristics of successful programs.” The authors note that a key limitation of the study was that only 40% of the target group participated in the intervention, so we do not know how those who did not participate may have responded to the intervention.
Our experience tells us that patients with high social needs range from highly engaged to disengaged, much like every patient population.
This begs a couple important questions. Does low engagement impede participation in social-needs programs that reduce utilization and costs? And what if intensive resources inadvertently go to patients with high social needs who are more engaged, and therefore may not need intensive support?
As a member of the National Quality Forum (NQF) Leadership Consortium, I’ve been grappling with questions about how to use data on patients’ social needs to improve outcomes and address other challenges, like costs and staff burnout. Our report, released last month, makes ten recommendations to help healthcare organizations address social needs by partnering with community services to connect patients with needed resources.
I’m realizing that what makes a successful program is not only connecting patients with resources, but specifically targeting intensive resources toward patients who need them most: Those with both high social needs and low engagement.
Take the case of HealthLinc, a federally qualified health center (FQHC) in Northern Indiana serving over 40,000 patients, more than half of whom are Medicaid beneficiaries. HealthLinc partnered with Phreesia to address social needs. We screened patients using the Protocol for Responding to & Assessing Patients’ Assets, Risks & Experiences (PRAPARE), and then assessed patients’ knowledge, skills and confidence to manage their own health using the Patient Activation Measure® (PAM®).
The PAM is a 100-point survey that sorts patients into four levels and tells us whether a patient is overwhelmed and discouraged in managing their care (Level 1) or goal-oriented and proactive (Level 4). When a patient screened positive for any social need, HealthLinc used the PAM to decide what kind of support and resources that patient needed to help them manage their health.
Lower-activated patients—those who scored lower on the PAM—required more support, like direct outreach from a community health worker (CHW), in addition to digital outreach. Higher-activated patients received digital outreach only.
And it worked. Within just five months, HealthLinc’s CHWs saw a 43% reduction in time spent on direct patient intervention. They eliminated unnecessary interventions, screened more people and focused their efforts on those who needed the most CHW support.
They also reported more substantive conversations with patients, indicating that segmenting patients by their PAM level improves the quality of social-needs support CHWs can provide. This segmentation approach is key to scaling SDOH programs, and it may be a factor in making such programs more cost-effective.
My hunch is that the Contra Costa case management program could have benefitted from a similar segmenting approach. The program was designed to target those at elevated risk for hospital use—a critical first step—but it did not stratify them by PAM level. If the intervention had also deployed PAM, researchers would likely have learned that some of the top hospital users are higher-activated patients who did not need intensive services, while lower-activated may have needed even more intensive support.
The program could have been more successful if the interventions were more targeted. At least, that’s what HealthLinc learned. Instead of giving intensive support to every patient with a social need, they used the limited resource of CHW time more efficiently when they focused on the patients who were least activated and needed the most support.
We need to continue to try new approaches to address social needs. I believe the most successful ones will use tools like the PAM to target resources effectively and have the greatest impact.
Read all the NQF Leadership Consortium’s recommendations, and learn about other new or existing projects to address SDOH, in the full report.
