Social determinants of health is now a popular concept as health systems across the country have rolled out various initiatives. But it's not always clear if organizations are putting real resources behind these efforts are just paying lip service to the idea.
The state of Iowa offers a lesson on how to make a real impact in underserved communities.
The Iowa Department of Public Health has made significant headway in improving health outcomes and access to care for Iowa mothers and their children by integrating social care with medical services. Over a two-year period, the state's Maternal and Child Health Title V Program has been able to increase the percentage of women receiving a regular source of obstetrical care from 67% to 97%.
The Iowa DPH has addressed more than 7 million social care needs for Iowa's vulnerable maternal and child population, marking a major milestone in its social determinants efforts. These social needs include providing transportation for families so they can see a healthcare provider for a well-child visit.
How did were they able to achieve this?
While Iowa DPH has been addressing social needs for decades, the agency was able to supercharge its efforts by partnering with healthcare technology company Signify Health in 2017 to develop a shared technology platform. This statewide community network enables community providers across the state's 99 counties to safely share information, coordinate services, and connect members to non-medical needs like transportation, housing, health management resources, and mental health services.
Signify Health is a technology company that supports in-home care and provides care management services. Launched in December 2017 as the result of a merger between CenseoHealth and Advance Health, Signify Health is run by former Athenahealth executive Kyle Armbrester.
In 2019, the Dallas-based company acquired TAV Health to build its capabilities to address social determinants of health.
The Iowa statewide community network is composed of a virtual care team of healthcare and social service partners. Today, the network spans the state’s 99 counties and collectively manages six Title V programs.
Overall, approximately 400,000 Iowans had a social care need met because Iowa DPH, using the Signify platform, was able to identify needs and coordinate help.
The 7 million SDOH-related activities include SDOH assessments, care coordination, interagency referrals, and care gap closure services such as immunizations, well-child visits, medical home identification, and health insurance access and eligibility.
"Prior to 2017, we had three different siloed data systems that were aging and we were looking for a solution that would bring all our populations into a single data system," Marcus Johnson-Miller, Title V Director and Bureau Chief at the Bureau of Family Health told Fierce Healthcare.
Using Signify Health's platform, community providers and agency workers are able to seamlessly transition families across the program beginning with obstetrical care for pregnant women and then into early childhood development and well-child visits.
"If a mom has transportation needs during pregnancy, she is likely to have those needs while trying to get her children into well-child exams as well. We are now able to see the broad scope of needs for our families," he said.
Public health workers may find that a mom who brings her newborn in for a check-up is no longer working to take care of her child. "She doesn’t have maternity leave and she doesn’t have any vacation and that impacts her so in many other ways, so she may need utility or rent assistance," Theresa West, Signify national vice president of community solutions told Fierce Healthcare.
"Social care teams are able to refer her to a local community-based organization to receive the help that she needs. So they start to address all the needs and not just one single clinical need," she said.
"This innovative program and partnership is connecting health and human services like never before, providing a healthier start at life for thousands of children,” said Johnson-Miller. "We’re building a healthier Iowa by enabling community collaboration in a way that respects the dignity and privacy protections of our members - all to support the lives and outcomes of pregnant mothers through early child development.
And this at-risk population has been hit especially hard by the COVID-19 pandemic, Johnson-Miller said.
Social determinants of health has become a buzzword but the Iowa DPH has made significant progress by leveraging data and addressing non-medical needs, which then directly impacts medical and clinical conditions, according to West.
"When people think about care and the health system and the emergency room and impacting the cost of care, Iowa DPH has been looking at it from the perspective of, 'OK how do we do that, but’s lets truly go upstream'," West said.
She added, "It's a domino effect. You solve SDOH and then you directly impact that mom. Was she not getting care because she didn’t have transportation, didn’t have child care, or didn’t have food? By solving those issues, and at the same time connecting to clinical providers and resources, it brings it all full circle to addresses the complete needs."
Through the collaboration with Signify Health, the Iowa DPH program has resolved more than 1,400 cases related to member mental health challenges, including depression, anxiety, and trauma.
Signify Health is one among a growing list of companies attempting to use technology to identify and address the socioeconomic barriers to health. New York City-based Unite Us launched in 2013 with a software platform to help connect people to social services.
Solera Health developed a platform to address chronic conditions and SDOH and has scored significant backing from investors like HCSC Ventures, the wholly-owned investment firm of Blues parent Health Care Service Corp. Other companies in the space include NowPow, which works with NYC Health + Hospitals, among others, Papa, which offers “grandkids on-demand” and Alphabet-backed CityBlock Health, which has raised $85 million to date.
Signify Health's technology platform enables cross-sector collaboration by enabling participating organizations to safely share information within a formalized legal structure, managing members’ whole-health needs longitudinally across care settings. Additionally, the platform replaced Iowa DPH’s historically fragmented data collection processes, uniting all incoming data sources into a single system for real-time outcomes reporting to demonstrate program improvements, care gap closure, and SDOH resolution.
“IDPH is proving that SDOH can be identified and addressed at scale, with a strong team of health and community partners working together to sustainably improve outcomes,” Armbrester said in a statement.
Looking ahead, Johnson-Miller said the program wants to use the platform and the data to address health inequities across the state.
"If you look at Iowa data in general, we’re a fairly White state, there is not a lot of diversity, but there are pockets of diversity. We want to be able to use some of this data through assessments and screening to see if we should focus our energies on specific areas of the state because they are higher needs than other areas or specific populations that have higher needs," he said.