Oklahoma Gazette: OCCHD, others receive a federal grant to bridge gap between social, medical care

A year from now, when a mother brings her sick child suffering from a nagging cough into a local emergency room, they will leave with more than just a prescription for an asthma inhaler.

Under a new experimental program, the mother and her child would answer a series of questions that could reveal a mold infestation in their family’s home.

They would also be assigned a “community health navigator” to advocate for the family — in and outside the hospital, the navigator would seek community resources for combating the mold in hopes to improve the child’s health.

“The doctor provides the traditional care with writing the prescription,” explained Aundria Goree, a community health administrator with Oklahoma City-County Health Department (OCCHD), as she described the program in the context of poor housing and its effects on health. “The navigator is responsible for home visits and meetings with the client to combat the cause of their health issues.”

The scenario is just one example of how the federal accountable health communities’ model will benefit poor Oklahoma County residents enrolled in Medicaid or Medicare, Goree said during a recent Oklahoma Gazette interview.

In late April, the Centers for Medicaid and Medicare Services awarded the newly created Route 66 Consortium, which includes OCCHD and Tulsa Health Department, a $4.5 million grant for implementing the accountable health communities model.

In early 2018, navigators placed in Oklahoma County hospitals will start screening patients to see if they struggle with hunger, poor housing and other social problems. The model is designed to bridge the gap between social needs and medical care, improve health and save communities money.

It’s a major shift in health care that follows a growing body of research that shows addressing social needs is as critical to addressing medical needs.

In a 2011 national survey, physicians overwhelmingly agreed that it’s unmet social needs — like access to food, transportation assistance and suitable housing — that were leading to worsened health outcomes among Americans.

The federal model, implemented in 32 regions across the country, is an important step, according to Dr. David Kendrick of MyHealth Access Network, a nonprofit health information exchange and part of the Route 66 Consortium.

“Doctors are often challenged by patients who, despite receiving the correct prescriptions and recommendations, just don’t seem to be getting any better,” Kendrick said in a media statement. “One of the most common reasons for this is that the patient or family has other needs that aren’t getting met. It’s difficult to imagine spending money on medications or transportation to the doctor when your children are hungry or you don’t have housing or a safe living situation. This program aims to identify and address these issues for our most vulnerable neighbors so they can focus on getting healthy too.”

Combating chronic diseases

Oklahoma is among the least healthy states in the nation. With high rates of chronic diseases such as diabetes, heart disease and obesity; a lower health insurance rate than the national average; and higher rates of poverty, Oklahoma and its most populated county — Oklahoma County — are at a disadvantage in health outcomes compared to other parts of the country.

There’s no doubt that many health outcomes are closely linked with social, economic and environmental disadvantages, yet it’s also clear that without addressing those disadvantages, traditional health care can only go so far.

All too often, in health centers, physicians’ offices and emergency rooms, patients’ social needs are overlooked or ignored, Goree said.

“Unmet health needs like food insecurity, transportation issues and unstable housing can lead to developing risks for chronic diseases,” she said. “We want to combat individuals increasing their risks of developing chronic diseases through traditional health care with preventable care.”

Heart disease, cancer, diabetes, kidney failure, obesity and arthritis are just some of the chronic diseases and conditions that plague many Oklahomans with poor health that requires emergency room visits and hospitalizations. Though costly, these diseases are manageable and, more importantly, preventable.

Despite the adage “an ounce of prevention is worth a pound of cure,” the health care system hasn’t always encouraged prevention around social needs. Physicians don’t write prescriptions listing social services or instructions for addressing pressing needs like food assistance, adult education or employment services, utility services or legal aid.

Under the new federal model, that’s effectively what Medicaid and Medicare patients would receive; however, the recommendations and assistance come from the navigator.

The model is similar to a pilot program between the OCCHD and three local hospitals in which community health workers redirect non-urgent patients from an emergency room to a physician’s office or community health resource, Goree said. It benefits patients and the emergency department. Patients receive care that is equally effective but less expensive and more convenient.

Emergency rooms — set up to handle serious life-threatening illnesses and injuries — are free to help those who do require emergency hospital care.

The new model goes much further, bridging the gap between medical care and issues patients face in the community that affect their health, Goree said.

“Usually, we don’t pay attention to our health until it’s too late,” she said. “With this program, we are able to combat, treat and prevent at the same time. It’s a benefit when you have healthier and productive citizens.”

Print headline: Bold initiative; OCCHD and others receive a federal grant to bridge the gap between social and medical care.

This article originally appeared in the Oklahoma Gazette. Read it here.