To explore a reader question about successful programs that address social determinants of health, NC Health News visited a program for HIV-positive people that ventures beyond the confines of traditional healthcare to keep patients out of the hospital.
By Liora Engel-Smith
When Christopher Jones was thinking of going back to school for his bachelorâ€™s degree, he shot a text to staff at the clinic where he gets his medical care to ask for advice.
The Cumberland County resident knew he couldnâ€™t keep his full-time job and go to school at the same time. But without full-time employment, heâ€™d have trouble paying his rent.
It wasnâ€™t long before his caseworker from CommWell Health pinged back with a suggestion: The name and contact information of a local organization that offers housing support.
Jones, who has HIV, dreams of being a spokesman for a fashion company or designer. He said that without the support he gets from the clinic, he wouldnâ€™t have been healthy enough to be thinking about his future.
That support runs the gamut. Jonesâ€™ caseworker makes sure he has his HIV medications and annual physicals. When it comes time for blood tests, dental checkups or screenings, Jones can request a ride to and from the clinic. And if he needs advice, information or a sympathetic ear, a caseworker is a phone call or a text message away.
His caseworker makes life easier, Jones said, but she also keeps him healthy.
Things werenâ€™t always as seamless for the 36 year old. When he learned he had HIV about eight years ago, Jones did not have health insurance. At some point, his parents helped him pay for medication out of pocket. But a month of medication cost as much as a used car, he said, and after two or three months, Jones stopped. With HIV churning through his immune system uninterrupted, it wasnâ€™t long before Jones landed in the hospital with pneumonia.
â€œBefore you know it, theyâ€™re putting stuff in my arms, (and) theyâ€™re telling me I canâ€™t go home,â€� he recalled.
But with a stream of small, relatively inexpensive interventions, the staff at the CommWell Healthâ€™s Positive Life, a program that supports participants with HIV, has helped Jones and others like him stay out of the hospital. The program has 572 participants, most of whom are uninsured. As of August, almost 90 percent of them had viral counts so low their HIV was undetectable.
The program, Jones said, has made it so easy to access care that he canâ€™t help but be healthy.
â€œTheyâ€™re the only reason why Iâ€™m undetectable today,â€� he said.
Beyond traditional health care
Positive Life is successful precisely because it focuses on the entire patient, taking into account things that arenâ€™t usually a part of health care, said Lisa McKeithan, the program director.
Itâ€™s about tackling as many barriers to health as possible, she said.
That idea of addressing social conditions â€” income, transportation and education, among others â€” to improve health is not new. These so-called social determinants of health make up 60 percent of the risk for premature death, with health care and genetics accounting for the other 40 percent, according to an influential 2007 New England Journal of Medicine study.
Conversations about social determinants came to the fore in recent years even as North Carolina announced it will transform how it pays for Medicaid, moving from a fee-for-service model to pay based on health outcomes. Alongside these changes, the state is also launching Healthy Opportunities, a project that will fund pilots that, like Positive Life, focus on social barriers to health. The Centers for Medicare and Medicaid Services authorized up to $650 million over the next five years for these initiatives, which the state says will focus on the highest-need Medicaid enrollees.
What are the social determinants of health?
Social determinants are factors that contribute to health and disease, encompassing the
â€œconditions in which people grow, live, work and age,â€� according to Kaiser Family Foundation. These include:
- Economic factors, such as income and medical bills
- Environmental factors like housing, transportation and geography
- Education, including literacy and language skills
- Food, including access to enough nourishment and to healthy options
- Social factors, such as stress, discrimination, and support systems
- Health care factors, such as health insurance coverage and provider availability
The most common barrier participants in Positive Life have is transportation, McKeithan said. So getting them to the clinic â€” either by giving them a ride or gas cards â€” removes a major obstacle to accessing services at the federally qualified health center. But other factors play into keeping participants healthy too. Positive Lifeâ€™s caseworkers can also connect people with social services they might need, such as food stamps, housing assistance and more.
The program also meets some of the participantsâ€™ emotional needs, tackling the shame, guilt and stigma that might prevent patients from telling caseworkers about risky behaviors or unmet needs.
â€œI usually tell patients, â€˜Iâ€™m your best friend until one of us leaves CommWell Health. Weâ€™re like family. Iâ€™m here to help you the best way I can,â€™â€� said Albrea Crowder, a case manager with the program. â€œThis is a judgment-free environment.â€�
At the clinic, patients can take advantage of what McKeithan says is a â€œone-stop shopâ€� for health care. With behavioral health, dental and primary care providers, as well as a pharmacy and WIC office, and even an inpatient substance use treatment facility all on the same campus, the clinic offers almost anything a patient might need.
â€œWeâ€™re concerned about their mental health,â€� she said. â€œWeâ€™re concerned about their dental hygiene. Weâ€™re concerned about their specialty appointments, you know (the) eye doctor â€¦ or a cardiologist â€¦ If thereâ€™s a need, weâ€™re gonna help.â€�
Aiming for utopia
That ethos is one that CommWellâ€™s CEO Pamela Tripp has come to embrace. Tripp, who started her 40-year career in health care education and hospital administration, has one goal for her remaining years in the field: she wants to help people get healthier.
And in the largely rural six-county swath that CommWell serves, that task is far from easy. Here, geography and poverty create hurdles that can be difficult to overcome. The nonprofit organization served just under 25,500 people last year, and roughly half were uninsured. Two out of three also lived in poverty, according to data from CommWell.
â€œThese are your people that really struggle,â€� Tripp said. â€œ (With this population) â€¦ you canâ€™t help but think about social determinants.â€�
The nonprofit organization â€” which has clinics in Sampson, Bladen, Brunswick, Johnston and Pender Counties and a transitional living facility in Wayne Countyâ€“ integrated that approach into many facets of the care it provides, she added. In addition to giving rides to behavioral health patients, CommWell staff go into schools, community events and churches to educate, screen and treat people. The organization also offers evening and weekend hours to accommodate patients who canâ€™t go to the doctor during work hours.
A few years ago, staff noticed that transportation difficulties meant parents werenâ€™t bringing their children to the dentist as often, Tripp said. Staff piloted a program that brought dental care into schools with low-income children, and many parents opted in.
To make this pilot a regular part of care, CommWell sought a federal grant to purchase a half-million dollar mobile dental unit that now treats children in schools regularly. The program has been so successful that CommWell is looking to buy an additional unit, this one offering mental health and primary care in addition to dental care, Tripp said.
If Tripp had it her way, CommWell would offer more programs that address transportation barriers. But the organization is limited by the grants it can line up to support its efforts.
Thus far, only behavioral health and Positive Life patients can get rides to and from the clinic, for example, but Tripp said other patients who come through the door have similar challenges. And other patients, even those who are healthy, could benefit from case management, even if it is just a periodic check-in.
â€œIt is a utopia,â€� Tripp said, â€œBut how cool would that be?â€�