Awake at 4 a.m. one morning last November, Felicia Silva of Albuquerque, New Mexico, assumed the dull ache in her left shoulder was a cramp – or maybe she’d slept on it wrong. She pushed through the pain and went to work, but her colleagues, seeing her disorientation and hearing her stutter, urged her to get medical help. Hours later, Silva found herself at Presbyterian Rust Medical Center in nearby Rio Rancho, diagnosed with a minor stroke and admitted for treatment.
Then, about a week after she was sent home, Silva got a surprising call from an administrator at Presbyterian, and it wasn’t about her hospital bill.
“She just reached out to me: ‘I got your number from our system and I just want to know if you needed anything,'” Silva recalls. “At that time I was just out of the hospital. And I said, ‘No, I’m OK.'” The agent, Amy, said she’d call back in a few weeks.
By then, Silva was dealing with a chain reaction triggered by her stroke. Forced to take short-term disability to recover, she’d seen her take-home pay plunge; food for Silva and her two school-age sons had run low, and her utility company was about to shut off the lights over a $800 past-due bill. So when Amy called again, Silva acknowledged that she was in trouble.
“I said, ‘Actually, I haven’t gotten paid this month at all. My rent is paid, but I’m worried about groceries. All I care about is like feeding my boys and they have a roof over their head.'”
Within minutes, Amy had connected Silva to state and federal resources to help her pay her bill, and a local food pantry so she and her children could eat. “That was a huge weight lifted off my shoulders – huge,” says Silva, who has fully recovered and is back at her job at a pharmaceutical company.
A view of Presbyterian Rust Medical Center in Rio Rancho, N.M., where Felicia Silva was treated.(Adria Malcolm for USN&WR)
She didn’t realize it at the time, but Silva had benefited from a growing movement in medical care that considers patients’ access to healthy food and stable housing and relief from financial stress to be as important to address as their blood pressure, heart rate and the images from an MRI. Hospitals, health systems and federally subsidized clinics are increasingly focused on the “social health” of patients – external factors, called social determinants of health, that have short- and long-term impacts on their physical well-being.
“Trying to help patients address their social needs is really an important emerging issue for health care managers,” says Amanda Brewster, assistant professor of health policy and management at the University of California–Berkeley. “We’ve really seen increased attention to this topic for the past five or 10 years. And there’s quite a lot of research going on across the U.S. to try to figure out what are the best ways of doing this.”
The issue catapulted to the top of the national agenda last year, when headlines about the disproportionate effect of the coronavirus pandemic on Black and brown neighborhoods collided with dramatic images of protests condemning the police killings of George Floyd in Minneapolis and Breonna Taylor in Louisville, Kentucky. Experts said the same social forces that contributed to the deaths of Floyd and Taylor were helping to intensify the deadliness of the contagion in communities of color. The Centers for Disease Control and Prevention, which in April declared racism a serious public health threat, attributes the higher mortality rate among African Americans – twice that of whites – in part to profound inequalities commonly found in underserved communities. Harvard researchers studying socioeconomic data on COVID fatalities found that, even on an individual level, people with markers for poor socioeconomic status – racial minorities, poor people and the undereducated, in particular – were significantly more likely to bear a disproportionate burden of COVID-19 mortality.
That finding was yet another data point adding to the evidence that solving long-standing health differentials between populations requires systemic solutions. Food deserts in the neighborhoods where impoverished people live, lack of quality affordable housing, employment insecurity and financial stress are among the root causes of chronic diseases like obesity and diabetes, which are particularly endemic among African Americans and Latinos. Those diseases, in turn, increase the likelihood of critical, potentially life-threatening illnesses like heart disease and kidney failure.
Meanwhile, reduced or lost income like Silva experienced can make it more difficult to buy prescriptions and keep follow-up or physical therapy appointments, impeding a patient’s recovery from an illness.
Epidemiologists also blame poor health outcomes on lack of access to the health care system: For too many people, quality primary – preventive – care and the latest advances in medicine are out of reach. That helps explain why African Americans have for decades had the highest overall cancer mortality rate of any racial or ethnic group in the country.
Health disparities between African Americans and whites have “been around for forever,” says Dr. Alisahah Cole, system vice president of population health innovation and policy at CommonSpirit Health. And until recently there hadn’t been much effort to address them. Now, says Cole, she sees “a very intentional interest” in working toward health equity. Indeed, an increasing number of health systems are offering access to or information on food pantries, housing assistance, employment, substance abuse and financial assistance.
At the same time, more systems are creating C-suite positions focused on achieving health equity. Rush University Medical Center, Mass General Brigham, CommonSpirit Health and Nationwide Children’s Hospital, among others, have all added equity officers. The 174-year-old American Medical Association hired its first chief health equity officer in 2019: Dr. Aletha Maybank, who previously directed the Center for Health Equity within New York City’s public health department.
A 2020 report published in Health Affairs indicates that 57 health systems nationwide had spent some $2.5 billion on programs addressing social determinants of health. While the lion’s share of that sum has gone to housing, other programs address issues ranging from food insecurity to transportation and job training.
In Toledo, Ohio, for example, ProMedica chipped in $11.5 million to Ebeid Neighborhood Promise, a $50 million neighborhood development project focused in part on health, education, jobs, family stability and social and educational services.
In Detroit, the Henry Ford Health System joined forces with the ride-sharing giant Lyft to create a system aimed at getting patients who need transportation to and from appointments. Kaiser Permanente spent more than $100 million in 2020 in support of housing and food security, economic opportunity, health in schools and equity. Some has gone toward providing entrepreneurs of color with access to capital, some to grants that will give a few hundred high school students a chance to go to college, and some to support an affordable housing nonprofit engaged in California’s effort to provide interim housing and services to people experiencing homelessness.
“I do think leaders, especially health care system leaders, are being really thoughtful about this work now” and are including it in long-term strategic plans, Cole says. “I really base my work on one of my favorite Arthur Ashe quotes: ‘Start where you are, use what you have, and do what you can.'”
Still, most hospitals that get tax breaks caring for indigent patients continue to spend more on unreimbursed care than they do investing to improve the health of a community, possibly because the skills and infrastructure required are so different from what’s involved in delivering care.
Gun violence, which kills more than 100 people and wounds more than 230 people every day – many of whom are boys and men of color – is one factor contributing to wide disparities in life expectancy in some communities, and is an area gaining caregiver focus. People experiencing interpersonal violence, experts say, are at elevated risk for re-injury and violence perpetration, creating a “revolving door” of victims and offenders cycling through emergency rooms.
To close that door, hospitals are turning to hospital-based violence intervention programs, or HB-VIPs, to convince those involved to get help and choose another path. “I can have a patient come in, shot at age 18, shot again at 22, in a recovery bed at 23,” says Dr. Charity Evans, an associate surgery professor at the University of Nebraska Medical Center. “Our feeling is, when these individuals come in with their first and second gunshot wounds, that that was our opportunity to intervene.”
Using a “credible messenger” to make a bedside visit – “someone from their community, that’s gone through what they’ve gone through, who’s been injured before, been in that bed,” Evans says – the hospital looks to redirect the patient away from violence, offering a range of services to help with everything from battling the effects of poverty to education and job training.
Partnerships with other organizations are key to hospitals’ ability to improve patients’ situations, Brewster says; the medical community can’t solve the problem alone. “It does take a village, if you will,” agrees Barbara Petee, chief advocacy and government relations officer at ProMedica and executive director of the Root Cause Coalition, a nonprofit organization that links the health care industry with community groups to share ideas and best practices and partner to address socially-driven health disparities.
“It takes hospitals, health systems and insurance companies working with social service organizations, faith-based groups and foundations” as well as federal, state and local government, Petee says.
Amen, says Andrea Norberg, executive director of the Francois-Xavier Bagnoud Center, a Rutgers University-affiliated community clinic in Newark, New Jersey. Formed in 1987 as part of the School of Nursing, the clinic was an early adopter of caregiver-community partnerships, largely because of its mission: providing family-centered care for HIV/AIDS patients as well as adults and children with other infectious diseases and immunologic disorders.
Because employers, landlords, families and even doctors often ostracized or shunned them, it wasn’t unusual for AIDS patients to suffer, and often die, impoverished, with next to no financial or emotional support. The staff included specialists who connected patients to social service resources.
Over time, the clinic’s prime directive has evolved to include eliminating “barriers to interdisciplinary, client-centered, equitable, high-quality health care for those at the greatest risk for socially determined health vulnerabilities,” according to its mission statement. That includes helping people gain access to job training, child care, education and behavioral health services. “You can’t really achieve your health goals unless your social situation is also addressed,” explains Norberg.
Consider patients who have severe hypertension, putting them at risk for a stroke or kidney failure. Generally, Norberg says, they are sent home with blood pressure monitoring equipment. That’s not possible when a patient lives on the street.
“If you’re homeless, it’s very difficult for you to prioritize your blood pressure,” she says. The focus becomes “thinking about all of the needs that a person has,” she says. “Trying to help them to navigate the complexities of systems and trying to help them get to a better place.”
For Felicia Silva, the offer from Presbyterian Rust Medical Center to help with getting the bills paid and putting food on the table accomplished that mission. Without that phone call from the hospital, she says, “I would have never even known, you know, that there was actually this much help out there. And there was so much help.”
Excerpted from U.S. News’ “Best Hospitals 2022,” the definitive consumer guidebook to U.S. hospitals. Order your copy now.