New research out Monday shows that when primary care patients get help attaining basic resources — like food, housing, heat and access to affordable medicines — it leads to improvements in their blood pressure and cholesterol levels.
The findings, published in JAMA Internal Medicine, may be intuitive. But they provide further evidence that a Boston-based nonprofit founded 20 years ago by a Harvard undergraduate is on the right track by focusing on patients' "unmet social needs" as a critical pathway toward true health.
The nonprofit, Health Leads, was co-founded by health entrepreneur Rebecca Onie, who received a MacArthur Genius Grant in 2009. At her Cambridge home recently, Onie recounted this story (lightly edited) to convey the goals of the organization:
This summer, a young man arrived at a Baltimore primary care clinic, thin and frail. He'd been rapidly losing weight, a lot of weight. As doctors gathered to discuss a possible diagnosis, they talked about which blood tests to order, and what metabolic panel should be run.
An advocate from Health Leads was listening closely and wondered aloud if the patient might not have enough food. A doctor responded: "He's never said anything like that, but you can ask him if you want." It turns out the advocate was right: The patient was hungry. He'd recently lost his housing, didn't have enough money to buy food most weeks, and wasn't sure how to access any benefit programs. And while he didn't volunteer this information to the doctors; he told the advocate he appreciated that "someone finally asked."
The anecdote, Onie says, illustrates how health care systems and medical providers sometimes overlook the obvious: the most essential ways to make people healthy. Health Leads' mission is to try to refocus the system's priorities in ways "most relevant to patients," she says. In other words: "Why don't we ask patients, 'Are you hungry?' before ordering the metabolic panel?"
Health Leads began in 1996 when Onie, then a Harvard sophomore working at Greater Boston Legal Services in the affordable housing unit, had an epiphany: Pretty much every family who had inadequate housing also had an underlying health problem. And these health needs could never be fully managed unless people's basic socioeconomic needs were also addressed. If a family's apartment was full of mold, dust and roaches, for instance, the child's asthma medication was pretty much useless.
So, Onie thought, what if waiting rooms could be transformed into places that actually improve health? What if doctors could write prescriptions for food or housing to patients in need? "It should be part of any medical history," she says. "You know blood pressure, height, weight — and you also ask 'Does a patient have food at home?' It becomes another set of vital signs."
Working with pediatrician Barry Zuckerman, then at Boston City Hospital, the nonprofit recruited undergraduate volunteers to staff health clinics and offered them specialized training.
Now, Health Leads is working with doctors and senior executives at major health systems around the nation — in Northern California, Cleveland, New York City and Boston, among other locations — to create locally tailored social needs interventions. And while "it can be daunting for a health system to feel all of a sudden responsible for poverty," Onie says, there's a "huge appetite" for this kind of work as a way to cut costs and also deepen connections between doctors and their patients. Last year, Health Leads says, it connected about 14,000 patients, representing households totaling nearly 50,000 people, to services.
Dr. Nirav Shah, chief operating officer at Kaiser Permanente Southern California, says that Health Leads' new screening toolkit, a 20-page, in-depth overview of social needs screening practices based on clinically validated sources, "has been downloaded nearly 1,500 times in the past few months. It's a great example of how Health Leads is packaging and sharing its expertise."
Now, 20 years after Onie's once-radical realization — that screening for social needs should be part of standard medical care — the concept is more widely embraced, and her innovations are getting tested across the nation.
In January, the federal Centers for Medicare and Medicaid Innovation Center designated $157 million for a pilot project, part of the "Accountable Health Communities" model, to test whether screening patients and then addressing social needs could improve their health, while also saving money and reducing utilization.
When the program is fully implemented, more than 15 million patients will be undergoing this type of social needs screening, Onie estimates, up from perhaps hundreds of thousands today.
There's already growing evidence to back this approach.
As part of the new study out Monday, 5,125 Mass. General Hospital primary care patients were screened for unmet social needs; 1,774 had at least one unmet need, and 1,021 of the patients agreed to enroll in the Health Leads program.
MGH internist and researcher Dr. Seth A. Berkowitz led the study, which concluded that patients who worked with Health Leads to get various needs met, including access to affordable medication and food, saw "modest" but significant improvement in their blood pressure and cholesterol numbers compared to patients who received standard care. The improvement in blood pressure was particularly noteworthy, says Berkowitz, and, for some patients, was similar to adding a new blood pressure medication to a patients' regimen, but with no side effects. (The study did not evaluate any issues related to cost or potential savings.)
The study, however, found no improvement in blood glucose levels, as indicated by a critical measure for patients with diabetes called Hemoglobin A1c. And while the research didn't set out to determine why the interventions were more effective in certain clinical areas compared to others, Berkowitz says, it's likely a number of factors are at play. It's possible, he said, that while study patients with diabetes may have gained greater access to food, for instance, it's not clear what variety of food they obtained and whether it was the right type of nutrition to help control their illness.
Overall, he says, many patients in the study have complex needs: "Linear logic doesn't always pan out," he says. "Because there are so many competing demands and tradeoffs."
Often, he says, patients say they need help in one area, but in fact their problems are much broader. An example: People come in saying they can't afford medicine, but they already have many drug benefits available. If you dig deeper, though, these families may have gone into debt paying utility bills and so have no additional funds for medicines.
"In many cases, there are a limited amount of resources and people are constantly juggling what gets paid when — and what doesn't," Berkowitz said.
A 2015 study, also conducted by researchers at MGH and Health Leads, found that patients with unmet social needs are more likely than others to struggle with a range of medical conditions, including:
- nearly twice the rate of depression;
- 60 percent higher prevalence of diabetes;
- more than 50 percent higher prevalence of high cholesterol and elevated hemoglobin A1c, a signal of diabetes;
- more than double the rate of emergency department visits;
- and more than double the rate of no-shows to clinic appointments.
Whether or not the Trump administration will continue to back efforts to understand and assess the impact of social needs on health remains unclear. But, Onie says, health leaders from across the country "will move forward no matter what ... If Medicaid gets pulled back — which is what many people expect — these patients will still come in, they'll just come in through the ER. And they will still present with unmet social needs.
Don Berwick, a pediatrician and former administrator of the Centers for Medicare and Medicaid Services under President Obama, reiterates that it's unknown at this point if the new administration "will devote energy and resources to social determinants of disease."
Still, he says, it would be wise do so. And he says, Health Leads has "set a new standard for health care delivery" with an approach that clearly states, "If you have not addressed social determinants, you have not completed the job."
He explains via email:
[Health Leads] has taken the often-vague concept of "social determinants of disease," and converted it into an energetic, effective plan for action. Perhaps more than any other organization of the past decade, Health Leads has made available to hospitals and other health systems a clear and feasible method for mobilizing community resources to address the underlying needs of patients and their families for supports - such as housing, nutrition, legal services, counseling, education, and many others. That help gives them a far better chance to heal and remain well.