Medical schools and teaching hospitals across the United States play a pivotal role in initiatives aimed at addressing critical social determinants that create barriers to health for tens of millions of people.
Academic medicine is using both research and innovative programs to address problems that prevent vulnerable populations from receiving medical care. With approximately 40.6 million people living in poverty in 2016, teaching hospitals are using practical approaches to link patients in need with important social services and health initiatives to improve outcomes.
Researchers and health care providers have found that lack of access to healthy food, adequate housing, transportation, and education account for 40% of what contributes to poor health within vulnerable populations. Addressing these social determinants of health can lead to better health outcomes in local communities and save costs by preventing expensive medical interventions down the road.
Providing prescriptive relief for food insecurity
Academic medicine is taking the lead in helping individuals who have limited access to healthy, nutritious food with innovative yet practical programs to address food insecurity.
Food insecurity, which is defined as limited or uncertain access to adequate food, affects more than 12.7% of U.S. households, or roughly 15.8 million people. Researchers have found that adults who are food insecure are at increased risk of developing chronic diseases, while children are at risk for developmental issues.
Health care providers recognized that for some patients struggling with chronic illnesses like diabetes, kidney disease, and heart disease, a lack of financial resources or living in a so-called food desert — an area where it is difficult to buy affordable or good-quality fresh food — can compromise their ability to stay healthy.
To address food insecurity, Geisinger Health Fresh Food Farmacy in Pennsylvania screens patients for uncontrolled diabetes and then provides a "prescription" for its Fresh Food Farmacy. Patients who enroll in the program receive care management, coaching, and education. They also receive a weekly supply of food to prepare healthy meals. With healthy food and continual education, some participants have been able to reduce or even eliminate their diabetes medications.
Since food insecurity is also documented as a key factor in hospital readmissions, teaching hospitals work to help patients before they leave the hospital. Eskenazi Health in Indiana partnered with Meals on Wheels to offer medically tailored meals to seniors being discharged from the hospital and link patients to food pantries within walking distance to their homes.
In another program, the Boston Medical Center emergency department partnered with more than 20 clinics to screen patients for food insecurity and provide a written prescription for free groceries to be picked up at the medical center’s on-site Preventative Food Pantry. The program now feeds 7,000 to 8,000 patients and their families each month.
Access to transportation limits patients’ ability to seek care
Health care providers also found that while food insecurity was a major issue for some patients, others had difficulty getting to and from medical facilities, and some were physically unable to leave their homes to seek care.
About 2 million Medicare beneficiaries are either completely or partially homebound, according to a study in JAMA Internal Medicine. In addition, roughly 3.6 million Americans do not seek medical care because they either don’t own a vehicle or don’t have access to public transportation. Typically, these individuals on average are female, poor, older, have less education, and are more likely to be a member of a minority group.
In a 2013 review of 25 studies published in the Journal of Community Health, researchers found transportation was an obstacle to access to medical services for many low-income patients. One of the studies showed that 58% of patients who had cars missed medical appointments, while patients who used public buses were twice as likely to skip appointments compared to those who had cars.
To address the problem, a few initiatives have been supported by medical schools and teaching hospitals, including:
- MedStar Health's Medical House Calls Program. The initiative offers 24/7 access to care management and on-call physicians for elderly and disabled patients who have difficulty leaving their homes. This program serves about 600 patients who might face institutionalization or repeat hospitalization because they are unable to access community-based ambulatory services. Participants receiving house calls had 17% lower Medicare costs, 9% lower hospital admissions, and 27% fewer nursing home bed days.
- Denver Health. After determining that lack of transportation played a significant role in patients' high no-show rate for appointments, Denver Health began providing bus and taxi vouchers to patients, as well as a private car service using a donated vehicle and volunteer drivers. It is also one of a growing list of teaching hospitals that use specialized software to order and pay for services through ridesharing programs such as Lyft and Uber.
Addressing housing instability
Coupled with food insecurity and lack of transportation, inadequate housing ranks among the most challenging barriers to good health for many individuals. People who are homeless tend to suffer from multiple chronic illnesses or periodic acute illnesses that result in them being seen frequently in emergency departments or admitted to the hospital.
“We are an urban health system engaged in tackling complex social issues that affect health. Lack of housing has been shown to have serious health effects. Without a home base, getting and staying healthy is extremely difficult, and this is why we have decided to reinvest in this program”
Robert Barish, MD, MBA
Vice Chancellor for Health Affairs at the University of Illinois at Chicago
In 2015, the University of Illinois Hospital in Chicago, Illinois, piloted a program in collaboration with local nonprofit groups to implement a “housing first” initiative, which helped place chronically homeless emergency department patients into permanent housing. Through the program, which initially assisted 26 patients, the hospital pays $1,000 towards housing costs and provides case management services for each participant. In 2018, it added support for another 25 patients. The Better Health Through Housing program saw an 18% decrease in health care costs for the patients it served.
“We are an urban health system engaged in tackling complex social issues that affect health,” said Robert Barish, MD, MBA, vice chancellor for health affairs at the University of Illinois at Chicago. “Lack of housing has been shown to have serious health effects. Without a home base, getting and staying healthy is extremely difficult, and this is why we have decided to reinvest in this program.”
Student health linked to readiness to learn
In addition to access to food, transportation, and housing, researchers have found a link between the health of students and their academic attainment. When young people are healthy, they are ready to learn. Teaching hospitals and schools of medicine are, as a result, creating partnerships with K-12 schools and investing in education early on.
Children’s Hospital of Philadelphia (CHOP) is partnering with schools in their community to use a telehealth program that ensures students are getting the primary care that they need. The CHOP health care provider coordinates care with a school nurse using either a tablet or laptop computer equipped with a webcam for a virtual visit. The nurse has on-site medical equipment, and the CHOP provider can prescribe medication electronically and offer other helpful information and services. The pilot program strives to decrease student absenteeism, prevent increasing acuity of health issues, and reduce health care costs.
Along with reducing health care costs, teaching hospitals are also seeking ways to reduce health inequities. The Morehouse School of Medicine (MSM) in Atlanta, Georgia, has partnerships with Atlanta public schools to encourage youth to pursue studies in science, engineering, math, the arts, and medicine. One program pairs MSM faculty, staff, and students with students from the Tuskegee Airman Global Academy to provide mentoring, help with science fair projects, and offer resources for in-class learning.
Other programs focus on helping students turn their dreams into plans. University of Texas Health Science Center at San Antonio Joe R. and Teresa Lozano Long School of Medicine UT Teen Health program works to reduce teen pregnancy rates by providing reproductive health education and promoting healthy life choices through evidence-based, culturally competent programming. Since the program launched in 2003, San Antonio’s teen birth rate has declined by more than 40%.
Reaching out to underinsured and uninsured
Individuals without health insurance or who are underinsured often wait to seek care even if they need it and then receive care by visiting the emergency room of a teaching hospital. These delays can lead to a more costly medical intervention for a problem that could have been controlled with access to preventative care.
An estimated 28 million U.S. residents have no health insurance, and millions more have inadequate coverage with significant patient cost-sharing or coverage limitations.
While teaching hospitals spend billions of dollars in uncompensated care, they also invest significant resources to help eligible patients enroll in Medicaid, the Children's' Health Insurance Program, or the Affordable Care Act insurance exchange program.
Many medical schools, such as the University of Colorado School of Medicine, are among the growing number of institutions with Student Run Free Clinics (SRFCs), in which faculty-supervised students, residents, and other trainees provide free care to uninsured patients. A 2014 survey noted that the number of AAMC-member institutions with an SRFC has more than doubled since the last national survey was conducted in 2005, and SRFCs are now present at more than 75% of medical schools.
Some SRFCs are open just a few hours each week and are staffed by faculty and medical residents from just one school. Others, such as CommunityHealth in Chicago, Illinois, are broadly supported by their locality’s academic medicine community. In addition, CommunityHealth serves as a clinical site for four Chicago-based residency programs, six medical and osteopathic schools, and eight other health professions training programs.
Access to health care, especially when it is limited to emergency and acute inpatient care, is not enough for patients who face problems accessing healthy foods or transportation to get to medical appointments. Inadequate housing, educational limitations, limited health insurance, or other challenges can also block patients from achieving good health. Medical schools and teaching hospitals are reaching beyond traditional, hospital-centric health care delivery models by partnering with their communities to remove access barriers and achieve healthier communities.