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The Importance of Addressing Social Determinants in Healthcare

Episode 10
Dr. Joseph Webb, Nashville General Hospital CEO and author of the hub and spoke health equity model, discusses the science of healthcare delivery. “This evidence-based approach to care is statistically, scientifically, and empirically proven to produce desired outcomes.” Webb shares how Nashville General is putting evidence-based models to work to remove barriers to care and improve outcomes in the populations it serves.
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View Show Notes and Transcript

Things You’ll Learn:

  • Social determinants of health play a significant role in shaping health outcomes.
  • The concept of a food pharmacy highlights the importance of addressing food insecurity as a key determinant of health.
  • Measuring and tracking the success of healthcare programs is essential for evaluating their impact and refining strategies for better outcomes.
  • Public hospitals play a vital role in providing quality healthcare to diverse populations, including those with limited access to resources.
  • By focusing on addressing social determinants and providing holistic care, healthcare systems can work towards achieving health equity and improving overall community health.

Resources:

  • Connect with and follow Dr. Joseph Webb on LinkedIn and Facebook.
  • Visit Dr. Webb’s website.
  • Learn more about Nashville General Hospital on LinkedIn and their website.
  • Read the Health Equity Model by Dr. Webb here
  • Discover more about the Whitehall Study here.
  • Find out more about the Congregational Health and Education Network (CHEN) here

Transcript:

Rachel Schreiber:

Hello and welcome to the Spark, a view of Innovation in Healthcare. I’m Rachel Schreiber, your co-host, and in this episode we’re speaking with Dr. Joseph Webb, CEO of Nashville General Hospital. Dr. Webb is the author of the health equity model, a hub and spoke of healthcare delivery process, founded on the principles of evidence-based management. The model addresses health literacy, creates referrals to care through community organizations, and ensures continuity of care. We’re really excited to speak with you, Dr. Webb. I view you as a leader in this type of unique approach, and it’s really important the work that you’re doing in healthcare. And I’m also joined by Stuart Hansen, CEO of Avenir Health.

Stuart Hanson:

Great to have you. Thank you for joining us, and thanks Rachel for the intro. Dr. Webb, first of all, I’ll just give you kudos. I love your city, but I also really, really love the work you’re doing and the web model is really inspiring. So super excited to have you join this conversational dialogue that we’re having with industry leaders that are really impacting healthcare. One of the first things we always cover with our guests is we like to really dig in personally into your source of motivation, because you know this as well as we do, changing anything in healthcare is hard. There’s so much complexity, there’s so much critical or kinetic energy and momentum around the status quo, but it’s so important and it really takes passionate leaders like yourself with persistence, with faith, with drive, with resiliency. And I would love to peel back and understand what gave you the inspiration or what inspires you every day to do the great work that you’re doing at Nashville General and more broadly.

Dr. Joseph Webb:

Yeah, it’s a privilege to be able to express that to a broader audience as to how I go about getting myself motivated every day to come in. And I tell people that while this is a job, I feel blessed that I don’t feel like I go to work every day.

Stuart Hanson:

It’s a passion, right?

Dr. Joseph Webb:

I’ve been in healthcare a number of years. I started my career in behavioral health and really learned a lot about, from the very beginning, dealing with individuals with personal issues and fast forward, moved into the acute care, help medical acute care setting, and that’s where I’ve spent most of my time. But those first few years in behavioral health really gave me a good platform for understanding human behavior. And some of the issues that we don’t see because they’re not as tangible, such as diabetes or congestive heart failure or COPD or some of the other more traditional type medical conditions that you use. Medication to care for health is somewhat of a tricky thing.

It’s a complete physical, mental and emotional state of wellbeing and not just the absence of disease or infirmity, and that’s a world health organization definition from 1946. Wow. So it’s been around a long time. As we look at that and we understand that healthcare is the connection to our health, without our health, not much else is going to matter. And so as we think about that, the issue of health equity and health disparities that we hear so much about, and they oftentimes are just kind of catchphrases or the phrase of the month, and you see it all over the place, we’re going to improve health equity, we’re going to eliminate health disparities. What’s not the easiest thing in the world to do? You got to understand what you’re dealing with. So going back to the early 1990s, late 1980s, this issue of social determinants of health was really being researched heavily probably before that, but really started to come to the surface around that time.

And in health disparities, health disparities. And there was a determination that there is a real disproportionate impact on certain individuals, particularly people of color and marginalized populations. They tended to have worse outcomes. And when you drill down into that and you see some of the reasons for that, it is so multifactorial that it raises the level of complexity that it’s not a one fix kind of deal. You really got to understand the complexities of what creates a lifespan for an African-American compared to the lifespan of a white individual. So when you’re seeing that type of disparity and you drill down into that and you look at what are some of the social determinants of health and drive that, and the thing about social determinants of health, which is identified, which are identified as areas such as access to healthcare, access to education and education attainment, access to a job where you live, work, play, grow, all of those elements will determine your lifespan.

And honestly, this is also true among homogeneous cultures and populations where even if you are, and there was a study called the Whitehall Studies that was done back in the seventies, and then subsequent to that Whitehall two studies, but it showed that even the homogeneous population in England, I believe, where the individuals that were of the lower socioeconomic status experienced more chronic conditions, even though they were of the same race. And there was just that difference in the socioeconomic status that caused them to experience more chronic conditions. And so if you apply that to the United States where you have this melting pot of different races and ethnicities, some tend to struggle with more of those social determinants of health being prevalent in their lives than others. So you can imagine if it happens with a more homogeneous population, what that heterogeneous population is going to look like when those groups with those social determinants of health.

So that research was done and it was determined that particularly among African-Americans, health disparities were creating lots of issues and concerns. And it was something that I became very concerned about early on and only to find out that a lot of the things that were contributing to those were within the control of the individuals that were experiencing them. So things like behavior, lifestyle, and the social settings. And so there’s only, the statistics show that 20% of your health outcome is actually related to healthcare medical care itself, and the other 80% has more to do with the lifestyle behaviors and other issues that are choices to a large degree. So we try to, here, fast forward. What we do is we focus on the chronic care model of healthcare delivery at Nashville General Hospital. It is a model that was created by a gentleman by the name of Ed Wagner from the McCall Institute some years ago.

And it is still very relevant to conditions today because what it does is it focuses on continuously caring for those chronic conditions and preventing them wherever possible, but certainly constantly monitoring those so that individuals, for instance, that might be prone to be diabetic or hypertensive, have the level of care that prevents them from getting into crisis or if they have social issues or economic issues. The community resources is a component of the chronic care model. Policy is a component of the chronic care model. And so if you build a system that basically supports that model, there are six components of that model. If you build a system that basically supports those six components, then you essentially created a model that is capable of addressing the chronic conditions of a population, which tends to drive the mortality and morbidity within that population. So that’s what we’ve done.

And the motivation, actually, I would go back to, came from getting an understanding from the research, the national research that was done on health disparities and what are some of the causal factors that was intriguing to me. And so early on, I started working with faith-based communities because in my opinion, particularly African-Americans and the science will show that there are certain populations that rely heavily on their faith-based organizations in order to get their needs met, whether it’s social, economic, emotional, psychological, whatever it is, certain populations rely heavily on their faith-based organizations and their faith-based leaders, African-Americans are among the highest.

It’s a natural fit then that if we can engage our faith-based leaders with a, and learning and understanding more comprehensively the impact of these social conditions and these issues that create these health disparities and how we can help to mitigate those conditions, then it will create a downstream effect that will be more tolerable and will enhance the lives, the mortality and morbidity of that population. And so I can get into that later on under the innovative aspects of what we have done here. And I also did it earlier in my career. So it’s kind of like an upgrade in the faith-based approach to what we’ve done here in Nashville.

Stuart Hanson:

Well, hey, listen, I love, that was an amazing answer. I love the depth and the breadth of the source of your passion. I think the mental behavioral health component being kind of the original foundation, but blending in all the social determinants, which are still, as you well know, major topics, major challenges that large systems, large healthcare providers, small healthcare providers, everybody in between are still struggling with how to best address that. So I love the fact that you’ve kind of blended all that together with the faith-based perseverance that you’ve brought to what you’re doing in Nashville. And I love the proactive healthcare model of wellness care and the focus on what else you can do. Just as a side note, we did an interview a few podcasts ago with a company CEO who’s helping solve the medical transport problem for those individuals that have access challenges. And it was a really enlightening discussion for us. So I’d be happy to connect you with that CEO if that’d be helpful. Great guy. But let’s take it a level deeper. Would love to hear what are the innovative things that you’re really focused on and really enthusiastic about, and how have you guys brought that stuff to your community?

Dr. Joseph Webb:

Okay, so as I talked about the Faith-based initiative, I’m going to start with that one because from an innovative standpoint, we have created a 501C3 structure for what is now a membership of 108 congregations. It’s called the Congregational Health and Education Network, CHEN. In order to change the health equity aspect among within a population, you must create a more equitable distribution of the social determinants of health.

In order to improve on health equity or population, you must first change and make the distribution of the social determinants of health more equitable because the social determinants are causal factors for health disparities, right? If you change those and shift it so that the social determinants now are more equitable across the entire population, then you don’t have those who are disproportionately affected, right? So you pick out that disproportionate effect. Now, in order to do that, we looked at, as I rebounded from my first endeavor with a faith-based initiative. What is the number one variable in the social determinants of health that can actually impact the others at a higher level? In other words, has the strongest correlation with the other social determinants of health. If you’re looking at access to healthcare, access to transportation, access to housing, access to food, access to education attainment, it would be education.

Because on the social gradient of health, the higher your education attainment, the higher you tend to be statistically on the social gradient of health. So if I target then your education attainment, which is one of the elements of CHEN, targeting, education attainment, creating opportunities for individuals, cohort groups to improve their education attainment, then we can move a cohort group across the continuum to a different place on the social gradient of health, right? If you go from, high school education to having a college education or an associate’s degree or a trade degree where your income now goes up, you’re going to shift on that social gradient. That changes, has the potential to change all of the other variables that are considered social determinants of health. Now you’re at a better place. You can start to make some better decisions. It’s not a cure all because with that has to come other things such as under CHEN, the other aspects of CHEN health literacy, I already mentioned educational attainment, health literacy, and access to healthcare and supporting, providing support for those member institutions. Those are the four components of CHEN. And so that’s the effect there. We’re doing some major projects right now as we speak with our CHEN, or they’re connected through our community care team, which is the hospital-based caregivers. They’re connected to the CHEN organizations. They go into the community. Yes.

Stuart Hanson:

Just really quickly, I want to make sure the four areas were health literacy, educational access, healthcare access, and what was the fourth?

Dr. Joseph Webb:

Supporting the member organizations.

Stuart Hanson:

Gotcha. Yeah, sorry, I didn’t want that to be lost on our audience or me, so thank you for repeating that.

Dr. Joseph Webb:

Okay. And so that’s what we’re doing with our CHEN organization is getting into the community through our community care team, which is the element within the hospital that has the behavioral health initiatives and resources, the nurse practitioner resources, the dietician resources. So all of those are aligned within our clinical environment, and that’s where these individuals are able to go to receive their care. So when they come in to receive their care, for instance, if it’s a diabetic patient, they’re diabetic groups that they will be a part of. They learn about their disease condition, they learned how to eat, they learned how, I was talking to one patient one day and I asked him what he had learned about his condition. He said, I’ve certainly learned not to go around kicking things because I have diabetes, and if I get a cut, then it could get infected.

And so it was obvious that he was learning about his condition. And so long story short, just that educational aspect of connecting that faith-based community to the care team at the hospital, which is where we have a 24 hour, seven day a week emergency room, and all of the major specialties we have and to the model, the web model that was mentioned on the front end, the hub and spoke model, we have five clinics, ambulatory clinics around the city that are access points for our patient population. And each one of them when they’re not in the doctor’s office or in the hospital, which is we try to minimize individuals having to be in front of caregivers because the best care you’re going to get is care you’re going to give to yourself and try to educate them on that. So it is a way of making sure that these individuals do not get into crisis.

The main thing is if you’re diabetic or if you’re hypertensive, you can get into hypertensive crisis, cardiovascular crisis, or you can get into the diabetic crisis. You can end up spending time in the ICU emergency room. And in these areas where the avoidable approach is these individuals have regular appointments with providers, so you can scale and schedule those activities. And at the same time, what you’re basically doing is avoiding helping those individuals avoid getting into crisis by making sure that their A1C is being checked, their blood pressure checked, and all of those indicators are being checked regularly and their medications are prescribed properly.

Stuart Hanson:

Sounds really holistic.

Dr. Joseph Webb:

Absolutely.

Stuart Hanson:

I appreciate the basic premise of root cause analysis, but one that’s not done often in healthcare, right? You’re actually really trying to understand what are the root causes and how do you, because I would assume making a really minor tweak in the root cause can have dramatic impact on the end results. Are you guys able to, have you been able to measure and actually track some of the success of these programs? I got to imagine it’s going to be gigantic improvements.

Dr. Joseph Webb:

Yeah. We’re constantly looking at opportunities for measuring tracking and producing information to our audiences in the public on how these outcomes are beneficial to the population. By the way, our hospital, while we are a public hospital, we’ll celebrate 134 years next week.

Dr. Joseph Webb:

The population of patients that we serve is actually over 60% paying patients. Because if you’re going to remain viable fiscally, financially viable in healthcare in this day and age, you’ve got to be able to attract everyone by the natural ratio of the population of our city and our county. They’re actually more insured people here than not. It’s not an indigent city. Therefore, if you’re attracting from the natural population, then your healthcare quality is excellent, then you’re going to be able to attract more obviously, from the larger population. Now, the food pharmacy is the other innovation, and you got to hear about that. I don’t know if you guys have gotten any insight into,

Stuart Hanson:

Now tell me, you got me intrigued by food pharmacy because access to food is a big issue in a lot of these social determinant challenged areas.

Dr. Joseph Webb:

Absolutely. Food insecurity is a major challenge for our country, for the world, actually. So based on food insecurity being so prevalent in most areas, we created what is called the food pharmacy. I spent a number of years serving on the board of a food bank, a regional food bank that covered three states, delivered roughly around 20 million pounds of food a year. But one of the things that I had a curiosity about was if you are giving someone food, what is the quality from a health content of that food? Are you giving them that food to fill their belly or are you giving them that food as medicine? So food is medicine that’s been around for hundreds and hundreds of years, and there’s an old adage that you should eat your food as medicine or you will eat your medicine as food.

Stuart Hanson:

Clever. Yeah. I had not heard the term food pharmacy before. Love that idea.

Dr. Joseph Webb:

So the food pharmacy is structured this way. An individual comes into the hospital and every entry point of the hospital there is administered, they are administered a food insecurity survey. If you test positive on that survey, then that information is submitted into your record and it goes to your physician, your provider, and that provider will write a prescription that will be passed along to the care team. That individual should receive food, and this is the type of food that they will receive. It will identify their condition if they’re hypertensive or if they are congestive heart failure or if they’re diabetic. And also we have a cancer center here that is actually the second oldest in the region. It’s about 84 years old. And we found that our patients who receive chemotherapy and medications for cancer, when they lose weight, as you know, you have to be removed from your treatment regime until you can get your weight.

You have to keep your weight at a certain level in order to take the treatment. And so with our patients, they never experienced that because if they are food insecure, we have an area of our food pharmacy, which is a physical location that’s set up like a grocery store with coolers for fresh fruits and vegetables and shelf stable products. And then we have the caloric products for our cancer patients. And so the physician writes the order, then the dietician who is employed there in the food bank and in the program, I mean in the food pharmacy and in the program will make sure that the individual, when they come in, usually by appointment, they will be given a tote bag and the foods that they need, they will pick up and they stay on that until there’s a transition, a reasonable transition off. But otherwise we don’t kick them off. The way we see it is that if you’re struggling with food insecurity, then you’re likely to get whatever foods you can for you and your family to eat. Oftentimes that food will contribute to your disease process, which means you’re going to need to consume more medical care. And that’s not what we want you to have to do. We want you to be healthier, then you don’t have to consume that because that can also contribute to getting you into medical crisis, particularly if you’re diabetic or if you’re high.

Stuart Hanson:

Right. That’s awesome.

Dr. Joseph Webb:

It’s something that we don’t appreciate as much in healthcare, and I’ve been in healthcare leadership a lot of years. We don’t appreciate it as much. It’s called cost avoidance. We tend to look at the actual cost.

Stuart Hanson:

Cost. Yeah. How do you fund such a great food service? Well, you fund it because you’re avoiding all the medical consumption on the backend. Right.

Dr. Joseph Webb:

There you go. You’re a quick study.

Stuart Hanson:

Thank you.

Dr. Joseph Webb:

But that’s absolute truth. It’s very cool. And that’s the logic behind what we’re doing. And so we keep people out of the hospital, but they’re in our ambulatory setting and they’re following up on their visits and we’re tracking their A1C, we’re tracking their blood pressure, we’re making sure. And then there’s the 340 B program, which is a federal program. You might’ve heard of 340 B. It’s a designation for pharmaceuticals that pharma participates in that allows hospitals that are designated and other entities that are designated 340 B programs to give medications to their patient population that might be underserved at a much reduced price. And so that helps too. And you can imagine even from a behavioral standpoint, that’s also very beneficial.

Stuart Hanson:

That’s great work. I love hearing that story.

Rachel Schreiber:

I was curious as far as the barrier, this model is really important. And I know on the food pharmacy, the traditional model of food banks is lower cost food being distributed or it’s often like the second day old. There may be a high level of bakery goods or high carb, which goes against the goal of health improvement with many of the chronic conditions. And so the offering a food options that are more diverse and healthier, that’s extremely important and good work. What are some of the challenges you faced in implementing this model? Or if there’s other leaders that are interested in implementing something similar in their community, what are some of the challenges or barriers that someone needs to be aware of that you’ve been able to overcome?

Dr. Joseph Webb:

Well, as a public hospital, one of the challenges we face has been, and probably will remain political because politicians tend to transition in and out. And you never know what types of policies are going to be in place or what kind of funding is going to be in place. And there’s a need for cities and counties to provide some support, at least for healthcare, for the population that is indigent. And that’s how we address that here. We only request some support and resources for that population. Now, as far as resources like for the food pharmacy, that is something that we have a dietary here. So we have a food sourcing division that we can purchase. There’s also Second Harvest, which is a major food bank here that we are able to get food through that resource on as a much lower cost. Now the key here is that again, 5 to 7% or 5 to 10% of your population will consume 60 to 70% of your resources.

That’s something that most leaders, healthcare leaders don’t really factor in to their care delivery. And that again, speaks to the cost avoidance. Now, what you have to do, you’ve got to stratify risk, stratify that patient population so that you can get your finger on the pulse of the individuals that are high risk and you can get their matters, their situations under control. And that can be sometimes a very arduous challenge in getting your arms around, because what you’re going to find is you’re going to have comorbidities. We talked about behavioral health, and that’s going to always be one of the major causal factors in addition to that hypertensive, the congestive heart failure and the COPD. But when you combine all of that with maybe some kind of chemical dependency or some kind of abuse of some chemical, and then the behavioral health challenge, you have what is considered to be a high risk individual.

Now you’ve got to really focus some resources on that individual to get them. And that’s going to be, while that’s a minority of your patients, they’re going to consume a majority of your costs. So if you don’t manage that properly, you can really run into some cost issues or some financial issues and just trying to cover everything and everybody with the same level of resources, you don’t need to do that low risk patient. You just need to monitor them and to make sure they have what they need so that they don’t start to transition into the moderate or the high risk. So it’s a risk stratification balancing act that you have to know. And there are tools that help you to do that. So you don’t have to just do that on paper. There are methods that you can do that, that are more scientifically based and it helps you to be more effective, more accurate with tracking your outcomes and who falls into each one of those categories.

Stuart Hanson:

I’ve got dozens more questions we could go into. I know we’re quickly running out of time, but that’s really great advice and really insightful and inspiring. Go ahead, Rachel. Sorry.

Rachel Schreiber:

So as a wrap up, what key phrase describes the vision of what you’re creating?

Dr. Joseph Webb:

Now that’s a great question. And it is the science of healthcare delivery. The science of healthcare delivery. And the reason it is, I refer to it, and my team refers to it as the science of healthcare delivery is because all of our models are evidence-based. The models of care that we use here, our strategic goal is evidence-based. It is the triple aim. It is to improve the experience, improve the outcome, and to improve on the cost per capita. That is the triple aim. We utilize the chronic care model. And the chronic care model is supported by patient-centered care model and the patient-centered specialty practice model, PCH and PCSP. And those are both operational models that support the chronic care model. And I always say that they operationalize the chronic care model. Most don’t know that. But if you look at the elements of the chronic care model and look at the elements and the standards of the PCMH and the PCSP, you’ll see that they aligned.

And if you activate patient-centered Medical Home, which is your primary care providers and patient-centered specialty practice, which is your specialty physicians and the reciprocal referral relationship and how they operate and how other elements and standards operationalize the activities, you essentially see the chronic care model being carried out. So we did that not in advance of knowing that the two actually worked so collaboratively together, but as we studied the elements of each, we found that this is perfect and all we have to do is to make sure that we continue to execute both out of this model. And so those are the things that we use. So everything that we do here has a proven outcome associated with it and not something that we just made up on site. It is statistically and scientifically and empirically proven to produce desired outcomes. So that is science.

Rachel Schreiber:

It’s based on science. Right?

Stuart Hanson:

The science of healthcare.

Dr. Joseph Webb:

That’s a great, not the science of medicine and medicine’s always been based on the science, but the science of healthcare delivery is the phrase that we use to describe the care that we deliver.

Rachel Schreiber:

That’s really good. Well, I really appreciate the time that you’ve spent with us to describe the good work that you’re doing, and we need more leaders to do that as well. So if our listeners would like to keep up with your thought leadership, they can follow Dr. Webb on LinkedIn and Facebook. And he has a website, drwebb.org. So thank you for joining us today and keep up the great work. It’s inspired what you’re doing in the Nashville community and creating a model that can be implemented nationwide.

 

Dr. Joseph Webb, Nashville General Hospital CEO and author of the hub and spoke health equity model, discusses the science of healthcare delivery. “This evidence-based approach to care is statistically, scientifically, and empirically proven to produce desired outcomes.” Webb shares how Nashville General used an evidence-based approach to create innovative initiatives like food pharmacies and faith-based community partnerships to improve health literacy—an essential element in addressing social determinants and barriers to care.  

 

 

 

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