Why health equity requires aligning health with social care

Healthcare can do more for people today than ever before. We have myriad tools that can provide answers and hope for what were previously medical mysteries and challenging diagnoses. Because of these advances in science, technology and medicine, we have an opportunity to keep our communities healthier through greater prevention of illness, earlier detection of disease and more targeted and effective treatment. There is much we can do within our healthcare facilities, but these advances mean little if we don’t also address what happens before and after patients are in our care.

Research reveals that roughly 80% of a person’s health is determined by access to food, housing and social factors (Hood et al. 2016. County health rankings: Relationships between determinant factors and health outcomes). It’s challenging to be healthy without a home, access to healthy food or transportation. These issues are difficult to quantify, but they contribute to much of what causes preventable illness and premature death and they aren’t included in a person’s medical record.

In the US, these non-medical health factors are especially prevalent in communities of colour, an issue highlighted by the COVID-19 pandemic, which disproportionately impacted these communities. A fundamental failure of American healthcare is that, too often, a person’s zip code determines the quality of their health. This isn’t an issue exclusive to the US, as the COVID-19 pandemic has shown disparities in outcomes across the globe.

To help people live healthy lives, we must address the fragmentation of health and social care by implementing processes that close the gap between medical and non-medical determinants of health. We must address core needs and encourage private and public organizations to collaborate more. The healthcare system can be hard to access and complicated to navigate, so it’s no wonder that patients often get lost when trying to find the proper assistance. And, many people are simply unaware that aid is available.

New technologies make it possible to recognize and address social needs as part of routine healthcare. These digital platforms can identify people who would have previously fallen through the cracks. Food and housing insecurity, transportation issues, mental health concerns, addiction and caregiver stress can be more easily recognized and referred to community organizations aimed at addressing these issues. The goal is to eliminate disparities in healthcare outcomes based on race, ethnicity and socioeconomic factors. And, by focusing more on prevention, we can further enhance health equity and build stronger communities.

This large-scale change requires collaboration and, with patient well-being as the top priority, hospitals and healthcare systems are partnering with each other and organizations outside the industry to help close these gaps. At Hackensack Meridian Health, we’re focused on creating a network-wide strategy to address the social determinants of health and better connect our patients to the resources they need. One such partnership is with a digital platform that works in tandem with our current medical records software, assisting our care teams in helping to screen patients for non-medical needs and providing the necessary referrals at the point of care.

Since July 2021, we have made more than 1.5 million referrals to community resources and assisted more than 550,000 patients. These referrals put patients in touch with community organizations that help them pay rent, avoid eviction and address many other needs, even after they leave our care. Medical records are updated so we can confirm when that care is delivered.

Advanced technology helps Hackensack Meridian screen 5,000 patients daily and personalise referrals to patients in 152 languages. This system allows our care team to seamlessly connect with other providers and securely communicate essential patient data.

We’ve also partnered with the largest health insurance provider in our state. Like most insurance companies, it has significant patient data, which we can securely use to identify people at high risk. And Hackensack Meridian Health isn’t the only healthcare system taking part, meaning that once competing healthcare systems are working together to address these issues.

These partnerships are promising, but more collaboration is needed. With food insecurity set to increase around the globe and with it the illnesses associated with malnutrition, there is an increasing need for preventative measures to ensure patients don't get lost in the system. Putting patients in touch with resources that provide access to assistance is critical in preventing physical and mental health issues caused by food insecurity. When organizations collaborate in this way, it ensures healthcare facilities are not overwhelmed, a crucial issue given that many healthcare facilities are struggling with the strain caused by staffing issues.

Often, those who fall through the cracks end up in the hospital as preventable illnesses go untreated until they become an emergency. With the right infrastructure in place, we can work to prevent illnesses long before they become an emergency, which improves outcomes and delivers more value.

While these strides are something to be proud of, there is still much work to be done. Many stakeholders must unite to establish more equitable health outcomes. There is a strong need for more government involvement and cooperation from community-based organizations, healthcare organizations and educational institutions. Increased data and scale means that more ground can be covered and fewer people will get lost in the process.

This is a challenge with a significant human and financial impact and one that we can no longer ignore. The good news is we've seen promising results and, if we continue to push and expand our collaborations, we can ensure a healthier future for all communities.