A person shows up in an emergency room seeking help for a medical problem due to a lack of insurance. Help is offered, but the solution amounts to a bandage at best. “911 is America’s health care system for those who don’t have health care access,” says Dora Barilla, group vice president of community health investment for Providence St. Joseph Health (PSJH).
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Emergency medical services are the go-to for a system that frequently fails to address social determinants of health, which Barilla says are often entirely overlooked. “These are essentials of life,” she explains. “It’s food, security, housing, safety and socialization.” Other social determinants include factors such as exposure to violence — be it intimate partner abuse, elder abuse or community violence — as well as access to education, employment and childcare.
“If you don’t have health, it’s hard to function in anything else,” says Christopher Lee, clinical solutions marketing manager for Family Health Centers of San Diego. “What good is it if you have health care but don’t have proper housing?”
Or any housing, for that matter. Lee points to the particular challenge of treating the homeless, who not only lack stable housing but also move from place to place every few days. “How do you have any continuity of care with that?” he asks.
We’ve been rationing care through economics, and socioeconomic disparity is very significant.
Dora Barilla, community health investment at Providence St. Joseph Health
The answer to this question, and others, could depend on starting “upstream” from the actual point of care. This upstream concept stems from a belief that, by proactively helping broader communities and providing social services that address each community’s specific needs, health care systems can help reach the people who are most likely to wind up in the ER or forgo care altogether.
“We’re finding that housing, food, security and even social connections are really key for emergency prevention,” Barilla says. “We can help create communities that will support optimal health, which is where we need to go as a nation.”
PSJH operates a number of programs designed to implement this upstream approach, with a large focus on the problem affecting most major cities: homelessness. “We work on coordinated entry programs, rapid rehousing if someone loses their housing, and medical respite care for the homeless who have been discharged from a hospital but are not OK to be on the street,” Barilla explains.
Anchored Home Initiative, an upstream program in Alaska, is a collaboration between PSJH, the United Way, Alaska’s Housing Authority and other local community partners. It is dedicated to ending homelessness in the Anchorage area. “This program is excellent because it offers a continuum of care,” Barilla says, “not only housing, but supportive services homeless people might need such as Medicaid, mental health counseling and case management.”
To show how an upstream approach to health care can be at once so effective and so simple, Barilla offers an analogy: Picture a hospital located on a curved and busy roadway, the site of many accidents due to a lack of safety guardrails. The hospital brainstorms solutions to deal with the growing number of patients: add more ER beds, hire more specialty neurosurgeons to treat trauma patients, arrange for a helicopter to airlift victims to nearby trauma centers. All fine ideas, but even better and far less costly? Build guardrails and put up more cautionary traffic signs.
“That’s upstream care,” says Barilla.
It’s true that there’s a shift underway in how health care is practiced in the U.S. — especially with regard to Medicaid expansion across various states — but Barilla believes that treatment is still too focused on wealth and class: “We’ve been rationing care through economics, and socioeconomic disparity is very significant.” Her solution is to invite in more public and private partners.
“The reason programs like Anchored Home Initiative are going to work is because everyone is on board,” Barilla points out. “That program has more than 75 partners and organizations involved — everything from law offices to restaurants to police departments.”
Lee seconds this approach, agreeing that one organization, one city or one state can’t make a lasting impact: “There has to be better aligning of resources in order to address these issues early on.”