Community studies of COVID-19

By Dr. Mark Fourre, President, Coastal Healthcare Alliance | Jul 15, 2020

As a physician, I know that many non-medical conditions influence our wellbeing, including where we live, learn, work, play, worship and age.

For example, where we live determines the kind of food we can access, and how much we earn determines whether we can afford medicine. We call these the social determinants of health, and their impact is significant. Health care has as little as a 10% influence on a person’s well-being. Discounting for genetics, that leaves social determinants to account for up to 60% of a person’s health.

These numbers suggest that an important way to fulfill our vision of making our community the healthiest in America is to address the social determinants of health most common to our families and neighbors in Knox and Waldo counties.

For a concrete example of how a social determinant can affect both individual and community health, we can look at how our communities responded when COVID-19 forced local schools to close and switch to online learning. Although this change affected all students, it disproportionately hurt students from families with lower social economic status.

The reason: Many of these students receive free and reduced-priced lunch and breakfast programs at school for what is often their only balanced and nutritious meal of the day. With schools closed, where would those meals come from?

There are two social determinants at play here. The first, lower economic status, led to food insecurity – a second social determinant of health defined by an inconsistent access to adequate food because of limited financial resources.

Because low-cost food is often the most unhealthy, children from food insecure families are more likely to be obese and suffer the kinds of health problems that lead to more school absences. They are also more likely to suffer depression, anxiety and behavioral problems. This can affect the ability of food insecure children to learn. They often post lower reading and math scores on standardized tests and are more likely to drop out of high school. They are also less likely to participate in activities like sports and school clubs where they can learn social skills.

Fortunately, our local students continued to receive free and price-reduced meals even after the schools were closed. Across our coastal communities, school staff made thousands of meals a week for pickup by students and families, and the bus drivers delivered them to those with no transportation.

We applaud their efforts and their commitment to being student-centered. We thank them for helping us see food insecurity as a social determinant of health that we must address in a more sustainable way if we are to advance health equity in our community.

Although COVID-19 did not cause the underlying social determinants of this example, it did help to point out just how fragile life can be for those who live in the margins socially and economically.

Understanding this space in the margins is critical to our effort. Those who live there face a number of actionable social determinants of health. These include increased food insecurity, inadequate housing, lower paying jobs, limited transportation options, fewer opportunities for exercise and recreation, limited access to technology and fewer years of educational achievement, among many other challenges.

Of course, no individual is likely to face all of these. But as a group, those in the margins have these social determinants of health in common – and at a disproportionate rate when compared to those in higher socioeconomic groups. It is by addressing these commonalities that we can have the biggest impact on our community’s health.

Pen Bay Medical Center and Waldo County General Hospital have a long-standing commitment to the health and well-being of our community and actively participate in efforts to address these social determinants.

We regularly conduct a community needs assessment and, along with input from community forums, use it to refine our Community Health Implementation Plan. This plan sets the goals and guides the activities of two teams that, among other things, focuses on social determinants of health in our communities.

• Our Community Health & Wellness team offers health education classes, screenings, events and outreach programs to the entire community. This team also participates in a number of community groups dedicated to addressing the most common social determinants of health in our community.

• Our Population Health team focuses on the social determinants that affect our existing patients through the use of health and wellness coaching, care management and nursing support for those patients recently discharged from the hospital but who do not have other support services in place.

• Belfast Public Health Nursing Association (BPHNA) is an important part of this effort. An non-profit agency that receives support from Waldo County General Hospital and the City of Belfast, as well as from grants and donations, BPHNA has provided health care and other critical support services to the most disadvantaged and vulnerable members of our community for more than 100 years.

As we consider how we can better address the social determinants of health affecting our community, I think it is worth considering the work of Jeffrey Brenner, MD.

In 2011, he won a MacArthur Fellowship, often referred to as a MacArthur Genius Grant, for actively delivering preventative health care to high-risk patients living in densely populated settings in order to reduce health care costs. These so-called “medical hotspots” included low-income housing projects and long-term care facilities.

These days, Dr. Brenner has shifted his focus to addressing social determinants of health as a way to reduce health care costs. More specifically, he leads a program that provides rent-free housing to the homeless.

There are more than 500,000 homeless people in the U.S. Many stay in shelters but about a third live on the streets. When they need medical care or just a bed and a meal, many of them go to a hospital emergency department – one of the most expensive places to get health care. Medicaid reimbursements do not always cover the actual costs of these visits. Even when it does, the cost to society is high because it is taxpayers who fund Medicaid.

Dr. Brenner reasons that providing an apartment to the homeless at $600 a month is less costly than leaving them to check in to the emergency department at $3,000 or more per day. Moreover, he reasons, providing medical, social and behavior health care from offices inside the apartment complex where they live gives these former homeless residents access to the kind of help they need to get their lives back on track.

To be fair, Dr. Brenner’s program is much more complex than can be described here. For example, because it focuses on reducing health care costs, it targets only those homeless people who generate the highest health care costs, a small percentage of the total homeless population. Still, early results have been encouraging and the program has expanded beyond its original Phoenix, Arizona, location to more than 30 sites around the country.

Dr. Brenner’s work on a national scale informs our own efforts to improve the health of our communities in Knox and Waldo counties. It also confirms how difficult this will be. His early work around medical hotspots was unable to sustain a reduction in health care costs or an improvement in health outcomes.

For all the good data that Dr. Brenner had to work with, his efforts stumbled over the need to convince the marginalized population he was working with that they could now trust a system that they felt had let them down for years.

What I find inspiring about Dr. Brenner is that despite setbacks, he carries on with the long sustained effort that meaningful work often requires. It is a reminder that addressing the social determinants of health is not a panacea, but it is the right thing to do – and is the right investment to make to improve our community’s health and reduce the heavy financial burden that health inequity places on us all.

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Comments (1)
Posted by: Jane Conrad | Jul 15, 2020 09:54

The social and economic impacts of this pandemic have exposed the importance of addressing these needs.  I am grateful that our local health system is working to address them, and look forward to reading more about collaborations between healthcare providers and social service agencies to address the social determinants of health.

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