Expert to Expert: Karen DeSalvo & Mikelle Moore
The evidence is clear: Where and how you live affects your health significantly more than the medical care you receive. Hear from two national leaders about how systems are changing to tackle these social determinants of health.
After Hurricane Katrina devastated New Orleans in 2005, Karen DeSalvo, M.D., saw firsthand how social determinants of health — factors outside of medical care like clean water, housing and income — impacted her community’s ability to recover. Following the tragedy, as a faculty member at Tulane University and New Orleans health commissioner (2011-14), DeSalvo focused the city’s efforts on transforming the places where people live, learn, work and play into social and physical environments that promote health. The resulting model of neighborhood-based community health — renowned nationally for effectively serving those lacking adequate care — is one that others emulated and built upon as DeSalvo moved into leadership roles with the U.S. Department of Health and Human Services.
Now, halfway across the country, Intermountain Healthcare is leading an innovative collaboration to promote health, improve access to care and decrease health care costs known as the Utah Alliance for the Determinants of Health. At the helm of those efforts for Intermountain, a not-for-profit system of 23 hospitals, is Mikelle Moore, MBA, MHSA, senior vice president of community health.
Longtime colleagues Moore and DeSalvo — now a professor at Dell Medical School — connected by phone for a REthink conversation about the social determinants of health, community partnership and more.
Karen DeSalvo: As a new medical school created in partnership with its community, Dell Med has a unique focus on improving health locally, and this foundation informed how we structured our work early on. For example, Dell Med is one of only a handful medical schools with a Department of Population Health. The department helps to identify and support community-based health solutions, promotes the delivery of value-based primary care, enhances regional data resources and more.
How did Intermountain come to recognize the importance of social determinants of health?
Mikelle Moore: We began to really look at the things we were doing to improve health in the community and how we could do that more in partnership with the clinical part of our system. We invited all of our programs — cardiovascular, women’s health, pediatrics, behavioral health and so on — to work with our leadership team on understanding the health needs in the community and designing evidence-based interventions. It transformed the way we at Intermountain thought about community-based work because it became clear that our clinical influence was just one piece of the puzzle that we needed to solve.
For example, when we spoke with people about managing their pre-diabetic condition, we realized many faced significant issues like lack of access to healthy food or time to prepare it. Many of our patients didn't even have a living situation where they could appropriately store healthy food. Inviting our clinical teams to see these barriers is what enabled a transformation in our approach.
KD: Practitioners need to have a sense that there is much more to the story about what is preventing health, wellness or even recovery for our patients. During my time as national coordinator for health information technology, I saw how powerful technology and data could be in providing this bigger picture and advancing health.
I’m excited about Dell Med’s new Biomedical Data Science Hub that taps into data from myriad sources to give a fuller, more detailed picture of all the factors — clinical and nonclinical — that affect health in our community. The hub is analyzing and using that data to answer important questions like how to best prevent and treat prevalent diseases. One of the interesting and powerful approaches that Intermountain has taken is doing hotspotting.
How does that feed into the way you help build evidence and awareness, not only for your own organization but for the community?
MM: We have actually done hotspotting from two different points of view. One tactic is around clinical conditions and the way that they present in our system. We look at geographic data of where people live alongside clinical data to help us see who is using the emergency department for conditions that could be treated in an ambulatory setting. We are using that same type of geo-mapping data to see where people who have behavioral health conditions live to help us think about how we can orient services more effectively.
We are also hotspotting around deprivation through an index that uses census data, like quality of housing, income, education levels and other similar points. When we overlay the geo-mapping data and deprivation data, we see that the prevalence of things like emergency department use or disease reflects the common disparities in education, quality of housing and more. It has really helped us fine-tune how we apply resources.
KD: Speaking of data, Intermountain’s recently announced Utah Alliance effort will leverage that type of information and partnerships to improve health locally. Tell us about the vision for the alliance and what you might already be learning in that effort.
MM: It feels kind of funny to have you ask me this question because I think so much of what the Utah Alliance represents has been influenced by your coaching. There is beginning to be a space around the country of community-based programs that work — yet it does not seem like anyone has figured out how to create an economic model to fund how we address the social determinants of health. What dollars should we move from our health care pockets to our housing, transportation or food pockets? The vision of the Utah Alliance for the determinants of health is to really create a demonstration of how to make a sustainable economic model.
KD: How do you structure the work?
MM: The alliance’s efforts started by bringing together leaders from Utah’s Departments of Health, Human Services and Workforce Services as well as the governor's office and other partners to understand — given our aspirations to improve health for a specific population — how we might collaborate.
Ultimately, we decided that in order to do something that could be demonstrative for Utah, we needed to choose two communities where we could have geographic-based influence on the determinants of health and clearly measure health outcomes. We selected four ZIP codes on the basis of disparities as well as Intermountain’s SelectHealth claims data for Medicaid members.
When we first identified the ZIP codes, we went to our existing partners to talk about the alliance’s vision and whether our work would will be welcomed. The answer was yes — the alliance was invited to bring the additional lens and energy to the community. This invitation was foundational and important.
We tried to build on existing efforts that were underway rather than create our own infrastructure. In collaborating with those partners to support their efforts, we heard two remarkable things. No. 1: Their teams don’t have good data infrastructure for communicating with one another about serving an individual or a family — but want more of that capability. No. 2: They understand the needs of the people they are trying to serve but are maxed out trying to address those needs and can’t invest in the broader picture.
So, we committed to try to address those needs. For the latter, we undertook a piece of Institutional Review Board-approved research to go into people’s homes to talk with them about their life story and observe it in a very real way. By seeing what challenges they face — everything from childcare issues to coping with former trauma to caring for elderly family members — we can design interventions that build on all the existing resources but apply them in a way that is more informed.
KD: The health care system is not just a set of payment models or care models or data — we actually have humans that are working in the environment. How can we start to build a health care workforce that is more aware of the social determinants and more capable of addressing them?
MM: That is so important, Karen, and there are two pieces that are really important for us to get right.
No. 1: We need to develop an infrastructure that gives caregivers information about the people they're trying to care for. Health care workers are quick to check a patient’s vital signs for essential functions of the body. Why not apply that approach to social determinants to get crucial information on financial issues, housing problems and other health factors? We have to design care differently to account for a person’s lifestyle.
Mikelle Moore, MBA, MHSA
Senior Vice President of Community Health, Intermountain Healthcare
No. 2: We need to bring a team-based approach to care. Over time at Intermountain, we transitioned from thinking about individual best practices to thinking about the team-based care needed to deliver services more effectively. To address the social determinants of health, the care team needs to change. Not only do we need social workers on the team, we need to recognize the role of community health workers who are connected to the community they serve.
KD: Agreed on both fronts! I love seeing how UT Health Austin, the clinical practice of Dell Med, is using team-based models designed by our faculty and staff to improve patient experiences and outcomes. The freedom to start from scratch is leading to some important innovations — more is needed nationwide.
What's exciting about this new chapter around social determinants of health is how it creates another bridge for the various people and organizations that support patients and communities. There is a lot of work ahead in this space, but it will result in a much better way to address the needs of all people.
This conversation has been condensed and edited. Hear more of the interview in a podcast from Intermountain Healthcare.