When it comes to helping prevent heart attacks and strokes, we tend to focus on medical issues like managing cholesterol and blood pressure. But they’re not all that matters. Other factors, like financial well-being and access to healthy food, may be even more important.
Addressing social determinants of health is “the most significant” opportunity to reduce death and disability from cardiovascular disease, according to a 2015 statement from the American Heart Association.
“If a person has an issue of not getting enough food, their main priority isn’t going to be going to the primary care physician for a check-up,” says Stephanie Haskins, a medical management social worker. “If we help with other things going on in their lives, they don’t have to worry about (anything except) staying healthy.”
Tackling social determinants of health
Haskins is a member of a select team of nurses and social workers for Blue Cross and Blue Shield of Montana (BCBSMT) working to help close those care gaps in a pilot partnership with the American Heart Association.
“It opens the door to reach out to people we don’t have communication with."
These clinicians, trained by the AHA in heart and stroke care, are proactively reaching out to members in certain group health plans who are at risk of heart disease or stroke and may also have trouble paying their bills, getting healthy food or getting to doctor’s appointments.
The health plans target members diagnosed with high cholesterol, coronary artery disease, hypertension or diabetes. From there, they narrow the list using geographic data, because people living in “compromised” or “vulnerable” ZIP codes may be more likely to face social barriers to health.
“It opens the door to reach out to people we don’t have communication with,” Haskins says. Many of the members she calls haven’t talked to their health insurer in years.
Haskins and others make several calls a day, trying to connect to members. The goal is to get them connected to benefits and social services that may help keep them healthy, in all meanings of the word.
The conversations start with a routine review of the diagnosis and treatment plan. In some cases, this reveals that members don’t realize their plans include benefits that may help them manage their conditions.
One member, for example, shared that he knew he should be taking his blood pressure reading but didn’t have a cuff. Haskins was able to get him one at no cost using his health plan.
Listening and connecting
Once the traditional health care needs are addressed, the callers screen members for social and economic needs that may be undermining their health outcomes.
Using a standardized tool created by the American Academy of Family Physicians, they ask a few simple questions to find out where a member may need help.
The questions cover things like social support, housing, transportation and trouble paying bills. Based on the answers, the nurses and social workers hunt for community resources to address the member’s needs.
On a call to a member with high cholesterol, Haskins recalls, the questions revealed a much more complex picture.
The member was pregnant, had gestational diabetes and was going to be a single mother. Haskins was able to connect her with a food bank, a case management program for pregnant women in her town, and a charity that donates insulin to people in need.
“You hear their sentiment, worries, and appreciation of you actually calling and sending out these resources,” Haskins says. “It’s definitely rewarding.”
The help doesn’t stop there. Haskins and her colleagues in the pilot set goals for members and follow up with them to continually support them on their journey to get and stay healthy.
The pilot is brand new, but BCBSMT is measuring its impact by looking at metrics such as reductions in emergency room visits or improved health outcomes among the members who received calls.
Programs like this one that address the social dynamics associated with heart disease and strokes may help meet the AHA’s 2020 Impact Goal to improve heart health by 20% and reduce cardiovascular disease and stroke deaths by 20% by 2020.