Navigating Health: Build Bridges or Stay in Your Lane

The New York Health Foundation (NYHealth) Board of Directors regularly conducts site visits to different parts of the State to learn about various regions and see partners and grantees in action. We've been to many places over the years, but we'd never focused on New York City itself - home to more than 8 million people. We were overdue. To learn more about the City, its incredible diversity, and some of its health indicators, visit here.

We started at Bellevue Hospital, the oldest public hospital in the nation. While there, we heard from the NYC health commissioner and a panel of hospital and health center leaders. We visited God's Love We Deliver, which prepares and delivers more than 16,000 healthy, medically tailored meals per day to New Yorkers with serious illnesses. We also met with organizations working to increase access to affordable healthy food, improve maternal and child health, provide care and services for unhoused New Yorkers, and address a range of social factors that affect New Yorkers' health and wellbeing.

One question kept coming up: who is supposed to do what to improve health?

As the visit went on, the lines got blurrier across health care, public health, and broader drivers of health. This last category is often referred to as "social determinants of health" or "health-related social needs" - those factors outside of health care, like housing, employment, and education, that influence how healthy we are.

Deservedly, social needs are getting more attention. It's long been clear that our health is about more than medical care. In general, the clinical care we receive within the walls of a hospital, community health center, or doctor's office accounts for just 10%-15% of preventable mortality in the United States. New York State is directing more resources toward health-related social needs through its recent Medicaid Section 1115 Demonstration Waiver. Last month, Governor Hochul announced that 9 nonprofit organizations had been selected to receive a total of $500 million to connect Medicaid beneficiaries with healthy food, housing support, transportation, and other social services. Everyone agrees that those factors have a huge impact on health and wellbeing.

It's been common for health care providers and community-based organizations to team up - sometimes formally, sometimes loosely - to connect patients with services that meet their social needs. This might take the form of a doctor writing a prescription for food or heat or housing; from there, a community health worker, a social worker, or a lawyer might connect the patient to services through a community partner or a government agency. In these instances, the health care organization is an intermediary, not the direct provider of health-related social services.

But increasingly, hospitals are investing directly in health-related social needs. The American Hospital Association is encouraging and supporting its members to do so. A recent study identified 57 health systems across the country that had invested $2.5 billion to address social determinants of health. For example, MetroHealth in Ohio invested $60 million to build 250 affordable housing units. Children's Mercy Kansas City's Healthy Homes program offers environmental health assessments and repairs and renovations to improve housing stability in the community. A few health systems on the East Coast partnered with Uber to provide subsidized or free transportation to doctor appointments. Boston Medical Center has an on-site food pantry that distributes more than 15,000 pounds of healthy food every week. Several West Coast providers have invested in youth workforce development programs.

Many argue this is the right direction to go. After all, hospitals have a lot of resources. An expansive view of health means meeting patients where they are and addressing immediate needs like food and shelter, which have an obvious impact on their health. Why treat and stabilize an asthma patient, but then send them back to a home filled with triggers like mold and vermin? Chances are pretty good that patient will end up back in the hospital, and it was avoidable.

Others disagree, pointing to the risks of mission creep, as well as health systems' lack of expertise in addressing broader social needs. The main reason hospitals exist is to provide safer, high quality, and effective acute care. And frankly, they don't always succeed at that. Is it fair and realistic to ask them to also be responsible a for a patient's housing, food security, and things like that?

Last year, Drs. Sherry Glied and Thomas D'Aunno of the NYU Wagner School argued in a JAMA Network commentary that there "are fundamental mismatches between the priorities and capabilities of hospitals and health systems and the task of addressing social determinants of health" and that "a pivot from [their] central mission to addressing social needs can be a dangerous distraction." They point out that even cross-sector collaborations between hospitals and social service agencies are often fraught and ineffective; "… hospitals and health systems do not typically play well with others. They are bigger, stronger, and more politically well-connected than local community social service providers and differ from their erstwhile colleagues in their cultures, leadership styles, and managerial practices."

During our site visit, we could agree there are no clear, easy solutions. There is an excellent argument to be made that improving health requires an all-hands-on-deck approach, one that bridges the siloes of health care, social services, and public health. An equally strong argument can be made that each sector should stay in their lane and focus on doing what they do best. And adopting a patent-centered view, does it really matter? Does that asthma patient genuinely care which entity improved their home environment if it gets done?

As New York embarks on its newest Medicaid waiver, these questions will keep rising to the surface. I encourage you to share your thoughts and continue the conversation in the comments below.

By David Sandman, President and CEO, New York Health Foundation
Published on Medium on October 4, 2024

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