Social determinants – such as unmet housing needs, lack of income, unemployment, and legal status – are major contributors to poor health, stated physician Rishi Manchanda in a recent webinar presented by the Hospital Quality Institute.
Manchanda is a co-founder of the think tank HealthBegins, which aims to improve health care access and outcomes for low-income people. Social needs – like hunger, housing insecurity, and social isolation – account for 60 percent of preventable disease, according to the organization.
The Indian American physician developed the think tank with two co-founders in 2011, as he was working at St. John's Well Child and Family Centers, one of the largest community health clinics for low-income families in South Central Los Angeles, which treats about 40,000 patients a year (read India-West’s 2012 profile of Manchanda here).
Manchanda is also the author of “The Upstream Doctors: Medical Innovators Track Sickness to Its Source,” published in 2013. “The future of health care depends on growing and supporting more “upstreamists,” wrote Manchanda in the prologue to his book. “These are the rare innovators on the front lines of health care who see that health – like sickness – is more than a chemical equation that can be balanced with pills and procedures administered within clinic walls.”
“They see, rather, that health begins in our everyday lives, in the places where we live, work, eat, and play,” wrote Manchanda.
In his webinar for HQI, Manchanda explained the “upstream” approach to delivering health care, which partners medical resources with social services, such as free legal aid, food banks, and services for housing and transportation.
More than 300 clinics around the nation employ the “Medical Legal Partnership,” which combines health care with legal aid services.
Manchanda noted the health care crisis in Los Angeles, stating that – on any given night – 6,000 veterans are homeless, living on the street or in their cars. Eight out of 10 of their overall needs are related to legal issues, such as expired drivers’ licenses, denial of disability benefits and food stamps, employment discrimination, and problematic credit histories.
A medical legal partnership provides support to low-income families and veterans by providing legal and financial literacy programs at the clinic and at support service organizations, explained Manchanda. At the secondary level, physicians are equipped with a pocket guide to assess legal needs. Clinics can then subsidize legal aid or hire a legal counselor for low-income patients.
Clinics must also coordinate with local courts, banks, the DMV, and debt collectors to minimize legal barriers for high-risk health care populations, he said, adding that clinics could also advocate for an increase in the local minimum wage.
In October 2013, HealthBegins implemented an MLP into an acute intensive caring unit for homeless veterans who frequently used emergency services. The clinic was provided with a full-time attorney, to provide 139 veterans with legal representation.
Over the year of the pilot program, the clinic saw a 24 percent drop in chronic users, which saved the clinic over $500,000. The average legal aid cost per veteran was about $440, but the overall savings per veteran was about $3,600.
Insurers are increasingly looking at social determinants of health, and strategies to mitigate the impact of poor conditions, said Manchanda. “They are not looking at this as charity, but as investments,” he said.
Manchanda played a video of Uriah Martin, a former veteran who lost a job of many years, which began his descent into homelessness. Martin stopped taking his medication for diabetes, and was diagnosed as clinically depressed. He was brought into the emergency room on six different occasions – once in a diabetic coma – before Manchanda saw him at a clinic which utilized an MLP.
“It was a new start for me, putting back together the pieces of my life,” said Martin in the video. “It restored my sense of faith,” he said.