The Case for Integrating Social Determinants Into Palliative Care

Individually, palliative care and social determinants programs both have the potential to improve quality of life and reduce costs — but that potential may be greater when the two are combined.

Social determinants are non-medical needs that can have a significant impact on the trajectory of patients’ health, such as nutrition, transportation, social or caregiver support, and housing, among others. Social and economic factors like these drive 40% of health outcomes, according to the Better Medicare Alliance.

With the care model’s focus on patients’ goals and quality of life, palliative care providers may be uniquely suited to assess those needs, according to Terri Maxwell, general manager, chief clinical officer, and co-founder of Turn-Key Health, a CareCentrix company.

“The interdisciplinary nature of palliative care, especially the inclusion of social workers, positions palliative care nicely to help to address the myriad needs that people have,” Maxwell told Hospice News. “Palliative care is well positioned to be able to positively close gaps related to social determinants of health — if a program is structured to uncover what those gaps are.” 

Integrating social determinants of health into community-based palliative care improves patient outcomes and can reduce higher-acuity care, which can help providers demonstrate their value to payers.

Home-based palliative care could reduce societal health care costs by $103 billion within the next 20 years, the nonprofit economic research group Florida TaxWatch indicated in a 2019 report.

Programs to address social determinants have likewise been found to reduce health care expenditures.

For example, 2016 research found that close to 3.6 million people in the United States did not receive necessary medical care as a result of transportation barriers, contributing to an annual $150 million in preventable spending, according to the American Hospital Association.

“There is a strong business case for hospitals and health systems to address transportation needs since individuals experiencing these issues are more likely to miss appointments or not fill prescriptions, leading to delays in care and potentially to disease progression and complications or readmissions,” the AHA report said.

Food insecurity is a similar example. Not only are malnourished patients more likely to be hospitalized, but the cost of those stays is nearly twice as high as those for patients who have sufficient access to quality food, according to the Agency for Healthcare Research and Quality (AHRQ).

Among the organizations that have tested this theory is the accountable care organization (ACO) affiliated with Chicago-based Advocate Health Care. The health system in 2014 launched initiatives to reduce food insecurity among their patient that generated $4.8 million in savings within the first six months 

Health care providers, payers, and other stakeholders are increasingly paying more attention to both social determinants and palliative care, including Medicare and Medicaid. The need to address social determinants has been cited as an impetus for the push toward value-based reimbursement.

Case in point, the U.S. Centers for Medicare & Medicaid Services (CMS) as of 2020 allows Medicare Advantage plans to cover supplemental non-medical benefits, including transportation and food services and some home modifications, among others.

While offering these benefits is optional for MA plans, a rising number are embracing them. As of 2021, 67% of individual plans offered support related to meals, as well as 69% of special needs plans, according to the Kaiser Family Foundation.

In addition, about 38% of individual plans covered transportation benefits. Among special needs plans the proportion was 87%.

MA plans can also offer palliative care as a supplemental benefit for qualifying patients. Analysis by the consulting firm ATI Advisory found that the number of health plans offering home-based palliative care coverage jumped to 134 in 2021, up from 61 in 2020.

As of last year, a second avenue for palliative care reimbursement opened up within Medicare Advantage.

The hospice component of the value-based insurance design model also contains palliative care components, some of which can help address social determinants needs, according to J. Cameron Muir, M.D., chief innovation officer for the National Partnership for Healthcare and Hospice Innovation (NPHI), speaking at the Hospice News Palliative Care Conference in Chicago.

“In the VBID palliative care design, they’ve got 11 elements of a palliative care model. That supports the beginning of the seamless transition [of care],” Muir said. “It’s consultative. It includes advanced care planning and goals of care conversations. It gets into social determinants and behavioral and mental health support, medication reconciliation, and caregiver support.” 

The consultative elements of palliative care are among the reasons that those providers are well-positioned to identify and mitigate social determinants needs.

Others in the continuum, such as primary care practices or hospitals, often lack the skills, time, and resources to address those needs, Maxwell told Hospice News. CareCentrix screens patients in their serious illness care program for social determinants needs.

“What we find is that [assistance with social determinants] are primarily the type of interventions that are needed to help support people at home,” Maxwell said. “An in-home palliative care program can be a place for these more seriously ill people to have a team who can make that assessment and then do something about it, connecting people to those community resources.”

A rising number of hospice and palliative care providers are building community partnerships to accommodate patients’ nonmedical needs, allowing them to continue receiving care in the home. 

For example, VNS Health, formerly the Visiting Nurse Service of New York, partners with the tech platform Healthify to address social determinants of health. The companies collaborate on screening for social needs, locating resources and referring patients to community organizations. 

“If you have a medical palliative care program that’s focused primarily on the patient’s illness and the accompanying symptoms, and you’re not screening for social determinants of health, then you’re going to miss the mark,” Maxwell said. “They’re really critical when you’re evaluating somebody with serious illness.”