Social Determinants of Health (SDOH) in Action-Findings from the Field

What are the most prevalent SDOHs in Montana?

In 2015, Mountain-Pacific Quality Health partnered with three Montana communities to work on a Centers for Medicare & Medicaid Services (CMS) project to address complex care patients who frequently use the emergency department (ED) and experience hospital readmissions. The communities expected to see transportation and affordable housing as key SDOH, and they did, but these issues were not as prevalent as other factors that complicate patients’ medical care.

Health literacy and psychosocial issues topped the SDOH list for high-cost, high-needs patients in the program. This information caused Mountain-Pacific and its partners to reassess their approach for working with complex care patients.

Medication and doctors’ instructions were often confusing to patients who were taking multiple medications, dealing with more than one chronic condition and experiencing several episodes of care. As one patient described, “There are so many medicines I am taking, I don’t know which ones are helping and which aren’t at this point.” Therefore, interdisciplinary team members like pharmacists and care coordinators helped simplify medication lists and explain medications and their side effects to patients.

Behavioral health issues are also prevalent SDOH for these patients. Incorporating behavioral health professionals is key to providing better, more coordinated care. In one pilot location, the team was able to reduce readmissions for enrolled patients by 136 percent in a one-year period.

For a more in-depth view of this work, view the nationally televised PBS NewsHour segment or contact Lara Shadwick at lshadwick@mpqhf.org.

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