Socially Determined: The Healthcare Executive's Role in Health Equity

By Shawn Rossi, Karin VanZant and Kina L. White

While federal regulators and accrediting bodies have championed national health equity initiatives, the COVID-19 pandemic further underscored systemic health disparities and inspired action. Socially Determined explores how healthcare and public health organizations continue to work toward equitable, person-centered care. This book provides healthcare executives with an overview of the essential elements of health equity and explains the relationship between value-based care, healthcare quality, and health equity. The book' s core themes are the crucial role of community investments in improving the economic, social, and environmental realities of marginalized populations and the need for public-private partnerships to tackle issues at scale. Topics covered include new efforts to collect reliable data on social determinants of health and build a health analytics infrastructure to benchmark, monitor, and track progress toward health equity Mandates and accreditation requirements from the Centers for Medicare & Medicaid Services, the Joint Commission, the National Committee for Quality Assurance, and the Public Health Accreditation Board are woven throughout the chapters.

• Language: English
• Publisher: ACHE Learn
• Release date: Feb 20, 2025
• ISBN: 9781640554702

Book preview

Preface

As a hospital association executive for more than 20 years, I had a front-row seat for the volume-to-value transition in healthcare. I had heard numerous consultants warn hospital leaders about hypothetical shaky bridges, wrong-pocket problems, and the one-foot-in-two-canoes dilemma (with alligators waiting in the water). Then, in May 2018, I entered a doctor of health administration program that featured a cohort program designed for working students. My classmates and I were required to take two classes every semester with a doctoral research project that spanned the final year and no breaks until May 2021. Of course, at the beginning of this journey, we were all ignorant of what was to come with the pandemic. COVID-19 changed our jobs (and research projects) overnight, whether we were nurse practitioners, physicians, physical therapists, or communicators like me.

In my mixed-methods research project, I set out to establish a baseline of hospital executives’ self-assessed readiness to tackle social determinants of health (SDOH) in their community and to identify their perceptions of the work that needed to be done (and their role in that work). Asking chief-level executives at all types of Mississippi acute care hospitals—from critical access hospitals to academic medical centers—to answer surveys and set aside time for one-on-one interviews during the pandemic was a big ask, but they showed up.

COVID-19 made the timing less than perfect but the conversations more fascinating, as a national discussion about healthcare disparities, including access to vaccines and differences in outcomes, was beginning. I coupled the surveys and interviews with a document analysis of Mississippi community health needs assessments (CHNAs) and Internal Revenue Service (IRS) Form 990 Schedule H forms. The document review allowed me to see the financial resources that hospitals were investing in SDOH work.

Some of the executives interviewed had been in healthcare much longer than I had. They came from a heads-in-beds era and were struggling with the transition toward population health that entered full swing with the Affordable Care Act. Many executives understood that healthcare organizations needed to play an important role in SDOH work, but they were also confused about how to garner patient and community engagement, which they knew would be required for success. They were also befuddled about how to best help in a national system that was still paying them to treat sick patients, not keep them well. They felt that insufficient infrastructure was in place for this work . . . that they were building the plane while flying it.

My research was focused on Mississippi, but its product was a four-part learning series on SDOH, as the executives had identified a lack of staff training as a barrier to success. I initially conducted these workshops in Mississippi in 2021 but was also invited to present in other states. Wherever I went, I kept hearing the same frustrations from healthcare executives. In response, I presented social needs in a language that they could understand: return on investment. (Many steps could begin at little or no cost, for instance.)

My research showed that hospital community-benefit dollars largely had been spent on clinical care, not social care. So, I emphasized in the workshops how CHNAs could be used to invest in SDOH work, not just meet an IRS requirement. I focused on how the high-cost American healthcare system was rooted in the country’s political, economic, and social history. I noted that we lived in the only high-income country without universal healthcare but have much higher levels of administrative spending and the highest level of pharmaceutical spending per capita compared to peer countries.

Combining my doctoral research and the research that I continued to present on the topic after graduation, I started cobbling together a book. I had a vague idea of its purpose but not yet a complete thought. During this time, The Joint Commission and the Centers for Medicare & Medicaid Services introduced their new health equity requirements. No one needed a why now. They needed a how.

However, I continued to hear from those doing the work that establishing the why was still important, especially considering staffing shortages and negative operating margins. In the new year of 2023, I was invited to present at the American College of Healthcare Executives’ annual Congress. It was the perfect time to see if there was any interest in the book I had in mind.

When discussing the proposal with ACHE staff, I realized that my original draft only addressed hospital executives. To get a 360-degree picture, I would need to include information for health plan executives and leaders in public health. That’s when I decided to reach out to Kina and Karin, with whom I had worked but who didn’t know each other. I knew they were as passionate as me about this topic and experts in their fields. I am so glad that they said a hearty Yes! when I called out of the blue and asked if they wanted to write a book with me.

Collaboration is hard. We knew that when we started writing this book together. But bringing together our experiences, with the added perspectives of hospital, health plan, and public health executives from across the nation, made this book better. Just as in any community, there is no big picture without input from all. Hospitals, health plans, and public health entities too often operate in silos. The needle on health equity will only move if we all work together. This book is tailored to fit all healthcare executives who are ready to do that work.

Shawn Z. Rossi, DHA, FACHE

Mississippi Hospital Association

✦ ✦ ✦

IN 1995, I was a college student at Wright State University pursuing an undergraduate degree in biology and working with the men’s basketball and swimming and women’s softball teams. My focus was on studying for the MCAT and interning with orthopedic surgeons connected with my job in the athletic training department. My grades were good, my drive was strong, and I was well on my way to completing my degree in the four years I had planned.

Then I took a pregnancy test in my junior year, and my whole world changed. I did not have medical insurance and applied for Medicaid to cover pregnancy-related appointments. Over the next ten months, I fell out of love with medicine and the idea of becoming a doctor.

This was the first time in my life that I truly faced discrimination and felt less than a person. I knew I was not receiving the type of care with Medicaid that others with good insurance were receiving, which led me to recognize a different purpose than what I had mapped out in my four-year plan. I knew I’d always been meant to help people. Inspired by my personal encounter with healthcare’s safety net and all its gaps, I decided to move into social work.

My year of Medicaid interactions and away from college led me to access other safety-net programs. Fortunately, that year also led to a beautiful baby boy who was born healthy despite insufficient care. And I met so many other women who had suffered through much worse circumstances. They didn’t have family support or support from the father of their baby; they lacked basic needs such as housing, adequate food, and transportation. All of us were forced to settle for lackluster care, finding ourselves at the end of the line with a general feeling of being less than.

I share my story so that you understand the motivation and drive I have to strengthen the health and human services safety net. I want other young moms to have a different experience from mine and to see that people with a lot less support than I had can get the chance to thrive. I find that my story dispels a lot of myths about who a Medicaid mom is or what a person on welfare looks like. And it brings credibility and urgency to the conversation when those in positions of power to make community, organizational, and policy changes see that I have lived experience, not just academic experience.

I am honored to be part of the writing team for this book. As a social worker, community developer, and systems thinker on social services, safety-net care, and SDOH, I have seen a lot of successful models struggle to get to scale. I have also seen large, robust companies struggle to understand the day-to-day complexities of the people they are trying to serve. I believe that as the gap between the social services sector (i.e., social care) and clinical services narrows, our society will see an infusion of energy into system alignment that will lead to whole-person care.

Not just those who lack resources and depend on safety-net programs need whole-person care—everyone needs it. I encourage you to grow your role as a leader in the movement toward community-based, person-centered, whole-person care and find ways to influence the various sectors attempting to address poverty, racism, discrimination, and quality of life in your community. Seriously addressing the issues of housing, food and nutrition, workforce development, and education can bring about long-term improvement. You have the power to design a system to support all people, yourself included, as there is no escaping the healthcare system.

I would like to thank my husband, Nate. For more than 30 years, you have always been by my side, cheering me on in my attempts to change a very messy system. It hasn’t always been easy, but no matter what crazy ideas I had or how those ideas came to fruition, you gave me support and love. I know the early days of our marriage, parenting, and trying to get through school are a bit of a blur, but I am incredibly grateful that we have always chosen each other instead of giving up.

I am also grateful to my son for allowing me to tell the story of his birth over and over again to move healthcare professionals and those in positions of power to make changes. The day I realized I was pregnant was truly life changing and life giving. You are by far the best thing I have ever done, and I am so very proud to be your mom.

To the rest of my family and friends: You know that my work has never been work, it has always been my life. From the early days at the local community action agency to the most recent days of consulting with organizations serious about social determinants and health equity, each one of you has given me perspective, encouragement, feedback, and guardrails to guide the work. I hope I continue to make you all proud.

Karin VanZant, MPA

Clearlink Partners

✦ ✦ ✦

MY PURPOSE HAS always been my passion: to improve the lives of others through better access to care. As a 17-year-old biomedical research scholar, I gained the mentorship of a leading African American anesthesiologist who challenged me to pursue a career in health sciences. While learning about intubations, I observed the preparation of a neonate for open-heart surgery. It was fascinating for a young Black girl from West Jackson, Mississippi, to stand in an operating room and witness this medical moment. I felt invigorated and just knew that I had found my passion.

But when I returned from lunch, the operating room was empty. Sadly, the neonate had passed during the operation. My heart was shattered, and I told my mentor that I could not witness this tragedy ever again. He reminded me that there would be times when all we could do would still not be enough, but that I should stay the course.

I decided in that moment that if I couldn’t provide the care with my own two hands, then my education and career would be dedicated to improving care for all. Being invited to share my healthcare experience in this book, therefore, has been an honor.

The matrix of my healthcare journey spans many diverse settings and experiences. In 2005, as quality and patient safety practices were undergoing full-scale change, I served as the patient safety officer for a large nonprofit health system. Leading a culture of safety and removing barriers to change provided me deep insight into how challenging working across and within healthcare teams can be.

My transition from hospital administration to public health administration was highly motivated by the patients I watched being discharged home with no real safety net of care. All too frequently, people who looked like me would return to the emergency room because they lacked the resources to prevent and treat routine health needs. Pursuing my doctorate in public health was the bridge I needed to better understand the critical role of community–clinical linkages for improving population health outcomes in a state with results as disparate as Mississippi’s.

Cross-sector collaboration creates a synergy that collectively focuses expertise and resources to advance the communities we serve. At the height of the COVID-19 pandemic, public health strained to meet the emerging needs of older adults in home and community-based settings. As one of the fastest-growing demographics in the United States, older adults face significant social and economic needs. With these adults and their caregivers relying so heavily on human service agencies to provide support services, the pandemic shined a glaring light on how fragmented our public health system is for these parties. Realizing this need, I had a unique opportunity to work with a diverse group of leaders in public health, human services, hospitals, academia, transportation, faith-based organizations, gerontology, higher education, and other fields to develop age-friendly public health system practices.

As growth in US healthcare spending continues to outpace that of the economy, the need to work together to deliver equitable, person-centered care becomes more urgent. As healthcare executives, we must commit to advancing health equity and reducing health disparities in all care settings. This work is not for the faint of heart. COVID-19 knocked the wind out of many of our sails, but now we must get back under way and find new ways to move forward together for a positive outcome.

Kina L. White, DrPH, MHSA, FACHE

Mississippi State Department of Health

✦ ✦ ✦

POPULATION HEALTH INEQUITIES existed before the COVID-19 pandemic, but the crisis refocused attention on the need for action. During the pandemic, collaboration in healthcare—both within organizations and across the healthcare system—was necessary for survival. The lines blurred (just a little, and for just a little while) between healthcare practitioners, public health professionals, and payers. Since then, however, financial and workforce pressures have complicated the continued need to focus on health-related social priorities.

With COVID-19 having prompted a careful examination of the flaws in the current system, now is the time to fix these issues and create the next-generation public health system in collaboration with providers and health plans. If health is now more than healthcare, how does that change the role of hospitals, providers, health plans, and public health entities? How can healthcare leaders engage communities in contributing to their own improved health outcomes?

No one sector can solve these new healthcare challenges alone; nevertheless, we too often try to do so. Instead, we must collaborate. Writing this book together made us better collaborators and better partners, but most importantly, it resulted in a better book. All three of us hope you take that lesson to heart.

SZR, KVZ, and KLW

CHAPTER ONE

Why Me?

A black and white medical cross enclosed within a circular border, symbolizing healthcare and medical assistance.

Alvin is five years away from retirement. He is the CEO of General Hospital, a nonprofit hospital in a midsize town in the middle of America, and has led it for 25 years. He knows all about the community he serves— the good and bad. He understands the effect of external factors on health outcomes and sees them in action every day. What has Alvin confused is what he and his staff are supposed to do to change these factors.

Why me? he asks. It’s not our duty to fix social ills in our community. Our job is to heal the sick people who walk through our doors. If we are expected to work on social needs, too, we need to be compensated for that work. Otherwise, where will we get the resources? And I will need different staff with different skills to do that work. That kind of change takes time.

ALVIN IS NOT alone in his frustration. Most healthcare organizations lack the infrastructure to address the social determinants of health (SDOH): the conditions into which we are born, grow, work, and live—which in turn are shaped by environmental, societal, and political factors—that influence health status and outcomes.

Healthcare in the United States is an evidence-based, clinical institution. Because conditions such as diabetes, dementia, or broken bones have well-known, researched, and approved treatment protocols, the federal government forbids physicians from prescribing experimental remedies for these issues. However, when an emergency department (ED) patient is diagnosed with SDOH such as homelessness or housing insecurity during intake screening, clinicians have no immediate, approved (or even experimental) way to prescribe the fix for that: housing. Governmental housing programs are available, but gaining access is a time-intensive, complicated process operated by an entirely different sector of the community—not healthcare. Even when organizations attempt cross-sector collaboration, funding to help those who need it is often siloed and severely restricted within those sectors.

Likewise, healthcare executives might not know what resources are needed to cure housing insecurity and what solutions (if any) are available in their communities. They certainly know that most hospitals (and all EDs) cannot provide cost-effective housing. However, housing policies, funding, and partnerships are too often underresourced and may actually hinder access to services across social care, physical care, and behavioral healthcare. The lack of collaboration among clinicians, health plans, social service organizations, and public health organizations can also lead to duplicated efforts and limited time and money being wasted on responses to such issues as housing insecurity.

This book aims to outline treatment protocols currently in place for SDOH diagnoses and help healthcare executives build the infrastructure they need to do this work well. Doing this work well has become crucial: The CMS (Centers for Medicare & Medicaid Services) is moving its approach from the carrot (incentivizing SDOH efforts) to the stick (financially penalizing healthcare organizations that perform poorly in this area). Given the razorthin margins in healthcare today, falling behind in SDOH efforts could determine whether a healthcare organization thrives or barely survives.

Another important factor is that much of this socially centered work