Social determinants of health (SDOH), such as access to nutritious food and transportation, safe housing, and good jobs, can impact up to 80% of an individual’s health outcomes. That’s why an increasing number of U.S. health system payers and providers have created programs to help identify and address basic social needs.
To be effective, an organization’s SDOH strategy must assess the unique risks faced by each population it serves and expand care to address those needs, including connecting patients with appropriate community resources. Doing so can improve individual health outcomes while also reducing unnecessary emergency visits, lowering hospital readmission rates, and decreasing total cost of care.
One tenet of Highmark Health’s SDOH strategy is that identifying and addressing the needs of a community should be done with the community. A community’s members often have the clearest insights, along with the necessary trust and relationships, to develop and deliver successful solutions with lasting benefits.
An example of this in practice: Highmark Health’s collaboration with Thrive18, a door-to-door neighborhood initiative serving Pittsburgh’s North Side. Created in 2018 through a Build Health Challenge Grant, Thrive18 connects the most vulnerable people with integrated support through community health workers and a centralized wellness center. Thrive18, led by Project Destiny, works with Allegheny County Department of Human Services, Allegheny County Health Department, the City of Pittsburgh, and The Buhl Foundation, as well as teams across the Highmark Health organization.
Thrive18’s community health workers identify health-related social needs and barriers to care that may not be known to a person’s health care providers. Food insecurity, housing, and issues related to education, transportation, and utilities account for nearly two-thirds of barriers to health and well-being in identified households. Dedicated community health workers step in to connect residents with access to healthy foods, liaise with landlords to remedy housing issues, assist with GED and citizenship paperwork, and much more. They provide warm hand-offs to other community-based organizations who can assist with specific issues, while also referring residents back into the health system to address health care needs.
This community-focused approach has proven successful. Thrive18 has sustained a 93% engagement rate among those with identified needs. From those actively engaged households, nearly two-thirds of identified needs have been met. To date, nearly 3,000 North Side residents have gained better access to health care and social services, leading to more stable living conditions and improved well-being.
“This level of engagement is a crucial steppingstone on our journey upstream to address root causes of poor health, and that engagement comes from partnering with trusted organizations and individuals in the communities we serve,” says Dan Onorato, chief corporate affairs officer, Highmark Health. “We are optimistic that we can take what we’ve learned here and adjust to build impactful place-based initiatives with local partners in vulnerable communities across our footprint.”
Learn more about Thrive18, its dedicated workers, and people helped by the program, in the feature video below.
Renita Freeman: How can I say it, this makes me happy to work for an organization that I know is really helping people and getting results.
Diana Bucco: There are multiple social barriers to health in the North Side. We have a large number of North Siders who, according to census, are living in poverty or working poor.
Dr. Imran Qadeer: It breaks my heart when the patients are re-admitted, and we know the issues are related to food insecurity and not even being able to afford housing.
Nebeyou Abebe: Let's build something innovative and unique that would address the needs of the community but also address the needs of the healthcare system.
Ellen Duffield: With all these voices working together to make those connections to community resources is really highly aligned with addressing the whole person as a part of Wholecare.
Diana Bucco: And collectively we came together to create Thrive18.
Rev. Brenda Gregg: We really wanted to hear from the family themselves, and see how can we work with you to make sure you get the resources that you need?
Dr. Imran Qadeer: When the team screens the patient, and they screen positive, they're referred to a community organization such as Thrive18 as well as a Healthy Food Center to address those needs.
Rev. Brenda Gregg: We first started Thrive, we were looking at trying to reach about five of the neighborhoods on the North Side. We now have been in every neighborhood.
Dan Onorato: I spent over 52 years of my life here on the North Side. I was born on Sheffield and used to go to church on Juniata. Now, here I am working for Highmark and AHN. It gives me personal pleasure to be part of the strategy to pull this off. There's a lot of good intentions from a lot of organizations and people, and the one mistake they make is they enter a neighborhood with people that aren't from there. And people are skeptical. Having the people in the neighborhood is the only thing that's make this a success from beginning.
Renita Freeman: Deniza is a lovely young woman. She's quiet, but she's strong.
Deniza: I like to cook. And I cook every day.
Renita Freeman: To entice the kids to eat rice. She puts food coloring in it. So the rice is always pretty.
Deniza: Africans, sometimes we are scared of Americans. That’s why I said, ‘Renita? Why is this woman coming with me?’ I didn’t tell her but I was scared in my heart.
Renita strongn: I met her through a program that Thrive18 was asked to spearhead for the health department. First it started out with something she was dealing with in the house.
Deniza: Yeah, it was like the basement. It was it was too much rain. And all the water was coming in downstairs.
Renita Freeman: And so, I contacted housing authority for her with that, and I found out that she wanted to do her citizenship. So helped her get connected to some of those things that she needed. Knowing that she's able to stay here in the country, she's more confident. I didn't even know she had went, but she called me and she let me know she passed it. I was so proud of her.
Deniza: I'm so happy. I have another mother.
Renita Freeman: We give out food twice a month to families. And we load it in their car. Thank you guys for coming.
Camera Operator: You’re thanking them?
Renita Freeman: Always! Because without participation, our program would mean nothing.
Rev. Brenda Gregg: She's a typical family member that knows how to give help delicately. So people aren't harmed. And I think both Renita and Rhandi are both examples of that.
Rhandi Belland: Before I started working with Thrive18, I was actually a family that was in need of help. From there, I've been working with Thrive18 for two and a half years now because I know the need.
Rebecca: I've not always been the greatest parent. I tried to be the supermom, super wife, and I fell down for a minute. And we as a family have had to overcome a lot of things. And I think places like Thrive18 helps address some of those things.
Rhandi Belland: She's always been a kind-hearted person. Anytime she calls me I make sure I answer. She’ll be like, ‘Hey Rhandi, how are you doing?’ And I’m like, ‘I’m doing good. How are you?’ And she’ll be like, ‘I’m doing so much better today.’
Rebecca: I met Rhandi, her son attends school I work at. When I was enrolled in Thrive18, she just happened to be the worker assigned to me. So, it felt a little more personal to me. But I had been in hospital a couple of times with pneumonia, and I was referred to Thrive18 to get a COVID shot because COVID shots we're not even open to immune compromised people yet. Thrive18 has provided me with food services, produce.
Rhandi Belland: Even with helping Miss Rebecca get her Duquesne Light bill situated, I reached out to my supervisor, and I was like, ‘Listen, Miss Rebecca needs help.’
Rebecca: And while she was calling me to let me know that they will be contacting me, the gentleman was already on the phone beeping in. Between Thrive18 and my children, I eat healthier. I definitely feel more energized. My children are relieved with Thrive18 because they feel safe was Rhandi.
Nebeyou Abebe: We have to think about things totally differently. If we really want to transform healthcare, we got to be able to start from a blank sheet and rethink how we do business.
Ellen Duffield: Through the Thrive18 program, Highmark Wholecare has been able to work with over 2,000 members in addressing their very specific needs.
Erin Dalton: Testing these kinds of approaches, we need to be patient and understanding how they work and ideally we see lots of individual outcomes that are better than we would have expected. I think that's very likely the question on the table is can we accomplish community level change through this kind of intervention?
Rev. Brenda Gregg: Our neighbors are used to things coming and going. And I think that's what I appreciate with Highmark. They're here. They're listening and they want to be a part of the solution for the community.
Deniza: I was so happy because I found a friend. She loved me and I love her too.
Rebecca: Most kids if you give them their self-esteem, and you help them along the way, give some discipline and give them plenty of love, their day will be OK. They can at least survive it.