The Social Determinants of Health - Changing the way we see health and social program management

2. The Social Determinants of Health
- Changing the way we see health and social program
management
Jia Chen
Director, Health Solutions, Smarter Cities

3. What are the social 'determinants' of health?
“The social determinants of health are the circumstances in which people
are born, grow up, live, work and age, and the systems put in place to deal
with illness. These circumstances are in turn shaped by a wider set of forces:
economics, social policies, and politics.” [ from WHO]
• Availability of resources to meet daily needs, such as
educational and job opportunities, living wages, or
healthful foods
• Social norms and attitudes, such as discrimination
• Exposure to crime, violence, and social disorder
• Social support and social interactions
• Exposure to mass media and emerging technologies,
such as the Internet or cell phones
• Socioeconomic conditions, such as concentrated
poverty
•Quality schools
•Transportation options
•Public safety
•Residential segregation
• Natural environment
• Built environment, such as buildings
or transportation
• Worksites, schools, and recreational
settings
• Housing, homes, and neighborhoods
• Exposure to toxic substances and
other physical hazards
• Physical barriers, especially for people
with disabilities
• Aesthetic elements, such as good
lighting, trees, or benches

4. NYC Department City Planning, IOM 092010
New York City Department of City Planning
IOM, Public health Strategies to Improve Population Health, 09 2010

5. High school grads: 90%
Unemployment: 4%
Poverty: 7%
Home ownership: 64%
Non-White: 49%
ALAMEDA COUNTY

6. High school grads: 81%
Unemployment: 6%
Poverty: 10%
Home ownership: 52%
Non-White: 59%
ALAMEDA COUNTY

7. High school grads: 65%
Unemployment: 12%
Poverty: 25%
Home ownership: 38%
Non-White: 89%
ALAMEDA COUNTY

8. Social determinants impact a person’s wellness and life expectancy
• It has been estimated that the healthcare delivery system accounts for less than a
quarter of the health status of populations.
• Most of the 20th century’s 30 year increase in life expectancy has been attributable
to public health interventions in societal sectors other than the health care delivery
system, e.g. water, food transportation, workplace safety and smoking reductions
6 miles apart with a 20
year difference in life
expectancy
Source: Lloyd B. Minor, M.D. John
Hopkins
Source: Sowad, Barbara J. A call to be whole:
the fundamentals of health care reform, CT. 53
The medical systems treats people
and then sends them back to the
socio-economic conditions that made
them ill

9. Michigan
9
“… attention to the
social determinants
of health that may
have greater impact
on the individual
health status than
does medical care” 1
New Jersey
“Better care … is disruptive change … it takes a community to
begin to address these issues (of high cost, high need patients)”
Dr. Jeffrey Brenner, Camden Coalition of Healthcare Providers (CCHP)
56% reduction in costs and 46% reduction in visits with an integrated care model
Oregon
U.S. Integrated Social and Health Care Examples
The team focuses on the 25% of CareOregon adult patients who account for 83% of
the spending last year -- $311 million.
… 65 patients enrolled with a community outreach worker … cut emergency room
visits in half and average costs per patient by 62%. Total saved: about $726,000.
http://www.oregonlive.com/health/index.ssf/2012/02/to_save_money_on_health_care_o.html

10. The path forward
… enabling holistic and individualized care to optimize outcomes and lower costs
Coordination
Engage, convene, collaborate and cross boundaries
to deliver an integrated plan to achieve optimal
outcomes and lower costs
Engage
Understand
Foundation
Know individuals and populations; recognize
intervention opportunities to apply evidence-based
and standardized care planning
Know
Wellness
Analytics and Cognitive Computing
Gain understanding through data-driven insights
that enable providers to act with greater visibility
into outcomes and cost

11. IBM integrated portfolio for Smarter Care
Coordination
Care identification
Care planning Care collaboration Outcome evaluation
Analytics and Cognitive Computing
Population analytics Diagnostic support Care pathways Operational reporting
Foundation
Data warehouse
and data models
“Single view”
customer EMPI
(MDM)
Portals, mobile
and
collaboration
Remote monitoring
and medical device
connectivity
Paper and Fax
capture, conversion
and extraction
Cognitive computing
BI, reports and
dashboards
Comprehensive global consulting, technology, infrastructure and managed services

12. Eldercare in China
• China is aging rapidly, by 2015 there will be 220 million over-60s
and 500 million within 40 years, roughly 1/3 of a population that is
expected to be just shy of 1.5 billion.
• However, eldercare is in severe shortage. At one of Beijing's
most popular nursing homes, the waiting list is currently 100 years
long.
• Beijing government leverages a 3-tiered delivery model for
eldercare:
- Home Care (90%); Home Care + Day Care Centers (6%);
Nursing Home for disabled (4%)
• Many services are available (safety, companionship, hygiene
care, meals, housekeeping etc) but not delivered in a coordinated
way; and there is no holistic view of the citizen, in terms of his/her
integrated social and health needs.
• Solution
- Deploy a program for coordinated care planning and delivery
- Leverage telehealth and ambient intelligence sensing
capabilities to monitor senior citizen's physical environmental
safety and personal health

13. Sensors, health monitors, wearable devices
Real time data
Remote Monitoring
Specialist Therapist GP
Hospitals Community Health Centers
Health Services
ElderCare Management Platform
Call Center Cleaning services
Volunteer
Club House Day care
Home Services Center
Living Services
Long term care facilities
Service
management
Care Team Outcome
management
Assessment Care Plan Care
Management
Elderly Personal Health Record
Coordinated Eldercare Framework

14. 14
Historical
values
Alerts
based on
threshold
List of contributing
factors
Improve prediction provides
a list of informative factors

15. Bolzano - Safe Living
• 3 people over the age of 65 for
every 2 under the age of 20
• City & council budgets fixed or
being reduced over the next 10
years.
• A group of citizens of age 80s were
remotely monitored with in-home
sensor gear.
• Aimed at improving the quality of
life of elderly people by integrating
a net of sensors that send data to a
control room where data will be
analyzed.
• 31% saving to the Bolzano City
Council for the cost of related care
for the elderly.

16. Coordinate care across silo’s of organization to reduce cost - an example in Europe
Medication expenses by chronic disease patients
• Nationalized Healthcare – Government Payor
• ~7M residents/$4B annual budget
• Complex Chronic Disease Management
– CRG – 7 Rating (3 or more Chronic conditions)
– 2 or more inpatient incidents
 Knowledge Shared view of best practices and a holistic
view of the patient allows individualized care plans that
engage both clinical and social providers
 Collaboration across stakeholders allows a unified view
of care plan status, effectiveness and informs
adjustments and reassessments required
 Coordination Of resources to support care delivery in
home settings and referral management to timely and
collaboratively support incoming requests
360 view of citizen Integrated Care Plan
Multi-discipline Team Collaboration

17. Action Impact
Engagement 15% increase of mean number of contacts with health services
Emergency Room
Admission
10% reduction in emergency room admission
Hospital Admission 10-15% reduction in hospital admission
30-day Readmission 10% reduction in 30-day readmission
Patient Satisfaction Satisfaction over 85 score
Quality of Life Improved Quality of Life (Euroqol) score
Intervention Over 80% medication plan reviewed at least 2 times a year
17
Coordinated Health Management improves care efficiency

18. 18
Questions: jiachenjc@cn.ibm.com
Phone: +86 1365 1850 498
Thank you !

19. Coordinated Eldercare Management Platform
Client Director Care Team
yes
Register
Peron
Create Home
Visit Task
Assign Home
Visit Task
Accept Home
Visit Task
Home Visit
Information
Collection
Eligibility
Check
Create
Integrated
Case
Create
Outcome
Plan
Medical
Assessment
Living
Assessment
Add
Services
Service
Delivery
Sign
Agreement
Monitor
Progress
Eligibile?
结束
no
Client
Registration
Home
Visit
Build
Care Plan
Monitor
Progress
Decision

22. Health System: More Maternal Education, Better Life Expectancy and
Infant Survival

23. Health System: Higher Income, Longer Life

24. Dubuque - Smarter City Living Laboratory
Only American city in FastCompany’s
Top 10 Smart Cities on the Planet
Partnership – Living Lab
IBM Research, City of Dubuque, ECIA,
Dubuque 2.0 (NGO), 1000+ Volunteer households
Business partners – Neptune Technology, Alliant
Energy, Black Hills Natural Gas, Verizon Wireless,
Airsage

25. City planning
Chinese State Physical Culture
Administration invests in thousands
of fitness centers in parks,
schools and other convenient urban
locations with the goal of 40% of the
population exercise regularly
City of Toronto reduces
incidents of diabetes through
investment in 1500 parks
Brookings Institution ranked
Rochester the 3rd Best metro
economy in the U.S. and 46th in the
world. Low cost and high quality
cited as a major contributor