2017 Health Leads Inc.

Working Collaboratively to Address

Jennifer Valenzuela, LICSW, MPH, Principal of Program, Health Leads

Michelle Zambrano, Program Manager, Health Leads NY

28th Annual Conference of the Network for Social Work Management

June 15, 2017

Fordham University Graduate School of Social Service

New York, NY

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1 in 5 Americans receives healthcare via Medicaid, including 45M children

Many present with significant unmet basic resource needs food, heat, electricity, housing, education

Data shows these patients disproportionately struggle with obesity, asthma, high blood pressure, depression, and diabetes

Mismatch Between Drivers of Health & Spending

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Source: Healthy People/Healthy Economy: An Initiative to Make Massachusetts the National Leader in Health and Wellness. 2015.Data from NEHI 2013. http://www.tbf.org/tbf/56/hphe/Health-Crisis.

outside the clinic drive vast majority of health outcomes

Unmet Social Needs: At What Cost?

$35 - $7,000 = cost range of comprehensive metabolic panel

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Source: Variation in charges for 10 common blood tests in California hospitals: a cross-sectional analysisR. Hsia - Y. Antwi - J. Nath - BMJ Open 2014; 4 http://bmjopen.bmj.com/content/4/8/e005482.full

http://bmjopen.bmj.com/content/4/8/e005482.full

The Impact

Unmet social needs impact health practice

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Patients do not receive help paying gas/electric bills be hospitalized

Children with food insecurity more likely to be in fair or poor health from childhood to adulthood

Difficulty paying rent care utilization and emergency room visits

4 in 5 physicians surveyedsaid:

as important to address as their medical conditions

Unmet social needs are directly leading to worse health

They are not confident in their

social needs

1. Frank, D., Neault, N., Skalicky, A., Cook, J., Wilson, J., Levenson, S., Meyers, A., Heeren, T., Cutts, D., Casey, P., Black, Ye2006. 2. Cook J.T., Frank D.A., Berkowitz C., Black M.M., Casey P.H.., Cutts D.B., Meyers A.F., Zaldivar N., Skalicky A., Levens Journal of Nutrition 2004; 134:1432- re Among Low- f the Robert Wood Johnson Foundation in Fall 2011 among 1,000 physicians, of which 690 were primary care physicians and 310 were pediatricians.

We envision a healthcare system that

needs as a standard part of quality care.

2017 Health Leads Inc.

The Health Leads Vision

Our Clinical Partners

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Plus, more than 200 provider organizations

that have participated in

other HL engagements

http://www.bmc.org/http://cchealth.org/medicalcenter/http://www.dimock.org/https://healthy.kaiserpermanente.org/html/kaiser/index.shtml

Our Direct Service Approach

Clinical Communication

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Follow-up

Resource Referral & Plan

Intake

Screening