By Christopher Cheney
Nashville (Tenn.) General Hospital is committed to addressing social determinants of health and health equity.
Social determinants of health such as food security and housing have a greater impact on health outcomes than clinical care. Health equity has become a hot topic in healthcare during the coronavirus pandemic, with the disproportionate impact on vulnerable populations such as African Americans highlighting health inequities in the United States.
The national health inequities during the pandemic have played out in the Nashville area, says Joseph Webb, DSc, MS, chief executive officer of Nashville General Hospital. “We have a marginalized population. We have the disproportionate impact that occurs on certain populations—which has been pronounced during the COVID-19 pandemic. Health disparities seem to surface with any type of epidemic or pandemic particularly as it relates to the marginalized population.”
Nashville General Hospital has several programs targeting social determinants of health and health equity, including a “food pharmacy” that addresses food insecurity and an initiative featuring faith-based organizations that focuses on education attainment, health literacy, and healthcare access.
Addressing food insecurity
The Food Pharmacy at Nashville General Hospital provides free food for patients who screen positive for food insecurity. “We realized there were several individuals whose food insecurity conditions were exacerbating their health outcomes,” Webb says.
All hospital patients are eligible to receive assistance from The Food Pharmacy, he says. “For each patient that encounters our hospital—whether that contact point is in our emergency room or one of our clinics—a food insecurity questionnaire is administered. If someone indicates that they are struggling with food insecurity based on the questionnaire, then that individual is referred to The Food Pharmacy by their physician. Initially, 12 weeks of free food are provided, then we reassess them for that food need.”
The program has improved the survival rate of the hospital’s cancer patients, Webb says. “We have a cancer care program here and cancer patients rely heavily on maintaining a certain weight so they can tolerate chemotherapy. Any time cancer patients struggle with food insecurity, it puts them at greater risk of mortality. So, by having this program in place, we have a section of The Food Pharmacy with high-calorie food to keep our cancer care patients healthy and at a certain weight level.”
The hospital’s director of food services plays a leading role in selecting and supplying the food. The major food bank in Nashville—Second Harvest—also allows the hospital to purchase food at a reduced price. There are several sources of funding that go into purchasing the food, including donations to the hospital’s foundation and employee contributions that are earmarked for The Food Pharmacy.
Nashville General Hospital, which is a safety net hospital with 150 inpatient beds, has launched a faith-based initiative to address social determinants of health and health equity called the Congregational Health and Education Network (CHEN). More than 100 congregations are members of CHEN. The hospital’s chaplain plays a leadership role in the nonprofit organization and a manager runs the program.
There are three pillars at CHEN, Webb says. “Number One is education attainment because we believe that there is a strong correlation between education and all of the other social determinants of health. If you can impact education, you can typically impact income, housing, and other social determinants of health. The other two pillars are health literacy and access to healthcare.”
CHEN has multiple approaches to boosting education attainment, he says. “CHEN has aligned with our health sciences program here at the hospital. We have several educational programs that produce graduates. For example, we have radiology technologists and certified nursing assistants. We teamed up with CHEN and the state in a workforce development program. In addition, CHEN has gotten awards for scholarships that are distributed to congregation members.”
The hospital has held health literacy forums for CHEN members and there are materials that go out to the church networks for addressing health literacy. Webb calls health literacy a “silent giant” in health disparities.
“Health literacy is the ability to take the information that is being provided to you by a healthcare provider, interpret that information, and apply that information to your condition. If you can do that, you are health literate. If you cannot do that, then there is a risk that when you go home you will do almost none of what you were instructed to do. If you are not carrying out what you were instructed to do, that is a disparity,” he says.
Within the healthcare access pillar, CHEN is making sure that individuals understand that they have access to healthcare and that healthcare is available to them regardless of their ability to pay, Webb says.
“For us, it is much more cost-effective and effective in terms of health outcomes if we can get you into our ambulatory division and start providing care to you before you get into crisis and must come into the emergency room or go to the ICU, which is where the cost in healthcare starts to spiral. We see providing care access as a way of controlling costs; and as a safety net hospital, it is cost avoidance. Any time we can engage in cost avoidance, those are dollars we can use for other efforts,” he says.
The hospital provides financial counseling to patients. For patients who are uninsured, the hospital tries to enroll them in health plans such as Medicaid. “After we exhaust all opportunities to get them under some kind of coverage, then we will put them into our charity program.”
The health equity challenge
Health equity poses a daunting challenge for U.S. healthcare, Webb says.
“We are not going to cure health inequities until there is a more equitable distribution of the social determinants of health. Social determinants of health are the drivers of health inequities and health disparities. If we cannot address this maldistribution of social determinants of health, how then are we going to ever address health equity?” he says.
It is going to be hard to address health equity without universal health coverage, Webb says.
“There is no magic wand that you can wave so that everyone is going to have equity in healthcare. That is not going to happen because the national, state, and local policies are never politically going to get to the point where they create a completely equitable healthcare system. The issue is that healthcare in this country is not a right. That creates the framework for how we execute healthcare delivery in this country. There is no mandate that everyone has healthcare. So, we have that disparity and inequity to begin with at a national level.”
Christopher Cheney is the senior clinical care editor at HealthLeaders.