Whole-Person Care: Addressing Social Determinants of Health

As the U.S. population ages, the challenges surrounding Medicare are becoming increasingly significant. With healthcare spending projected to reach nearly $7 trillion by 2030, driven largely by an aging population and increased utilization, innovative solutions are essential for improving outcomes while managing costs. One promising approach gaining traction is whole-person care, which emphasizes addressing both medical and non-medical factors (called social determinants of health) impacting health.

What is Whole-Person Care?

Whole-person care acknowledges that health is shaped by a range of factors beyond medical treatment. Clinicians with extensive experience with in-home visits emphasize that understanding a patient’s health necessitates a comprehensive perspective that includes their psychological and social circumstances (referred to as social determinants of health). This approach aligns with the biopsychosocial model, which examines how different aspects of a person’s life influence their overall health. Adopting this perspective has become a central priority for the Centers for Medicare & Medicaid Services (CMS) as part of its core initiatives aimed at promoting health equity.

Key Facets of Whole-Person Care:

• Medical Needs: Addressing chronic illnesses and ensuring proper medication management.
• Psychosocial Factors: Understanding mental health issues, social support systems, and community resources.
• Environmental Influences: Evaluating living conditions and access to necessary services.

Healthcare providers, hospital systems, and health payers that focus on including these non-medical determinants into their care model are no longer just treating symptoms but addressing root causes. 

The Social Determinants of Health

Economic stability is often regarded as the most significant social determinant of health due to its interconnectedness with every other facet of well-being.

Healthcare and Nutrition

Economic stability directly influences an individual’s ability to afford healthcare and nutritious food. People with financial security are more likely to:

• Seek preventive care and regular check-ups, leading to early detection and treatment of health issues
• Afford necessary medications and treatments, improving management of chronic conditions
• Purchase and consume a balanced, nutritious diet, which is crucial for maintaining good health and preventing diet-related diseases

Conversely, those facing economic instability often postpone healthcare due to cost concerns, leading to more serious and costly health conditions in the long run.

Education and Health Literacy

Access to quality education can lead to better job opportunities and improved health literacy. This impacts health in several ways:

• Higher-paying jobs often come with better health insurance benefits, enabling access to quality healthcare
• Improved health literacy allows individuals to make informed decisions about their health, understand medical instructions, and navigate the healthcare system more effectively
• Better education is associated with healthier lifestyle choices, such as regular exercise and avoiding harmful behaviors like smoking

Housing and Environment

Safe housing and access to recreational spaces in neighborhoods promote healthier lifestyles. This affects health by:

• Reducing exposure to environmental hazards like lead paint or mold, which can cause serious health issues
• Providing opportunities for physical activity through parks and recreational facilities, contributing to better cardiovascular health and weight management
• Creating a sense of community and reducing stress, which has positive effects on mental health

Social Support Systems

Strong social support systems provide emotional and practical assistance, helping individuals navigate health challenges more effectively. This impacts health by:

• Reducing stress and improving mental health through emotional support
• Providing practical help during illness, such as transportation to medical appointments or assistance with daily tasks
• Encouraging healthy behaviors and adherence to medical advice through positive social influence

What is clear, and has been recognized by the healthcare community, is that these factors are deeply interconnected and collectively shape an individual’s overall health. Economic stability forms the foundation, enabling access to healthcare, nutrition, education, and safe living environments. This, in turn, supports the development of strong social networks and health literacy, creating a positive cycle that promotes better health outcomes.

When individuals do not have a strong economic base to begin with, their likelihood of realizing positive health outcomes shrinks considerably. To address these social determinants and reduce health disparities, the CMS Innovation Center is testing various pilot programs (known as models) as part of their long-term strategy to bring health equity by 2030:

1. Implementing HRSN screening and referral to community resources and social services
2. Focusing on specific areas, such as maternal health, to reduce disparities
3. Providing access to care navigators, community health workers, and organizations that provide in-home health assessments like Matrix Medical Network to connect patients with the relevant resources
4. Requiring industry members to develop plans for achieving greater health equity

It remains to be seen which of the pilot programs are most effective. What is universal, though, is that evaluating the efficacy of these innovative pilot programs requires robust, high-quality healthcare data. However, the process of gathering and acquiring such valuable data is far from straightforward.

How Home Health Agencies Contribute to Data Gathering

For Medicare Advantage plans, utilizing home health agencies for annual in-home assessments is already common practice. Health plans can leverage these visits to gain insights into non-medical factors affecting health, such as living conditions and social support networks. By meeting patients where they are—both physically and emotionally—healthcare professionals can coordinate care more effectively and address the unique needs of each individual.

This collaborative approach benefits both the payer and the data provider: accurate data not only ensures ongoing engagement for the third-party provider but also enables health plans to develop future strategies that more effectively address their member population’s needs. This synergy creates a win-win scenario for all involved.

Dual Eligibles: A Unique Population

A significant focus within whole-person care is on dual eligibles—individuals who qualify for both Medicare and Medicaid. This population often faces complex health challenges due to their age, income level, and prevalence of chronic conditions. Approximately 40% of dual eligibles report being in fair or poor health, highlighting the need for tailored support that addresses both their medical needs and social circumstances.

Closing Thoughts

The shift towards whole-person care represents a critical evolution in how healthcare is delivered to Medicare/Medicaid beneficiaries. By recognizing the interconnectedness of medical treatment and social factors, health plans can create more effective strategies for improving patient outcomes and design plans for future years that are more closely aligned with their members’ needs. As we continue to navigate the complexities of an aging population and rising healthcare costs, embracing holistic approaches will be vital for fostering healthier communities.