Socially responsible care: how a New York study could spark fresh thinking in the NHS
A study of the Montefiore Health System, addressing the social roots of poor health, could be the catalyst for change
A study of New York’s Montefiore Health System, which addresses the social roots of poor health, could be the catalyst for change
What is the point of lecturing a person with diabetes on her diet if she is about to lose her house?
That question is at the heart of an analysis by think tank the King’s Fund exploring how a healthcare system with a clear sense of purpose can bring sustainable health improvements to an economically deprived community.
The Bronx, the northernmost borough of New York City, is geographically close to the ostentatious wealth of midtown Manhattan but in terms of income, chronic disease and life expectancy it is a world away.
The amount by which life expectancy falls for every mile travelled from New York’s wealthy Upper East Side to the Bronx
Looking beyond illness
Its residents might glimpse Trump Tower in the distance, writes King’s Fund project director Ben Collins, ‘ but like the view from Oldham to Manchester, or Tower Hamlets to the City of London, the wealth there may as well be on another planet’.
Mr Collins’ report on the Montefiore Health System does not lead to neat conclusions or simple lessons for the NHS. Rather, it describes Montefiore’s journey from modest beginnings to its present-day status as an organisation that looks well beyond ‘illness’ to address the social roots of poor health.
But telling that story may well generate fresh thinking on approaches to population health in this country.
Ethos of social responsibility
In the late 19th century, prosperous philanthropists from New York’s Jewish community met to consider worthy causes to mark the 100th birthday of Sir Moses Montefiore, a well-known Jewish leader. Healthcare prevailed as the chosen cause and the Montefiore Home for Chronic Invalids was established.
From humble origins Montefiore grew, and today it reaches well beyond the Bronx to other areas of New York State. It pioneered medical treatments, undertook structured trials, established a medical school and, by the early years of this century, had developed a primary care system that is one of the largest in the US.
‘When we identify conditions contributing a significant amount of total medical expense we consider alternative approaches to care delivery’
Throughout it has maintained the ethos of social responsibility on which it was founded.
Janet Kasoff, a registered nurse and senior director at Montefiore’s care management organisation (see box), told Primary Health Care that a significant proportion of Montefiore staff are Bronx residents and are ‘personally committed to improving the community’s health’.
people are served by the Montefiore Health System
A seat at the table
A guiding principle in that endeavour is collaboration. Mr Collins describes how Montefiore engages with and acts on a ‘panoply of factors’ that determine a society’s health. To that end, it always aims to have a seat at the table when subjects such as education, diet, transport, care of older people, employment or public spaces are being discussed.
‘No single organisation has the wingspan to touch more than a handful of these issues on its own,’ Mr Collins writes. So Montefiore rarely acts as a ‘lone crusader’, operating instead as part of coalitions that seek to achieve collective impact.
Ms Kasoff adds that Montefiore conducts regular community-wide health assessments to identify the status and trends in disease-specific patterns, public health challenges and social determinants that affect the health of local people.
Attaining these goals requires plenty of money and sound financial management, yet by the early 1990s Montefiore had neither, and was close to bankruptcy. But now, even though many of those it serves depend for healthcare on low-paying government insurance schemes, it has achieved financial sustainability through efficient management of resources.
Reduction in positive pregnancy tests among teenage girls at one high school covered by the Montefiore School Health Program, compared with students who had no health clinic at their school
Source: Montefiore Health System
Information technology (IT) and analytics have played a significant part in that. Investment in IT infrastructure has resulted in valuable data that can help evaluate interventions. For example, a small peer-support programme for people with diabetes showed a marked improvement in diabetes control among participants. Similar programmes are now being developed for hypertension.
But IT is nothing without clinicians and systems to manage the care they deliver, and Montefiore’s care management organisation (CMO) is described by Mr Collins as the jewel in its crown.
‘It crunches the numbers to identify opportunities to improve quality and bring down costs,’ his report says. ‘It also takes charge of patients with particularly complex needs to improve their care, and brings disparate primary care, hospital, social care and voluntary services together to work as a coherent team.’
Ms Kasoff explains that the CMO analyses insurance claims data to identify patients with complex conditions and to flag high-cost conditions.
‘When we identify high-risk patients we enrol them in care management to provide assistance in accessing care and support between physician visits,’ she says.
‘And when we identify conditions contributing a significant amount of total medical expense we consider alternative approaches to care delivery.’
What the UK can learn
Examples include locating care providers with expertise in substance misuse in emergency departments and primary care centres.
Ms Kasoff says: ‘Our approach is guided by a “quadruple aim” – improve the quality of care, decrease the cost of care, enhance the patient experience and help our workforce achieve joy in their work.’
Nursing is crucial to Montefiore’s success, she says. ‘Nurses play a key role in our community education efforts, and in our home care and care management efforts. They provide the clinical leadership for our state-sponsored “health home” initiatives, which involve community-outreach workers assisting patients in the community based on care plans developed by registered nurses.’
James Buchan, professor in the faculty of health and social sciences at Queen Margaret University in Edinburgh and a Nursing Standard columnist, believes the UK can learn from systems like Montefiore.
‘We’re becoming increasingly aware of the social determinants of health and the need to look beyond NHS services to address the underlying causes of health problems,’ says Professor Buchan, who has long experience of international health policy, practice and research.
Locally led initiatives
‘The Montefiore example, and others emerging at local level in several countries, emphasises that there is scope for more effective cooperation across health, social care, community engagement and non-governmental organisations to come at the problem with a joined-up approach.’
He adds: ‘In the UK this requires more than “top-down” public health interventions and merging of NHS and social services. It requires an approach that enables and supports locally led initiatives.’
Asked what lessons other health systems might learn from the Montefiore example, Ms Kasoff also emphasises the value of partnerships with other agencies, and of assessing and addressing all an individual’s health needs.
‘These include the social determinants of health, and building comprehensive care plans that address acute, chronic and behavioural healthcare needs as well as the social-economic factors that influence health such as housing and access to government benefits.’
She adds: ‘And timely interventions are critical to success.’
Care management in action
Montefiore’s care management organisation (CMO) includes 200 nurse case managers and social workers who work with patients to determine underlying problems contributing to their ill health. The case managers can bring in specialist services to help resolve specific issues, such as housing.
King’s Fund project director Ben Collins writes: ‘When the case managers identify housing as a critical issue, they don’t simply “signpost” patients to housing services.
‘They prepare the housing application, hound the housing department to do something, or sit with people in their interviews with housing associations if required.’
Nurse Janet Kasoff, senior director of care management learning and development for the Montefiore CMO, says: ‘Our investments in staff development and technology, and our organisational infrastructure, have allowed us to do a better job providing the right care, in the right setting, at the right time.’
As examples of that investment, she says multidisciplinary teams in health centres were trained in motivational interviewing and ‘cultural competency’ to strengthen their ability to connect with patients.
‘And we trained our care managers in evidence-based approaches to chronic care management and development of comprehensive care plans to help patients set realistic goals and elect effective interventions.’