Health Leads

Summary

Health Leads is a social enterprise working to improve health systems by treating prevention, socioeconomic, and social service needs as a form of healthcare. Health Leads believes that doctors should be able to “prescribe” basic social services such as food, safe housing, heat, and other key resources. Hospitals, health centers, and clinics can partner with Health Leads to build individual social needs interventions. For organizations looking to integrate basic social service skills into their health practice, there is the Health Leads Prepare Workshop. It is a five-week curriculum, consisting of weekly 90-minute webinars, individual coaching calls, and weekly activities designed to help launch or refine an organization’s social needs strategy – including design, implementation, and measurement steps. Participation costs $1,500 per organization, with a discounted rate of $1,000 for free clinics and federally qualified health centers (FQHC).^[1] For organizations and practices looking for more insights, Health Leads offers Assessment and Design Services on a consulting basis, working with organizations for 8-12 weeks to develop custom social needs interventions. Implementation Services are also available to support the integration of the social needs strategy and includes access to a “Dedicated Health Leads Advisor” who consults with the organization weekly to improve workflow, and to the Health Leads Collaborative, a monthly web-based series where organizations can share best practices and drive improvement.^[2]

Keys to Success

Data-driven

Organizations looking for a simple way to track their interventions and manage patients’ social service needs can purchase Health Leads Reach – the first and only cloud-based platform designed to enable health systems to manage social determinants such as food, housing, and heat, and to track the success of their social needs interventions.^[3] The platform can be used to screen patients for social service needs, identify relevant community resources, track progress, and analyze performance with reports to drive continuous improvement. The platform can be accessed from multiple devices as it is a secure web-based platform. However, for those looking to incorporate the platform into existing workflow, Health Leads Reach can be integrated into electronic health records (EHR) systems.  Health Leads not only advocates for greater attention to the social determinants of health in clinical setting but also uses technology to incorporate this practice into health centers.

Training passionate advocates and developing future healthcare leaders

Health Leads builds greater consciousness around the social determinants of health and helps prepare more socially conscious healthcare professionals through its Advocate program. Health Leads Advocates are college students at partner universities who volunteer at least eight hours a week in clinics and hospitals to connect individuals and families to the basic resources they need to be healthy. These volunteer advocates can assist clinics and hospitals that may not have the capacity to fully address their patients’ social service needs. This program therefore adds value to existing health care delivery systems while simultaneously teaching students social service connection skills they may not have the opportunity to develop in college or medical school, preparing these future professionals to practice more holistic healthcare.^[4]

Ability to Inspire

For over 20 years, Health Leads has been a leading advocate for integrating social needs into healthcare – an approach that has gained greater traction in recent years, perhaps best indicated by The Centers for Medicare & Medicaid Services (CMS) announcement of the new Accountable Health Communities (AHC) model in 2016.    The AHC model “represents the first government-funded integration of social needs interventions into healthcare.”^[5] CMS is currently funding 32 organizations over five years to screen their patients for unmet health-related social needs, refer them to community services, provide navigation services to high-risk individuals to help them access community services, and promote alignment between clinical and community services.^[6]

CMS’ recent embracing of health-related social needs was built on evidence that addressing these needs, which were traditionally considered outside the scope of clinical care, can actually improve health outcomes and reduce health system costs. The research on Health Leads certainly seemed to have contributed to this movement. In one JAMA study assessing the impact of the Health Leads program in primary care patients with unmet basic resource needs, patients whose unmet social service needs were addressed with Health Leads’ assistance reported reductions in blood pressure (systolic and diastolic) and LDL cholesterol levels, establishing a clear link between social service needs and clinical outcomes.^[7]

Health Leads CEO, Rebecca Onie, who founded Health Leads (then Project HEALTH) as a college sophomore, has received national recognition and multiple awards including a MacArthur Genius Fellowship, the Robert Wood Johnson Young Leader Award, and an Aspen Institute Health Innovators Fellowship for her work in creating a definitive framework to address social needs within the health system.

Drawbacks and Limitations

While Health Leads has championed a rightful shift in the U.S. healthcare system toward addressing social service needs and expanding what constitutes healthcare, it is clear that for people with diabetes this approach has limits. In the same JAMA study that assessed the impact of Health Leads involvement on various clinical outcomes, it was reported that the participation in the program had no statistically significant impact on hemoglobin A1c levels. This finding suggests that while connection to basic resource needs may have some health benefits, patients with diabetes need additional engagement and resources to address and improve glycemic outcomes like HbA_1C.  Further research is still needed on the direct impact of programs like Health Leads on prediabetes and its progression to diabetes.