How Valley Addresses Social Determinants of Health - Valley Behavioral Health
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August 11, 2020 By Julie Rael, LCSW, CCO Valley Behavioral Health

Our patient’s social determinants of health (SDoH) is an equally essential element to consider along with care coordination. According to the World Health Organization, unmet needs in the areas that individuals work, live, and grow lead to health inequities and chronic health and behavioral health problems. At Valley, we have seen how addressing these needs to improve treatment outcomes. When new patients come to us upon discharge from the hospital or jail, they have multiple SDoH needs and are experiencing acute behavioral health needs. They are in a cycle of using emergency dispatch services or have been re-hospitalized soon after a previous hospitalization. They often have multiple basic living needs and have not successfully engaged in treatment. We established our care navigation team this year. This team helps our patients stepdown from higher levels of care. At intake, we immediately begin assessing our patient’s SDoH needs in five major areas that include: economic stability, education, health and access to health care, environmental living conditions, and the social state of one’s community. We develop a treatment plan that targets these needs and connects them to resources within our agency and with other providers and community resources. We have been working diligently and have seen the results of addressing SDoH on treatment outcomes along with our care coordination efforts. One of these outcomes is that we have seen a decrease in hospitalizations by 38% in the past year. We are thrilled and proud of the excellent care that our teams continue to provide. Below I illustrate how our services address our patients SDoH as they stabilize and engage in treatment.

We help our patients with low socio-economic status obtain and maintain their economic stability. We do this by helping those who were previously working stabilize their behavioral health concerns, access resources for occupational support, and training to return to work

after their symptoms have stabilized with new skills and employment options. For our patients that have developed a disability and are unable to return to work, we assist them in navigating the social security and disability application process. We connect them with financial support from the Department of Workforce Services while they move through this application process. After they obtain disability benefits, we work with a local payee company to help them maximize their disability benefits, develop a budget, and pay their bills. We support their food security by assisting them in applying for the Supplemental Assistance Program (SNAP) and connect them with local food donation centers to help them supplement their food supply, while they await their SNAP application.

Our patient’s education is supported across all ages in our various programs. Our adult residential programs partner with Granite Peaks to help our patients access weekly instruction to obtain their GED. Before the pandemic, they were providing instruction on-site multiple times a week. With new precautions, they are currently receiving on-line instruction. We also ensure our patients receiving residential obtain employment or stable income and are transitioning

to a sober living program while our recovery management team helps them obtain long-term housing. Our children’s day treatment programs partner with the Granite school district to ensure their academics are not neglected and can catch up academically. Our outpatient therapists work with schools and case managers to help the children access additional community resources as well as resources to help their parents obtain food and transportation services. These therapists participate in team meetings at the children’s school and other agencies including the division of child and family services.

Our patient’s access to a primary care provider and a medical specialist for chronic symptoms is a continued area of focus for us. Utah’s health information exchange notifies us when our clients have utilized the emergency services for medical or psychiatric needs. This is critical information that helps us identify which patients need more support in scheduling and making it to their appointments. We facilitate in-house referrals for medical case management. We provide integrated health services that allow them to see a psychiatric APRN for their physical and behavioral health needs. We offer a variety of therapeutic behavioral services focused on teaching, supporting, and encouraging good health practices, including stress management, meditation, Tai Chi, and yoga.

We help to improve the quality of our patient’s living environment by helping them obtain more desirable housing, access resources to repair and make improvements, and connect them to resources to obtain furnishings. We provide skills training around organization and cleanliness.

We encourage a healthy support network, feelings of social cohesion, and belonging by providing social support services that include socialization groups, events, and activities that reduce feelings of isolation and loneliness. We also refer them to other community

programs and volunteer opportunities to further increase participation in activities that utilize their strengths and talents and increase their feelings of connection and purpose.

 

References

World Health Organization. Social Determinants of Health https://www.who.int/social_determinants/en/

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