Four health system leaders from different corners of the country discussed their perspectives on this issue during an H&HN Executive Forum panel on Wednesday in Chicago. Perspectives may vary, but all agreed that they must find ways to address the social determinants of health.

Below are snapshots of what health system leaders said during the discussion:

Cook County Health & Hospitals System, Chicago

John Jay Shannon, M.D., CEO of the Chicago system faces the challenge of serving an Illinois population in which one in four residents is on Medicaid. His system is often looked at as the last resort for those who can’t get care elsewhere.

During social needs screenings, Cook County Health found that one in five are “virtually couch surfing” while the same ratio is having to decide between rent, food or medical care. Providers there face the challenge of trying to help a woman to continue her diabetes medication, but finding she lacks a refrigerator in which to keep her insulin, says Shannon.

For him, the problem, (in Illinois, at least), lies in dollars that continue to flow into the health care system, but have all but disappeared from social support agencies.

“One of the most common refrains I hear is that we don’t have the money to do what we need to do. I think what we’re all going to have to try and figure out is how you partner with other people from a policy standpoint.”

“But whether or not we should be running that, I don’t know,” he added.

KentuckyOne Health, Lexington, Ky.

The health system is following a two-pronged approach to population health that includes transformation inside the hospital as well as partnering with groups already involved in the community.

Advancing the system’s quality, safety and technology optimization is part of that first prong. To do that, KentuckyOne has created a total continuum of health collaborative comprising nearly every discipline in the system, from clinicians to those involved in the revenue cycle.

The collaborative addresses questions related to social determinants, such as: What happens to a patient after he or she leaves the hospital? What happens in the patient’s home? What is the patient's community like?

“You can do fantastic jobs in the health care system, [but] if we don’t address total health, we won’t be achieving whole health in the individual,” says Stephanie Mayfield Gibson, M.D., vice president of population health and chief medical officer

The second approach involves community outreach and establishing public and private sector partnerships to create what  Gibson terms an “accountable community.”

The ultimate goal is to incorporate health system leaders into already established groups on issues surrounding housing, financial resiliency, food insecurities and utilities, she says.

“We’re hoping between these advanced clinical protocols we’re developing and communities of practice, we’ll start seeing some traction in a state that’s very ill.”

University of North Carolina Physicians and UNC Health Care, Chapel Hill, N.C.

Allen Daugird, M.D., president of UNC Physicians and chief value officer of UNC Health Care, looks at population through the lens of the system’s three missions — serving the health of the community, research and teaching. Although it was growing under fee for service, it wasn’t feasible in the long term nor was it beneficial for improving the health of those it serves.

Daugird says the system has done a lot of little things, such as adopting a physician-created clinic for the homeless population in Chapel Hill, where homelessness is an issue.

“Sometimes, there’s already great work being done in individual communities and it’s a matter of coordinating with them and helping them do a better job with what they want to do.”

But, two things will greatly help toward gaining a better hold on population health: the creation of a Next Generation ACO with 30,000 initial participants beginning in January and a switch to mandatory managed Medicaid plans.

He admits the system has a long way to go, but once leaders takes a look at their community, addressing social determinants is obvious.

“I think when you start actually being responsible for the total cost of care, and realize that social determinants are probably a much bigger factor in cost of care, if you’re smart, you start realizing that to improve the health of populations you’re responsible for, it shouldn’t just be care delivery, but other things.”

Inova Health System, Falls Church, Va.

As one of the largest health systems in northern Virginia, Inova serves many of the uninsured. A series of safety net clinics were created for this demographic, including simplicity clinics, as Russ Mohawk, CEO of Inova Health Plans & Population Health Services, calls them. Residents pay $10 a week or $40 a visit and they have access to primary care as well as low-cost prescription drugs.

And while Mohawk says its demographic isn’t the same as many health systems, they’ve started to tailor care to the community they do serve. Inova’s Advanced Illness Program includes a clinic for those in their last 18 to 24 months of life, designed to keep patients out of the hospital and create a better end-of-life experience.

Similarly, Inova's geriatric assessment center houses a geriatric house calls program with three geriatricians who go to patients' homes to look at their home environment and social support situation.

Like all health systems on the panel, Mohawk says the move to population health is a process. “It’s a journey. We’re not anywhere near where we should be, but we’re getting there.”