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Pierce County Pilot on Chronic Heart Failure: Impacting Heart Health by Tackling the Social Determinants

By Carolynn Nofsinger

Elevate Health is partnering with Tacoma-Pierce County Health Department to launch a new pilot program to support people diagnosed with Chronic Heart Failure (CHF) within our communities to address the very real social and economic barriers impacting their wellness.

Launching in spring of 2021, the pilot program will target communities within Pierce County that have high incidences of CHF diagnosis, such as the Spanaway and Parkland areas. Elevate Health is partnering with Community Health Care to train community health workers to help people better manage their CHF symptoms and work alongside individuals to address their socioeconomic barriers to health and care over time. This includes a variety of actions such as: finding secure/stable housing, improving access to healthy food, ensuring access to culturally sensitive care and translation services, and coordinating transportation to/from medical appointments.

Research indicates that 80% of a person’s overall health is determined by factors that are managed outside of a hospital or primary care setting. The social determinants of health (SDoH) – the conditions people live, work, learn and play, such as employment, transportation, and housing – critically affect an individual’s ability to access appropriate health care or follow guidelines for managing chronic conditions.

Elevate Health is committed to chasing health rather than disease by addressing the SDoH that lend to and perpetuate chronic illness such as CHF, fighting both the illness and the SDoH that affect its management. This means challenging parts of a broken system head on to ensure equitable access to care across our community, especially for populations that are traditionally excluded from the healthcare system, such as people who are undocumented or experiencing homelessness.

Why Chronic Heart Failure?

In the United States, more than 6.2 million people over the age of 20 are diagnosed with CHF every year (1). Furthermore, almost 14% of death certificates list the cause of death as CHF (2). This chronic condition costs the healthcare system nearly $37 billion per year on average (3). This is primarily due to costly hospitalizations that could be prevented if people had earlier access to appropriate medical care and had the ability to address the social determinants interfering with their ability to manage their condition.

Managing diet, exercise, and stress level are commonly cited as strong tactics to ensure a healthy, functioning heart. Studies indicate that the lifetime risk of CHF is lower in people who maintain healthy lifestyle habits, including but not limited to: moderating alcohol intake, abstaining from tobacco use, regularly eating healthy foods like fruits and vegetables, and maintaining a healthy weight. On the surface, these habits appear easy to accomplish in day-to-day life. However, what if an individual’s social determinants make it difficult to follow this guidance?

Diet and Food Deserts

It is easier to ensure an intake of healthy fruits and vegetables when there are grocery stores close by, reliable transportation to access the grocery stores, and/or money to purchase fresh food and produce. An absence of access to healthy foods in a particular area is called a food desert. The incidence of a food desert in a community vastly affects the ability of the people who live in the area to follow a healthy diet. While some may have the resources to seek out fresh produce, this is not always the case. People must expend additional time, effort, and money to source healthy foods from outside of their local community. Inequitable access to foods that make up a healthy diet is a key issue for consideration when creating community interventions that address whole-person health.

We're helping address food insecurity in Pierce County. The community health workers (CHWs) in our Pathways Program often make referrals to food banks and/or food kits, and in collaboration with the State of Washington Department of Health and the Tacoma-Pierce County Health Department, have made food kits available as part of our COVID-19 relief program.

Exercise and Lifestyle Choices

Another often recommended, low-cost intervention to affecting heart health is exercising regularly (4). However, there are barriers around SDoH that prevent this practice. This includes access to childcare so that a parent may have time to exercise; finding time for a workout amongst multiple jobs; or simply finding the motivation to work out when one has chronic conditions and/or mental illness(es). To ensure equitable delivery of care, doctors are learning to take SDoH into account when creating a follow-up care plan or providing recommendations.

Elevate Health regularly promotes preventative practices like consistent exercise. Our Pathways Program Health team and other care coordinators within the Care Continuum Network are tasked with educating clients on the importance of exercise and stress control in managing chronic conditions. They often connect their clients with the resources needed to integrate exercise into their lifestyle such as childcare, job assistance, or identifying local exercise programs.

Alcohol and Tobacco Intake

Choosing to use tobacco or abuse alcohol is known to have a negative impact on heart health and CHF outcomes. Cigarette smoke is known to damage your heart and/or blood vessels, or cause plaque build-up in arteries that can lead to atherosclerosis (5). The FDA lists smoking as a “direct cause of cardiovascular disease and death” (6). Similarly, choosing to abuse alcohol and/or substances is damaging; large amounts of alcohol consumption and/or binge drinking patterns are linked to an increased risk in cardiovascular disease and mortality (7).

Elevate Health meets clients where they are and ensures that people who want to quit smoking, or would like to seek treatment for a substance abuse disorder, can find help. We also have teams and care coordinators that specialize in working with people with substance abuse disorders. In addition, Elevate Health is an active member of the Opioid Taskforce and is committed to continuing to battle the ongoing opioid epidemic, even during the pandemic.

Stress Versus Chronic Stressors

Maintaining a low level of stress is often recommended to manage heart conditions. However, this recommendation often overlooks the stressors that a person with barriers around the SDoH encounters every day. For example, an individual who has consistent housing and is confident they can pay their rent or mortgage is inherently going to be under considerably less daily stress than someone unhoused, or who is consistently worried about maintaining housing. When a person lacks resources to meet their most basic needs, such as shelter, food and water, and safety – these needs are preeminent to the exclusion of all others.

Sources of chronic stress vary widely across different populations. They also appear more pronounced in populations who are socioeconomically disadvantaged or traditionally underserved, such as people of color and undocumented immigrants (8). A person’s ability to manage their CHF is heavily impacted by the stressors associated with their socioeconomic situations. The American Heart Association found “patients from lower socioeconomic status (SES) neighborhoods had greater independent risk of in-hospital mortality, major bleeding, and a lower quality of discharge care. Research indicates there are opportunities to improve the quality of acute cardiac care in patients from the most disadvantaged neighborhoods.” (9). When a person’s lifestyle is not considered in their care or health planning, the barriers they face in following a heart healthy lifestyle can go overlooked. This mismanagement leads to a higher incidence of hospitalizations as the person’s condition continues to decline.

Racial Disparities in Health and Health Outcomes

Racial disparities are present within the overall prevalence of CHF. Studies show that when looking at CHF follow-up care across independent white and black female populations, black females have significantly more hospitalizations in the follow-up period, requiring higher levels of intervention (10). This demonstrates that real barriers exist for black females in the community who are trying to manage chronic conditions. Similarly, Hispanic males have more hospitalizations, on average, than white males in late-stage CHF due to the lack of access to services that could assist with managing the condition at home (11). The need to imminently address racial disparities in the management of CHF and other chronic diseases is clear. Systemic racism within healthcare systems and institutions allows for easier access to care for some, but not for all. Moreover, lack of attention to the SDoH affecting patients increases the incidence and progression of CHF in vulnerable and non-white populations, and becomes a costly burden to the healthcare system due to the higher level of hospitalizations and emergency care required to address uncontrolled cases of CHF.

Goals of the CHF Pilot Program

This CHF pilot program will collect robust data on the impact of working with a community health worker on the clients overall CHF symptoms and SDoH factors. By leveraging this data we’ll be better able to distill best practices and prioritize the levers that affect population health outcomes around CHF and other chronic conditions.

When the most basic needs of an individual are not met, the management of a chronic disease such as CHF become insurmountable barriers. It is in this space that Elevate Health seeks to intervene and lend support alongside prevention. Our Care Continuum Network is committed to serving the people of Pierce County through our care management programs, while evaluating the work along the way to see how we can better to serve our community and advance health equity.

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