In October, Dr. Karen Stephen, the Director of Behavioral Health at Partnership Health Plan,  attended the CIBHS 2015 California Behavioral Health Policy Forum. She returned with some reflections from a presentation by Marvin Southard, the much-beloved retiring Director of Los Angeles County Mental Health Department. He presented one slide that highlighted what is important to acknowledge in treating both behavioral health and substance abuse problems.  He entitled the slide, “What Counts.”

He said that if we look at what contributes to overall health outcomes in terms of both length of life and quality of life, there are two factors that account for 50% of that outcome. The first is the physical environment in which people live which contributes 10% to overall health outcomes. This includes housing, transit, and air and water quality. The second are social and economic factors which contribute 40% to health outcomes. These include education, employment, income, family and social support, and community safety.

The other 50% of overal health outcomes are determined by clinical care and health behaviors.  Clinical care accounts for 20% of the overall outcome and includes access to care and quality of care.  Health behaviors include tobacco use, diet and exercise, alcohol and drug use, and sexual activity and account for 30% of the overall outcome.

As clinical providers and as health plans, therefore,  we can maximally impact 50% of what contributes to good health outcomes. The other 50% of physical environment and sociodemographic factors are unchartered territory for health providers. Interestingly, what we know now as public health grew from attempts to improve these other 50%. One theory for instance suggested that diseases were due to “bad air”. Interventions were designed to improve “bad air” with improvements in living conditions and sanitation.

With the advent of  germ theory of disease, focus was shifted back to biological causes of illness. Therapies were developed to attack the underlying pathology of disease, whether its microbiologic or genetic in origin.

Now the pendulum is swinging back. Socio-cultural context is re-emerging as key contributors to health outcomes. Educational inequality, income inequality, blighted and poor neighborhoods, and social exclusion and isolation are now recognized as major players for poor health outcomes. Economically-associated factors such as housing instability, under or un-employment, food insecurity, and limited access to health care are now considered key contributors.

Finally, adverse life experiences including both early life and later life experiences called ‘trauma-informed care’. History of sexual abuse, substance-impaired parents, physical or emotional abuse, especially early in  life, can scar the patient for life, and adversely affect their life-long health.

Project 25 is a shining example of how addressing social determinants of health can impact health outcomes. Undertaken in San Diego from 2010 to 2013 , Project 25 provided an integrated program addressing physical and mental health, substance abuse, and criminality.  Twenty eight of the highest cost individuals in the public system (including both health and judicial costs) were enrolled in an intensive program of services which emphasized “housing first” (with ongoing support to landlords to support stable housing), a comprehensive medical home (with all physical, mental health, substance abuse, and social services received in one location), and both harm reduction and abstinence philosophies for substance abuse (how many other programs allow beer in the fridge!). This program was funded by United Way and involved the   cooperation of a large consortium of public and community based health and judicial organizations.

Preprogram costs for all public services (ED visits, hospitalizations, arrests, days in jail, ambulance transportation) were $111,000 per person in 2010, while the individuals were still living on the streets. The median expense in 2013 was only one-tenth of that amount, less than $12,000,  after being placed in permanent housing with comprehensive services.  At the end of the project, one third were able to maintain their lives on their own, one third were on their way to doing so, and one third were determined to need the intensive services for the rest of their lives (still a savings compared to what was being spent on them without those services).

Successful programs throughout the state have used similar approaches.

• First, a medical home with comprehensive mental and physical health services along with substance abuse treatment and social services.
• Second, a capacity to address homelessness with housing options.
• Third, the use of peer counselors to break down barriers
• Fourth, identifying needs and making connections while the recipient is still incarcerated or hospitalized, especially when services are immediately available upon discharge.

A very touching moment at the CIBHS program was when a rehabilitated career-criminal drug abuser told the audience of health professionals that what was most important in his success, where there had been zero success before, was seeing a person who “looked like him” when he stepped out of prison, having counselors listen with unconditional acceptance. being immediately offered a housing voucher, and having a client-centered goal setting approach in all services provided. We need to pay heed to those we serve.