Bonus Episode: Social Services Deep Dive

Dr. Alessi drills down on a number of topics discussed with Connecticut's Social Services Commissioner Andrea Barton Reeves, including Medicaid truths, social determinants of health, and how the ACEs survey fits into overall health. Submit questions for Healthy Rounds: [email protected] DSS Commissioner Andrea Barton Reeves: https://portal.ct.gov/dss/knowledge-base/articles/home/dss-commissioner UConn Health: https://www.uconnhealth.org Support from UConn Health Orthopedics and Sports Medicine: https://www.uconnhealth.org/orthopedics-sports-medicine Grant support from Coverys: www.coverys.com Transcript Dr. Alessi: Welcome to the Healthy Rounds Podcast, where we provide you with up-to-date and timely medical information from national and international leaders in their fields. This podcast is brought to you by UConn Health, with support from the Department of Orthopaedic Surgery and a grant from Coverys. It’s not designed to direct your personal health care, which only you should work out directly with your physician. I’m your host, Dr. Anthony Alessi, and it’s great to be with you for what has come to be known as our deep dive, and that is where we look at the most recent podcast we did and try to drill down on some of the topics that were only able to glance over. This particular podcast was done last week with Commissioner Andrea Barton Reeves. Ms. Barton Reeves is the commissioner for the Connecticut Department of Social Services. That is the part of our state government that oversees Medicaid, and Medicaid is a pretty general term here in Connecticut. We refer to it as HUSKY, but we always think of it as just being this kind of handout program where it just takes care of one thing, like doctor’s visits. Medicaid is an all-encompassing program, and it’s done in conjunction with the federal government for people who qualify economically. Now these are people, many of whom work, but they don’t make enough. They are below what is determined as the poverty line, and when you’re below that, you’ll need some assistance in order to provide meals for your family, to provide health insurance or health care, which is the HUSKY program, and some of it is hospitalization. It is used for durable goods, such as crutches and canes. It’s used for home health care, so there are a lot of different facets of it. Among them is also the nutrition program. We call it SNAP, the Supplemental Nutrition Assistance Program here in Connecticut. People refer to it as food stamps in the past, or an EBT card. This also provides free breakfast for children. So it looks at a lot of different aspects, and there are over a million people who’ve received some form of Medicaid in the state of Connecticut. So that’s a big part of our population and it has a $9 billion budget. But as I mentioned, it’s got a lot to do with a lot of different services. One of the things we talked about is the importance of those services in terms of childhood development and the risk factors going forward. I brought up the idea of childhood separation, which is something we’re hearing a lot about with people who might be undocumented immigrants who came here trying to find a better life for themselves now being separated from their children. And it brought to mind something we mentioned, which is the ACEs score, the Adverse Childhood Experiences score or survey. And this is a survey that was designed to look at experiences in childhood before the age of 18 that may in some way impact the future of children, specifically with respect to health. There are a lot of variations on the ACEs survey, but particularly what they look at are childhood experiences related to trauma, meaning death in the family, shooting. Was a parent or a close relative put in prison or incarcerated for a long period of time? Was there a lot of divorce or fighting in the family? Was it a broken home in some way, shape, or form? So these are all experiences. Also more violent ones: Were they witness to a crime? Did a close relative die by suicide? And what they have done is really looked at the social outcomes and these scores. And it’s interesting because it has clearly shown that children with a higher adverse score were more prone for increases of injury to themselves, sexually transmitted infections, early pregnancy were among them, but also chronic illnesses like cancer, diabetes, heart disease, and taking their own lives by suicide. So these scores are quite important in terms of how they stress the entire social services system, and it’s important that we look at that. The other factor that we talked about are the social determinants of health. And the social determinants of health was something I brought up, because it’s a firm belief of mine that unless we address social issues, we’re not going to make progress in terms of improving the health. We all hear about this Make America Healthy Again. Well, we need to take a step back and look at how we got unhealthy. And if you look back at that, a lot of it has to do with how society has changed and how we have to deal with these social determinants. So there are five basic social determinants of health. We look at education, access to education, and quality of education for an individual. We look at health care, access to health care. Do you live in a rural community? Do you not have transportation to get to good health care? And what is the quality of the health care where you’re living? We look at your neighborhood or what we call the built environment. Where are you living in terms of the physical structure? Is it an apartment? Is it a house? And the next thing that goes with that is kind of the social and community context of where you’re living. Is it truly a community? Is it a supportive community? It could be a church community, it could be a very supportive neighborhood and ethnic community. But again, it’s an important determinant. And obviously the last one being economic stability, economic stability being so important for these social determinants of health. What I found interesting is, in looking at some articles on social determinants of health, is how it relates back to a previous podcast we did with Dr. Peter Schulman. Dr. Schulman impressed upon us the fact that heart disease has really changed. It’s been a paradigm shift from ischemic heart disease or heart attacks to now heart failure, where the pump begins to fail, the heart itself, whether it be by infection or primarily old age as we live longer. So with heart failure, we are trying to address that with different medications, a lot of different care. It’s very different from angioplasty and bypass surgery and things such as that. So a recent article looked at people who were hospitalized for heart failure and they wanted to look at the readmission rate. So this has been a big factor throughout health care and something we monitor, when someone is in the hospital and gets discharged, how long before they are readmitted for the same problem? Right? Because when you’re thinking about it, you start thinking, “Well, maybe we didn’t fix the original problem and that’s why they needed to come back. Why did these people have to come back?” And what they found was in heart failure, one of the biggest reasons for people being readmitted were these social determinants of health, meaning we addressed the problem, but they were going back to an environment which was not supportive. They did not have good access to health care. They did not have the support. They lived alone, for example, didn’t have a support system for them, or it was just basic economic stability. Could they afford these very expensive medications to keep them out of heart failure? So I think when I came away from the interview we did with Commissioner Barton Reeves, it was awakening for me to see that how much her whole department really impacts everything we do in health care at UConn Health. And I think it’s important for us as people who deliver health care, as those of us who are friends of people who are ill, is that we have in the back of our minds how to keep our patients healthy, and work with them and ask more questions about their social position and what support services they have, after we treat patients. With that, I look forward to our next encounter. Next week we’re going to be chatting with my boss here at UConn Health, Dr. Isaac Moss. We did a taped interview with him that I know you’re going to enjoy about spine surgery, but also what’s it like being chairman of a department of a very busy, active department here at UConn Health? And I think you’re going to be amazed when I ask him the question of, what does the future look like in spine surgery? Many thanks for listening today, as always. If you have any questions or ideas for future programs, you could reach out to me at [email protected]. Jennifer Walker is executive producer of the Healthy Rounds podcast. Chris DeFrancesco is our studio producer for the podcast. Tessa Rickart is in charge of social media for Healthy Rounds. Until next week, this is Dr. Anthony Alessi. Please stay healthy.