Social issues can take a toll on health. How an insurer and doctors are helping people

Cathie Anderson
·8 min read

Stroke survivor Kenneth Lee struggled to get his diabetes under control while living out of a van for more than 10 years. Then something experimental happened: A community health advocate came on board at his doctor’s practice in Galt.

Within a few months, Lee said, he had a security deposit, an apartment and “a little village” with a range of services within walking distance.

“The doctor doesn’t necessarily have all the time in the world to meet and deal with all the intricate social issues that some of the patients have,” said Stuart Kosh, the community health advocate at Associated Family Physicians. “That’s why we’ve been brought on board. I have been working with Kenneth through this practice in Galt since November. It’s almost been a year.”

Blue Shield trained Kosh and about 20 other community health advocates and charged them with using technology and their own creativity to solve the social issues that often keep people from achieving good health.

“Formal medical care is really only accountable for about 20% of what produces health in a person,” said Peter Long, senior vice president of health care and community health transformation at Blue Shield. “The other “80% is from ... the rest of our lives. Those are things like housing, food security, transportation, (intimate partner) violence, all of those other issues. We started the health advocate program to be the bridge from the physicians’ office, the formal medical community, to all of those other services.”

Make no mistake, though, Long said, almost everyone can benefit from the help of a community health advocate, regardless of whether they’re living out of their automobile and on Medi-Cal or they’re a middle-class wage earner with employer-provided insurance.

From a van to his own apartment

Lee, 66, said he worked as a mechanic, drove a bus for the disabled and operated video stores before a series of strokes landed him in the hospital for two weeks. He never recovered physically or financially after that hospital admission, which included seven days in intensive care, he said, and he now lives on disability.

When Kosh started work at Associated Family Physicians, he said Lee would park his van in an adjacent parking lot and hang out until it was time for his appointment.

“Kenneth ... actually told me he didn’t need any services when we first started,” Kosh said. “He was living in his van. He was very comfortable there. I could understand. There were a lot of services that were not trying to meet him where he was at or trying to get him the things they thought he should have as opposed to listening to what he wanted for himself.”

What Kosh heard from Lee was that he’d put in an application at Galt Place Apartments two years earlier, but hadn’t been able to get off a wait list.

“We called together, and wouldn’t you know it, two weeks later, a spot opened up for Mr. Kenneth Lee,” Kosh said.

Still, there were many other hurdles to clear before Lee was able to move in March 3. They needed a down payment of $100. Fortunately, Lee had that much left over from his monthly disability check.

The next challenge, though, was too much for Lee. He would have to come up with a $550 security deposit at a time when the COVID-19 lockdown had shuttered the agency that typically would provide funds for it.

It was Kosh who floated the solution: How about a GoFundMe campaign?

At GoFundMe and other such crowdfunding sites, people ask friends and strangers to help them raise money for particular goals. Lee’s appeal raised $555, which they put toward the deposit.

“The big element of this program is the advocacy piece where somebody can come in for somebody like Kenneth and say, ‘Hey, just because Kenneth is struggling with X, Y and Z doesn’t mean he’s going to be a bad tenant,’” Kosh said. “Kenneth has now lived there very successfully for six months and has paid his rent on time. He even has a service animal.”

Lee lives within walking distance of his doctor, his dentist, a flea market and a church that has a food pantry. Now that he has a place to live, he’s also been able to tap into a meal delivery service that’s free to senior citizens in his income bracket.

Kosh still checks in with Lee regularly, Long noted, so this isn’t just a one-and-done transaction.

“Stuart didn’t consider it done when Kenneth got housing,” Long said. “If there’s anything we’ve learned about social determinants (of health), these outside factors that can affect your health, it is that they don’t just get fixed once. Someone might have a setback, or the system might turn against them or make things untenable. So you actually have to continue to be persistent and vigilant and form that relationship.”

In fact, Kosh has given patients his cellphone number and he has fielded calls for help from them over the weekend. In one case, he said, a landlord had put one woman’s belongings on the street, but her medication had been left in her room.

Kosh, however, knew the regulations on evictions, called the police and was able to get the woman reinstated in the group facility.

“So often this gets predicated upon whether people ... know the law and what their rights are or how to stand up,” Long said.

Lee said: “It helps to work with somebody who knows the ins and outs. They (landlords) don’t make it easy.”

How the program helps patients

Long noted that Blue Shield has made a number of investments to ensure its community health advocates have what they need to do their jobs:

While Kosh is based in a doctor’s practice, Long said, Blue Shield also has placed advocates within its organization and in community-based organizations. They also selected people who have a range of backgrounds. Kosh comes at this from the vantage point of a social worker, Long said, but others have community organizers or have done peer-to-peer support.

“We say to them, ‘Go solve the problem and we’ll help you figure it out. Whatever it takes, let us know and we can escalate it,’” Long said. “What’s been interesting is, most of the time, it just requires creativity and persistence.”

Long’s team at Blue Shield is evaluating what kind of emotional support health advocates need, how many clients each advocate can manage successfully and where it makes most sense to place them.

The health advocates are focused on clearing hurdles to good health for individuals, Long said, but the end game for this program is having a broad societal impact.

As the advocates track what’s working and what’s not working for patients, it gives Blue Shield a better picture of systemic or structural successes and failures.

“We have a very robust government affairs department, and so part of what our plan — and this is early, we’re just about a year into this — is to list up those issues and go to Sacramento and say, ‘We’ve got to fix this,’ whether on the local level or on the state level,” Long said. “We need to say when there’s a public policy issue that’s wrong or a funding issue that’s wrong. That’s our commitment to complete the circle.”

Understanding leads to commitment

Kosh said he makes it a practice to review patients’ electronic medical records ahead of their visits and examine what might be exacerbating their health issues. Initially, Long said, the idea that the advocates would do this alarmed some physicians who felt they would then have the frustration of not being able to help.

“What’s been really interesting is the feedback we’ve gotten is there’s now a real appreciation for whole person care,” Long said. “In health care, we’re often very frustrated with what we call no-show rates or missed appointments, but when you understand what’s happening in the person’s life, there’s a lot more not just sympathy for them but there’s actually a commitment to working with them to improve their health.”

There are countries where they have a lot more people in this community health advocate role than they have physicians trained in Western medicine, Long said. In a number of these nations, people spend much less money on health care than Americans do and yet produce very good health outcomes.

What they have, he said, are trusted peers advocating for clean water, healthier food, public transportation, jobs, housing and other things that will improve the lives of people in their communities.

“Community health workers have been around the world for 20 years,” Long said. “I don’t think we need to prove that community health workers will help a person’s health.”