Jacob Reider, MD, FAAFP

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As healthcare executives place a greater focus on addressing social determinants of health (SDoH), it’s important to look at the key factors that can advance those efforts. Two of the most critical are: 1.) well-curated networks that connect payers, providers and health plan members with social care; and 2.) the technology that facilitates those connections.

Like most organizations, non-profits that address the social needs of communities’ most vulnerable residents are starting to make strides in embracing technology. Payers are collaborating with providers to ensure that data is being used to refer patients to those community-based organizations to make sure that health plan resources are being used wisely, with a focus on better health care-and health-for members.

In some parts of the country, community-based organizations (CBOs) and medical provider groups-with the support of the payers in those regions-are effectively collaborating through technology-driven referral platforms as members of the same team to bring social care and health care together. By doing so in the context of well-curated networks, their communities’ most pressing social needsâincluding food insecurity, interpersonal violence, transportation challenges and housing instability-people’s well-being and overall health begin to improve.

But faxing information back and forth or sending patients off with a food pantry’s phone number on a sticky note and hoping they call may still happen all too oftenâeven though we all agree that in the hyper-connectedness of today, it shouldn’t. If teenagers in North Dakota can strike up fluid conversations with peers in Mumbai, surely there must be a way for a physician to refer an individual to a food pantry with confidence the CBO will receive the message and confirm that the individual's needs have been met.

Virginia, there is a way for this to work


	Modern, technology-driven platforms are available to facilitate referrals that address social needs, but they must possess key characteristics to achieve success. First, the platform must enable medical providers to connect individuals to social service organizations, such as behavioral health providers, benefit navigators, food pantries and workforce development agencies. Next, they must make it simple for these organizations to understand patients’ health statuses and how their social needs may be unique as a result. Finally, the systems need to have automated feedback that notify team members when patients receive services (and when they do not) so that appropriate action can be taken.

Just as importantly, referral platforms need to help CBOs and provider groups communicate effectively to address their patients’ needs and care plans in a unified way. Siloed technology can cause siloed processes and siloed decisionsâincreasing the risk that individuals could fall through the cracks between well-intentioned efforts to collaborate. Finally, these platforms must be capable of capturing the right information, based on claims data and information collected during the doctor or hospital visit, to measure the effectiveness of social interventions, including the extent to which interventions are producing desired health and financial outcomes.


	Reminiscent of the now-familiar story of the GPS app that 

, we’d be wise not to outsource all of our decisions to technology with no questions asked. As it relates to addressing SDoH, consider the electronic health record (EHR).

Most out-of-the-box EHR configurations do a poor job of capturing the breadth and depth of SDoH information that care teams (both social and medical) need to guide effective decision-making. And the solution isn’t as simple as “just add a new field to the EHR.”

If we go down that route, the question then becomes, “Okay, so what goes in the field?” If it’s free text, we could be creating a new problem: a situation where understandably confused providers will type in a bunch of unexpected information. Another option is to create a checkbox, but then that checkbox would ideally map to a semantic concept, which must in turn map to a 

 (a universal standard for identifying observations) or an 

 (social characteristics). In short, there’s no easy, obvious solution.


	While that’s just a single example, it illustrates a long-acknowledged truth: community-based health is a people-intensive process that relies heavily on relationships. That’s why, in addition to the right technology, the right network-a group of engaged, high-quality local medical providers, behavioral health providers, and social care providers-is critical.

A network that defines and then adheres to best practices and is committed to achieving positive outcomes for the community it serves will require a high level of curation. A well-curated network, in turn, is about creating an ecosystem that is reliable, functional and convenient.

In the context of SDoH, a well-curated network is one that makes the 

thing to do. For members of the network, the act of participating is a commitment to adhering to its standards of service-which may involve factors such as minimum response times, a commitment to accept referrals, and a commitment to communicate in a fluid manner with all other network members.

The bottom line: A network is much more than a simple directory of service providers or a three-ring binder of community resources. A network is a tightly knit tapestry of relationships, commitments, andâyesâtechnology.

As technology and information capture improve in the future, payers support SDoH data integration for providers and CBOs, and social care/health care networks become more fine-tuned, the business case will be built for addressing SDoH early to prevent the cascade of medicalization that leads to individual suffering and creates population health challenges. To get there, we’ll need to keep investing in both our technology and our networksâas both are necessary, but neither alone is sufficient to move SDoH goals forward.

Jacob Reider, MD, served as deputy director of the Office of the National Coordinator for Health Information Technology (ONC) during the Obama administration. He is currently CEO of 

, a company focused on helping Medicaid members and the uninsured 

Articles

When addressing social determinants of health, healthcare execs are focusing on two critical factors that can benefit those social determinants: well-curated networks and technology. 

How Technology, Well-Curated Community Networks Are Connecting Healthcare and Social Care

Health care is a term often associated with doctors, hospitals, and medical treatments. Indeed, dictionary definitions of the term often invoke medical interventions as examples of health care services. Yet the importance of social factors in the health of an individual or community can no longer be ignored. We, therefore, offer a clarified definition of health care to include the sum of three categories of service providers:

 Care Services (care management, physicians, hospitals, etc.)

 Health Care Services (psychologists, social workers, substance use treatment providers, etc.)

 Care Services (housing providers, food assistance providers, transportation assistance providers, etc.)

Social care providers, sometimes referred to as community-based organizations, are on the cusp of a disruptive change in the way they can operate financially. The old system of attaining funding by requesting grant money from the government or private foundations is rapidly being replaced by a move to receiving funding from health insurance companies and at-risk care delivery organizations who offer financial incentives-such as shared savings-for their part in keeping individuals healthier while reducing the total cost of care. 

This is all part of a shift in the focus of health care overall. In the past, medical care providers were paid based on fee-for-service (FFS) arrangements. As such, the services they delivered were completely independent of services delivered by social care providers. 

Today, health care payment policies are moving toward value-based models, where provider reimbursement from health insurance companies is based on improved health outcomes rather than volume of services provided. The healthier they keep their patients-and the more they can prevent them from needing the hospital or emergency department-the more money they make. Needless to say, this is a 180-degree turnaround, and it hasn’t been painless. Since reimbursement is tied to health outcomes, the spotlight is shining brighter on the social care providers to which they refer their patients.

Medical care providers can no longer simply refer an individual to a social care provider and consider their part finished. Both sides need to work together to track referrals and report on outcomes, preferably as part of an organized network, so they can both reap the rewards of the risk-based contracts. Some examples of states, managed care organizations (MCOs), and social care providers that 

Arizona, which requires coordination of community resources such as housing and utility assistance under its managed long-term services and supports contract.

The District of Columbia, which encourages MCOs to refer beneficiaries with three or more chronic conditions to the “My Health GPS” Home Health program. 

Louisiana, where plans are required to screen for problem gaming and tobacco use, and referrals to the Special Supplemental Nutrition Program for Women, Infants, and Children are required.

Nebraska, which requires MCOs to have staff trained on social determinants of health (SDoH) and to be familiar with community resources.

, a state-wide closed-loop referral network between social care providers, MCOs, and medical care providers.

Health payers have also taken an active interest in this new, integrated approach as evidenced by the announcement that 

 to equip all of the providers in its network with technology tools to address SDoH. Working with Unite Us, a health IT network that links social care organizations with medical providers, Kaiser Permanente is looking to create a seamless electronic platform for supporting connections between organizations. This concept was pioneered by Unite Us in partnership with Alliance for Better Health, which was a significant contributor to its SDoH model.

To survive and thrive in this new value-based world, social care providers will need to partner much more closely with medical care providers and demonstrate not only the activities they’ve undertaken but also the results they’ve achieved. Yet that can be difficult when their organizations aren’t traditionally set up to make referrals to each other or to track and report on shared activities such as assisting an individual in a truly collaborative manner. 

Helping to bridge that gap is a new generation of technology designed specifically to connect medical and social care providers together around the individual. It creates a platform both sides can use to track and manage referrals and referral outcomes electronically, eliminating the need for endless faxes and spreadsheets that never seem to be updated in a timely manner. It also makes it easier for social care providers to track and report the outcomes of their interventions in real time, demonstrating how they are keeping individuals healthier and reducing costs so they can more easily reap the benefits of value-based shared savings. 

Both insurance companies and medical care providers have become far more aware of the effects social factors have on the health of individuals, families, and communities. As a result, many are actively building or looking for existing networks of social care providers to which they can refer individuals.  

All too often, however, this action amounts to simply handing individuals a piece of paper or sending them to a website that lists local social care providers in various categories-perhaps making an introductory phone call or sending a fax. After that, the referral is out of the payer’s or provider’s hands, which means they may not even know if the individual has sought out the help they suggested. 

As a result, there often isn’t much discussion or collaboration between members of the medical care team and social care providers, or even between two social care organizations. Health plans and providers gain little sense of which social care providers are doing the best job of connecting with individuals and getting them the results they seek. 

How Does Chronic Illness Affect SDOH Perceptions?

A scalable technology platform that has been proven useful by both medical and social care providers makes it easy to establish-and maintain-lines of communication between health plans/health care organizations and social care providers. With the click of a button, health plans/providers can make direct electronic referrals, instantly see whether individuals enroll with the social care provider, and track the specific outcome achieved at that organization. The social care provider can also easily measure which health plans and/or medical care providers are delivering the most referrals so they can intensify their partnership efforts with them. 

Referrals are a two-way street, however, so the platform also makes it easy for social care providers to refer their individuals to primary care, or a particular hospital or health system. This is important not just for the sake of the individual's health, but also for taking advantage of value-based payments. 

In order to reap the financial rewards, social care providers must first be in the game. The more they can build strong referral networks with health plans and medical care providers, the more opportunities they will have to earn the trust of those organizations. 

Once they earn that trust, health plans and providers will likely find additional ways for social care providers to help them, such as contacting Medicaid to get an individual who has lost his/her eligibility reinstated or helping them close care gaps by arranging transportation to a laboratory for a required test. Then it comes down to performance. 

Social care providers have always focused on delivering the services their individuals need to better their lives. The strength of these organizations has been their singular dedication to making things happen. What most have not been asked to do, or have even needed to do, is quantify outcomes and align their performance in a meaningful way to medical care outcomes. With payment shifting to value, however, they no longer have that luxury. The core of value-based care and reimbursement is the ability to demonstrate that a particular intervention had an impact on the overall health of an individual, and of course, the quality and cost of care. 

Take the example above of the individual whose Medicaid eligibility is deactivated. Without it, their only option for care is the emergency department (ED), which they will start to visit more often in the face of any medical issue-even for something as trivial as a cold. 

By getting the individual reinstated, the social care provider ensures that the individual once again has access to primary care and any medications needed, which means visits to the ED are either eliminated or at least greatly reduced. There is not only a health benefit but a financial benefit to this that can be easily calculated as the reduction in the number of ED visits per month multiplied by the predicted cost of an ED visit. Being able to track and report on this change means the social care provider may reap a portion of the shared savings. 

4 Ways Health Plans and Communities Can Address SDOH

Using a proven technology platform that places social care on the same plane as medical care gives social care providers a simple yet reliable way to report on the outcomes they’re helping generate, whether it’s ensuring an individual with behavioral health issues is taking his/her medications as prescribed, an individual with transportation challenges is keeping all of his/her health care provider appointments, or an individual with food security challenges is receiving a weekly delivery of healthy food choices and using them. 

Each of these activities-and many others-have a direct impact on health outcomes. Now, social care providers have a convenient, evidence-based means of reporting on them so they can demonstrate their value and potentially gain more funding than they ever could have in the grant system. Additionally, health plans and medical care providers can run reports to see which social care providers are delivering the best performance and outcomes so they can direct more of their patients to those organizations, rewarding excellence in a way that has never been possible before. 

Most organizations (and people) don’t like change and are often resistant to it. A framework such as the one we describe is ideally a shared, horizontally integrated, community-wide resource. Like street lights and telephone wires, it’s not a competitive advantage for one health system, health plan, or physician practice. In this model, moving toward value-based care holds the potential for social care providers to benefit tremendously so they can offer more and better services to more of the people who need them. 

The even better news is that they don’t have to figure out how to manage it on their own. By taking advantage of these new technology platforms and the underlying services they offer, social care providers can exponentially, and almost instantly, improve their ability to send and receive referrals as well as track and report on the results they’re achieving-creating a win-win for all involved. 

Through the lens of supply chain management, the technology connecting organizations across the continuum becomes the required foundational layer that’s creating the means to drive payment models between medical care providers and social care providers. This same technology layer allows for the measurement of the progress, performance, and outcomes delivered by all parties involved in a fully accountable network.

Now that we have these networks established, a service that sits between the payer or at-risk providers and social care providers can be implemented to manage the standardized payment mechanisms that allow the performing social care providers to continually grow their impact, sustainability, and performance. Since the technology mandates standards of performance, standards of information capture, and standards of process, it becomes easy to measure costs, performance, and outcomes in a transparent manner; we’re now able to use these standards to deliver value-based payment at scale: making the 

This new service not only manages the payment, but also the quality reporting, contracting, cost accounting, operational tools and systems, and performance management needed to standardize integrated medical and social care delivery across communities.

In the end, this is a win-win for all parties. The medical care community cannot take on this endeavor alone. We need social care providers to provide quality social care, the technology to support the connections and track the outcomes, and the new intermediary service to allow the seamless business and operational framework enabling these two industries to integrate to improve health care as a whole.

The technologies bridging the gap between social care providers and medical care providers.

How Technology Infrastructure Will Help Social Care Providers Transition to Value-Based Payment

The increasing emphasis on social determinants of health is 

 “health starts in our homes, schools, workplaces, neighborhoods and communities.”

It’s well-documented that health plan members are often treated “downstream” of where their health problems actually begin. This is especially true of economically disadvantaged people who face housing, transportation, food, and related social challenges that exacerbate their health problems and that medical care alone can’t resolve.

Because of this, communities across the country are investing “upstream” in social services that address social factors (sometimes called social determinants of health-SDOH) to help improve the long-term health of their most vulnerable citizens, many of whom receive their healthcare from public programs such as Medicaid.

However, community-based social service delivery organizations tasked with these goals vary in size, shape, funding sources, and level of community interaction. Some organizations are very collaborative and interact with other social services providers and medical providers, while other organizations are more isolated, and often do not collaborate or interact with others. And, most social service delivery organizations have little experience with the principles of value-based payment or using data-driven performance measurement or performance-based payment models.

Creating synergies between social service providers and managed care

To address those challenges, some MCOs are working with social service delivery organizations in a more formalized way to identify and address social issues for better patient care and outcomes.

For example, in New York’s Capital Region, we have recognized the extraordinary potential of social service providers to contribute meaningfully to the improved health of our communities.  We have funded activities that are focused on curating and managing a high-performing, regionally shared network of accountable social service delivery organizations. The technology-driven network, built on top of the 

 referral platform, helps these organizations migrate toward value-based care through the execution of risk-sharing arrangements and facilitation of referrals, plus services such as process optimization assistance, group purchasing, and back-office.

Social Determinants of Health Play Growing Role in Hospital, Payer Strategies

The benefits of this synergistic approach include improved health of the population, reduced preventable emergency department visits and hospital admissions, as well as generally improved regional economic conditions.

As a product of this collaboration, here are four ways that MCOs and social service delivery organizations can work together via a connected network to address members’ individualized social and medical needs toward better health:

 patients in real time to both clinical and social service providers, such as homeless shelters, benefit navigators, workforce development agencies, behavioral health providers, and food pantries.

 patient progress and receive automated feedback from partners to ensure care and services are received.

 with community-wide teams to ensure that both social care providers and medical care providers are on the same page regarding their shared patients’ progress.

 data, including structured patient outcomes to measure the network’s impact, such as time to service and effectiveness of care.

Ideally, these networks allow everyone to electronically refer between each other and close the loop on every intervention. Enabling all organizations in the network to work together as one community service team helps ensure that the needs have been addressed.

Once more states have developed these kinds of cultural and technical collaborations, the next step is to scale the concept across the country and transform the entire care delivery continuum into one that recognizes the role of social factors in population health and incentivizes health and prevention. It sounds like a big goal-and it is!

In fact, it’s such a big goal that states can’t be expected to achieve it on their own. A 

 by the Association for Community Affiliated Plans, a national trade association, found that making social determinants-focused collaborations more common requires enhanced agency collaboration at the federal level. The Association represents not-for-profit safety net health plans and the Center for Health Care Strategies (CHCS), a nonprofit policy center dedicated to improving the health of low-income Americans.

The report found common themes in how states leverage systems and partnerships-and structure authority and funding-to most effectively address social determinants. Although it’s common for state contracts with MCOs to include provisions around social determinants, many states do not clarify within the contract how MCOs can take advantage of flexibilities within federal law to address social determinants, according to the report, which examined Medicaid managed care contracts in 40 states, as well as 25 approved demonstration projects. While many states set goals for social determinants in contracts, comparatively few offer payment incentives.

The report concludes with several policy recommendations that would expand innovative programs connecting medical and social service providers. One recommendation, for example, calls for CMS to improve vulnerable populations’ access to health services and care coordination, as well as to clarify how MCOs can improve (and pay for) social interventions.

One suggestion to help make collaboration more common, the report notes, would be for CMS to approve more demonstrations that test social care strategies, and provide support for outcomes-based payment for social interventions.  That way, dollars are being used on proven and successful initiatives and models.

The role of social factors in achieving IHI’s Triple Aim

Expanding these MCO/social service provider networks creates and maximizes civic value. That’s because they respond to, rather than dictate, community needs by providing services that extend well beyond necessary and avoidable care and focus instead on improving health for underserved community members. Additionally, provider groups benefit from the reduced friction and greater reliability of referrals into social service delivery organizations.

MCOs that participate in an accountable, reliable, predictable social care services coordination network can make a sustainable impact in achieving 

, by improving population health by supporting the performance objectives of existing regional efforts, which in turn reduces total cost of care and improves patient, employee, and provider satisfaction.

 in Albany, New York, a nonprofit organization that is building a unique model for using technology and services to provide a coordinated network of community-based social service delivery organizations that managed care organizations can tap into to address social determinants of health in their beneficiary populations. Dr. Reider previously served in the Obama administration as the Chief Medical Officer and Deputy National Coordinator for Health IT at the Office of the National Coordinator for Health IT (ONC).

The answers lie in innovation, collaboration, and a national approach.