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4 Ways Health Plans and Communities Can Address SDOH


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

Doctor with patient

The increasing emphasis on social determinants of health is based on recognizing that “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 Unite Us 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.

Related: 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:

  • Electronically connect 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.

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

  • Collaborate 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.

  • Capture 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.

Scaling the concept

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 December 2018 report 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 IHI’s Triple Aim, 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.

Jacob Reider, MD, FAAFP is CEO of Alliance for Better Health 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).

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