A recent report from the U.S. Government Accountability Office (GAO) found that social determinants are a major impediment to managing care for high-cost Medicaid beneficiaries. The biggest impediments include a lack of transportation to medical appointments, lack of stable housing, and inconsistent access to food and other basic resources (see Social Factors Are Primary Impediments To Managing Care For High-Cost Medicaid Beneficiaries). Additionally, a study by Kaiser Permanente found that 68% of their members—across commercial, Medicare, and Medicaid—have an unmet social need (see The 68%). The challenge then for provider organizations is to figure out how to best address these needs and turn that skill into an opportunity for partnerships with a payer.
At The 2019 OPEN MINDS Technology & Informatics Institute, I had the chance to hear from two organizations that have implemented innovative programs to improve access to social support services during the session, Expanding Access Through Technology: Innovative Approaches For Improving Access To Care, featuring Jeremy Blair, Chief Executive Officer, WellStone and Ellie Zuehlke, MPH, Director, Community Benefit and Engagement, Allina Health.
Both Allina Health and Wellstone first identified a need to increase access to social services. The organizations then designed a program to address access to those services. Only then did the organizations choose a technology to support the solution. Importantly, that technology allows tracking of program outcomes through data. By carefully tracking program outcomes, the organizations are able to measure performance and program success. The “success” data also allows them to pitch the programs to community stakeholders and get much-needed community buy-in (monetary or otherwise).
The key to success? Engage program staff in devising solutions to community problems and ensure that your internal processes are as efficient as possible. This is a formula to optimize team member effectiveness and to expand consumer access to care.
Increasing Access To Social Services
Allina Health is a mid-size health system located in Minnesota and Wisconsin with 12 hospitals and more than 90 clinics. The health system was awarded an Accountable Health Communities cooperative agreement with the Centers for Medicare & Medicaid Services (CMS). AHC identifies individuals with social service needs through the AHC Health-Related Social Needs Screening Tool. Individuals with social service needs are referred to community organizations and high-risk individuals receive more traditional case management and help accessing resources. Allina Health contracted with NowPow, an outside technology organization, to provide software that supports community referrals. Ms. Zuehlke explained the reason for the contract – Allina Health found that their case managers each had personal lists that they used to refer individuals to social services. By using an external vendor, they are able to outsource list maintenance and automate development of community resource information lists tailored to individual patient needs.
Over the course of a year in the Allina system, there were 211,594 unique individuals who were eligible for screening, 79% of those individuals were offered a screening and 58% actually completed the screening. A total of 21,800 individuals had at least one social service need. 60% of individuals with an identified need were food insecure, 47% had housing instability, and 33% had unreliable transportation. During the pilot phase of the program, Allina Health found that approximately 50% of individuals followed up with the organizations on their referral sheet. The next step for Allina Health is to increase the number of value-based payment arrangements they have to assist in covering the cost of the social supports program.
Improving Access For Individuals In Jails
WellStone is a community mental health center (CMHC) in Madison County, Alabama. One of the county’s major challenges is the number of individuals in the county jail with mental health conditions. Data shows that individuals with mental health challenges spend 15 months longer in jail than individuals without mental health conditions (see The New Asylums). To address the problem, the Madison County Sheriff joined the national Stepping Up Initiative, which is focused on reducing the number of individuals with mental illness booked into jails, shortening length of stays, increasing the number of connected to treatment, and reducing recidivism (see Stepping Up: A National Initiative to Reduce the Number of People with Mental Illnesses in Jails).
The sheriff’s involvement with Stepping Up opened the door to conversations with Wellstone about connecting inmates to treatment to expedite release from jail. One of the major problems identified was that individuals with mental illness often lacked housing and other supports outside of the jail, which increased their length of stay in jail. Wellstone developed a program focused on helping inmates re-enter the community. The process involves identification and screening of eligible inmates; treatment planning; approval of the treatment plan by a judge and the District Attorney; and release of the inmate to participate in treatment.
The Wellstone re-entry program runs for 12 to 24 months. During the first six months, transitional or temporary housing is secured, treatment services are provided, financial assistance is secured, and inmates receive vocational training. For the next six to 24 months, the Wellstone team finds permanent housing for the inmates and treatment continues. Upon completion of the program, the team recommends an aftercare program to the courts.
Implemented in 2018, the program has served 84 individuals and saved the county $1.5 million – seven times the initial investment. The recidivism rate of program participants is less than 4%. Program savings demonstrate a need for these types of programs and has been instrumental in expanding the types of programs offered for justice-involved individuals with behavioral health needs. Wellstone is currently developing a telehealth program to help police officers divert a mental health crisis when they are in the field and their success data is also allowing them to make the case for building a 24/7 crisis center.
These two examples illustrate that well-planned social service supports improve lives and reduce health and human service costs. For more on developing services that meet the social support needs of complex consumers check out these resources:
- Managing Chronic Illness & Social Determinants Of Health (SDoH) In A Community-Based Behavioral Health Setting
- Addressing Social Determinants: Impacting Health & Wellness Beyond Traditional Medicine (available on PsychU)
- Social Factors Are Primary Impediments To Managing Care For High-Cost Medicaid Beneficiaries
- Investing In SDoH Strategies: The Numbers Are In
- Addressing Social Determinants Of Health Via Medicaid Managed Care Contracts & Section 1115 Demonstrations
- Can Social Determinants Of Health Replace Traditional Utilization Management?: An Aetna Case Study
- CVS Health Launches New Social Care Network With Unite Us
- One Health Plan’s Partnership Approach To Social Determinants
- Northwell Partners With NowPow To Address Social Determinants Of Health
- Where Wellness & Prevention Fit In A Value-Based World
For even more, join us at The 2020 OPEN MINDS Performance Management Institute in Clearwater, Florida for the session, Key Performance Indicators For Value-Based Care: How To Use Performance Metrics To Build A Value Proposition For Health Plans featuring Blake A. Martin, MHA, Executive Vice President & Chief Development Officer, Monarch.