In 1965, Dr. Jack Geiger founded one of the first two community health centers in the U.S. in a desperately poor area of the Mississippi Delta. So many of his patients presented with malnutrition that he began writing prescriptions for food — patients could take the prescriptions for milk and meat, fruits and vegetables to the local supermarket, which would fill the prescriptions and charge the clinic pharmacy.

When the Office of Economic Opportunity, which was funding Geiger’s clinic, found out, they were furious — and sent an official down to Mississippi to inform Geiger that they expected their dollars to be used for medical care. To which Geiger famously replied: “The last time I checked my textbooks, the specific therapy for malnutrition was food.” [Excerpt from “Wellness is More than Not Being Sick” by Rebecca Onie, Chapter 18 in Creating Good Work: The World’s Leading Social Entrepreneurs Show How to Build A Healthy Economy edited by Ron Schultz]

Fifty-one years ago, what Dr. Geiger was addressing did not count as health care.

Addressing Social Co-morbidities

Fast forward to January 5, 2016. The Centers for Medicare & Medicaid Services (CMS) Innovation Center announced the Accountable Health Communities (AHC) model, which recognizes the same “social co-morbidities” that Dr. Geiger attempted to address decades ago. This is the first Innovation Center pilot to address this gap in the current delivery system by funding interventions that connect patients with the resources they need to be healthy. Through this model, CMS has at last recognized a broader and more realistic view of what counts as health care and brought 70 percent of the modifiable factors that influence health back to the table in a meaningful way (social, economic, physical, behavioral).

As noted in the CMS Funding Opportunity Announcement:

Historically, patients’ health-related social needs have not been addressed in traditional health care delivery systems. Many health systems lack the infrastructure and incentives to develop systematic screening and referral protocols or build relationships with existing community service providers. The Accountable Health Communities (AHC) model seeks to bridge the divide between the clinical health care delivery system and community service providers to address these health-related social needs.

Mitigating these social co-morbidities means recognizing that access to healthy food or electricity to refrigerate insulin is as relevant to achieving the goals of the Triple Aim as a diagnosis of obesity and diabetes. Specifically, the AHC model is based on growing evidence that addressing social co-morbidities through effective clinical community links can improve health outcomes (by mitigating the root causes of disease) and reduce cost (largely by reducing utilization of clinical health resources).

In short, the view of what counts as health care in the U.S. is beginning to shift toward Dr. Geiger’s, through both new care delivery and new payment models. The payment framework around the Accountable Health Community model and its different tracks requires providers and payers to think about how a value-based alternative payment world enables screening for and effectively addressing social co-morbidities.

Furthermore, the Accountable Health Communities model can also be seen as an extension of the health care sector’s commitment to patient-centered care and population health as a way to create greater value for the U.S. health care system. It is hard to imagine a truly “patient-centered” health system that ignores the reality of patients who are hungry, experiencing violence at home, unable to get to a medical appointment or go to the pharmacy, need behavioral health services, or are homeless. Moreover, it’s inconceivable to think we can move toward a sustainable value-based payment system that doesn’t have a clear strategy to address 70 percent of the modifiable factors of health.

This is a tremendous undertaking and the CMS funding for the AHC model represents only 1.57 percent of the Innovation Center’s $10 billion appropriation. There is massive opportunity to achieve far greater impact on population health, total cost of care, and clinical outcomes if other CMMI models incorporate social needs as a standard element in every model. Imagine the potential impact of these models if participants were required to integrate a social needs assessment strategy into their conceptual design.

At the same time, operationalizing the integration of social needs into care delivery will require more than incentives alone. For example, when the CMS chronic care management fee was first introduced in 2015, CMS estimated 35 million Medicare beneficiaries were eligible to receive these billable care-management services, but almost one year into the program the agency had received reimbursement requests for only about 100,000 due to practical implementation challenges on the ground. Developing a reliable and effective social needs screening and action program will require that health care institutions view their assets—infrastructure, process, tools, and relationships—through the lens of health, not simply disease, and deploy them accordingly.

Tip Of The Data Iceberg

For the last 20 years, truly innovative health care delivery organizations—from federally qualified health centers, to integrated delivery systems, to academic medical centers, to safety-net institutions—have tested different approaches to screening patients for unmet social needs as well as ensuring that those needs were met. The data and learnings from these initial tests affirm the achievability of doing this work in a high-quality, repeatable, data-driven way, but until social needs are increasingly integrated into the health system the scale, research, and innovation on this front will be not fully realized.

When health systems have incorporated social needs assessments, the results have enabled these institutions to more fully understand and act upon the drivers of patients’ health outcomes and experience and the relative strength of the community resource landscape:

  • Addressing patients’ unmet social needs is associated with clinically meaningful improvements in patients’ LDL-C cholesterol and blood pressure — the latter at a level greater than the threshold the FDA sets for a new drug.
  • When health care organizations assist patients in accessing basic resources, 69 percent of those patients are more likely to recommend their clinic.
  • One academic medical center assumed the screen positive rate for basic resource needs would reflect the clinic’s Medicaid population, which is just under 20 percent. The reality was that 58 percent of screened patients had a positive screen for basic resource needs.
  • One percent of available community resources are responsible for 50 percent of the successful resource connections made for patients.

Health systems should have this kind of data regarding unmet social needs and their resolution for their own patient populations/institutions. Operating in the absence of this information impairs their ability to achieve the results they need and want to deliver.

Five Steps To Address Social Co-Morbidities

Leading health care delivery organizations have enabled their patients to overcome bureaucratic, transportation, eligibility, language, and other barriers to secure the resources they need to be healthy. Their efforts offer critical insight into effectively tackling social co-morbidities:

1. Health systems need to commit to real clinical integration of social needs

The “population” in population health management is not composed solely of patients who are at high risk of being high cost. That’s a great place to start, but it shouldn’t be the only population targeted. The realities of patients’ lives inject themselves into patients’ health in all contexts.

One way to achieve clinical integration is by adding some basic fields capturing social needs information into the electronic medical record (EMR) — so that providers can approach every clinical encounter with the full set of information they need to understand patients’ health and deliver the highest quality clinical care.

2. Commit to developing a workforce that is truly focused on addressing social needs

It’s critical to have a core group of people whose responsibility it is to come into work every day to assist patients in navigating to the resources they need to be healthy. This cannot be something that is done only in the margins of already busy jobs.

This workforce could be community health workers, patient navigators, community resource specialists, or “promotoras,” but it could also be some of the hundreds of individuals who volunteer at health care institutions. Institutions can be creative in deploying other employees: engaging discharge planners not just to schedule follow-up visits to the primary care practitioner (PCP), but also to food pantries; or using financial counselors to enroll patients not just in Medicaid, but in SNAP benefits.

3. Commit to giving that workforce the information they need to do their jobs well

A comprehensive, searchable resource database is a necessity. Binders or Excel Spreadsheets last updated in 2011 do not work for information to guide patients’ clinical care, and will not work for their social needs either.

Automating resource connections through a technology platform enables clinicians and lay workforces to spend more time building relationships with patients and less time scrambling to find the resources they so desperately need. Implementations of an integrated, web-based client management and resource database has demonstrated a 43 percent increase in total resource connections, 55 percent stronger agreement by physicians that their clinic has adequate support to address patient resource needs, and a 60 percent reduction in the time it took to conduct a social needs intake.

4. Commit to follow up

Efforts to address social co-morbidities are unlikely to be successful if a physician simply tells a patient to eat healthy and exercise more, while ignoring the financial, language, information, and bureaucratic obstacles to making that advice actionable.

Weekly follow-up calls to patients produce a statistically significant increase in the odds of their connecting to the resources they need to be healthy. Patients who receive a follow-up call every 10 days demonstrated a higher yield of successful resource connections.

5. Commit to collecting and analyzing data

As yet, data on patients’ social needs have not been appropriately captured. Physicians know that their patients’ psychosocial needs exist, but are not able to access information about them.

In the short term, the industry can’t afford to wait for volumes of data about the precise impact of addressing social needs on clinical outcomes and costs. As with every other aspect of population health, including implementation of patient-centered medical homes, there will be a period of experimentation and exploration to figure out what works best in which settings. Health system leaders have been willing to bet on medical homes ahead of such data because the notion of team-based care oriented around patients makes sense.

These five steps provide an initial framework for re-designing a health care system when patients’ unmet social needs count as health care.

Ultimately, the Accountable Health Communities model is an opportunity to formally test a hypothesis around the impact of unmet human needs on quality and cost of care — and to realize better alignment between the economic realities of health care financing and what is right for patients. It recognizes that effective integration of social needs into the existing health care system is not a higher standard of patient care — it’s the minimum standard of person-centered care, one that has evaded the U.S. health care system from its inception but at last stands to be realized.