Conversations about providing better healthcare often focus on new diagnostic technologies, groundbreaking clinical procedures, or other transformative innovations in the hospital setting. These advances are certainly important, but they often overlook the importance of addressing whole-person care in the home and the community.
Payers, providers, and community organizations have traditionally struggled to meet these needs. Fee-for-service reimbursement models offer little incentive to make referrals for non-clinical, out-of-network, and community-based services. The recent push to improve documentation of social determinants of health (SDoH) represents an important step forward. Without a similar focus on improving care coordination and reimbursement, however, this practice only leads to increased referrals to agencies with limited resources to address an unanticipated increase in demand.
That said, there is mounting evidence that whole-person care is better care that improves health and well-being and reduces unnecessary utilization. More and more, meeting an individual’s behavioral, financial, and social needs with culturally congruent, community-based resources has been shown to bend the cost curve in the right direction. In particular, we see programs making a significant impact among Medicaid beneficiaries and other populations largely overlooked by the healthcare ecosystem.
Proven benefits for community-based partnerships
Three examples from Massachusetts and New York demonstrate the value of investing in community-based services as part of a larger strategy to provide whole-person care.
In New York, the Supportive Housing Initiative led by the state Medicaid Redesign Team has provided subsidized rent and other tenancy support services to more than 15,000 beneficiaries, focusing specifically on individuals with multiple comorbidities. Among participants in the program, overall Medicaid expenditures decreased 15%, emergency department (ED) visits dropped 26%, and the number of days spent in inpatient care dropped 40%. This shows how stable housing can have a substantial impact on clinical outcomes and the cost of care, not to mention quality of life and peace of mind.
In Massachusetts, a group of Federally Qualified Health Centers formed the Community Care Cooperative (C3) as a way of applying the principles of accountable care to community-based care. As the state’s only ACO founded and governed by FQHCs, C3 coordinates between health centers, community-based organizations (CBOs), and nutrition and housing programs to ensure the community’s health-related social needs are addressed. An impressive 93% of referred members have successfully connected to social services thanks to C3. This far exceeds the previously reported rates for successful referrals, which ranged from 5% to 33% when the burden was placed on the member to initiate outreach.
C3’s focus on social care has driven measurable improvements in population health. For example, data shows C3 has helped more diabetic members achieve their hemoglobin A1C goals, with an average HbA1c reduction of 0.9%. Additionally, fewer members need to go to the emergency room. C3 data shows the percentage of members who have visited the ED two or more times in the six months prior dropped 10 percentage points, from 41% to 31%.
Back in New York, Healthfirst’s Partnerships for Medical Outcomes program has created a network of CBOs staffed by members of the local community that can address a range of needs, from high-risk pregnancy to substance use to diabetes and hypertension management. Critically, CBOs receive referrals as well as reimbursements from Healthfirst and, with individual consent, can share data with Healthfirst that enables additional personalization of services. In one initiative, practices enrolled in the program were 24% more likely to meet HbA1c measures and 21% more likely to have high blood pressure under control compared to those not enrolled—providing a clear example of the benefits of community-based, culturally relevant support.
A blueprint for better care
These three examples may seem unique—but they do not have to be. Replicating this model in communities across the United States will increase access to better care and improve outcomes, especially among populations that have been underserved, overlooked, or ignored in more traditional care delivery models.
Replicating the models of the Supportive Housing Initiative, the Community Care Cooperative, and the Partnerships for Medical Outcomes also does not have to mean starting from scratch. Their success provides a blueprint for better care that consists of six intersecting components:
- A contracted network of CBOs that provides housing, nutrition, transportation, financial, and social support. Financial reimbursement for CBOs is important, as it ensures that provider organizations have a partner with the resources and capacity to accept the patients referred to it. Pharmacies should not be overlooked, given their role in supporting medication management.
- A commitment to evolving to value-based care and supporting the care coordination that goes along with it. Organizations must go beyond simply identifying and documenting SDoH and actually see to it that individuals receive the support they need from CBOs they trust. Stakeholders must agree on what value means and how to measure it, in terms of impacts on physical, behavioral, and social health and the total cost of care.
- Digital capabilities that enable collaboration and data sharing among all stakeholders—payers, providers, CBOs, patients, and caregivers—with an emphasis on support plans, shared outcomes, and how to close care gaps. Accessibility in native applications for all participants is a must-have; no one needs yet another login.
- A system with workflows that close the loop. Referral success rates of clinical-community referrals without structured programs in place tend to be very low (25% or worse). Your system must enable you to a) understand who has connected with services and b) automate workflows to follow up with members who aren’t successfully connected. C3 is a leader with its 93% engagement rate but is using its staff and technology to find those 7% of members who haven’t engaged to make sure no one is lost.
- Cleansed data sets for participating providers and opted-in individuals. This way, leadership gets a longitudinal view of program performance and can make more informed decisions about what initiatives to launch next. Plus, with the right predictive models in place, providers and CBOs can benefit from next-best-action recommendations for individuals at the point of care.
- A consent framework for sharing data that puts individuals at the center. It is imperative to balance the potential for more personalized service delivery with the desire for privacy. This is especially true for programs working with individuals who have struggled to build trust with traditional care providers in the past.
As our industry continues to pursue models of better care, it is important to remember what better care actually means. For many individuals, it is much less about what happens in the hospital and much more about how they receive care at home and in the community. Strong partnerships with CBOs—built on shared clinical goals, backed by shared financial incentives, and supported by shared technology resources—can help to ensure more individuals have access to the services they need to improve their health and their lives.
Scott Cleary is the president of Hyphen.