Here’s how three organizations targeted social determinants of health (SDoH) and accomplished improved health outcomes beyond the clinical walls.

During a live-streamed conference session led by Signify Health at the RISE National 2021 virtual summit in March 2021, panelists shared the innovative solutions their organizations have implemented in their respective markets to achieve true member centricity.

Kronkosky Charitable Foundation’s Alamo Area Community Network (AACN)

Cara Magrane, director of initiatives and partnerships, Kronkosky Charitable Foundation, shared the initiatives of AANC, a community referral platform, to bring together community-based organizations (CBOs), payers, providers, and funders in the Signify Health platform to impact the wellbeing and health of the San Antonio community.

AACN goes far beyond just an electronic referral platform, said Magrane. The community network strives to cultivate a deeper level of collaboration between nonprofits and funders to ensure CBOs and nonprofits, who have long addressed SDoH, have a voice at the table due to their critical work that has a fiscal impact on the community and health systems.

“Often, we’re very well intentioned as stakeholders, whether we are funders, or community-based organizations, or payers, and we really want to impact the SDoH realm of our world, however, in order to do so there’s a lot of silos to be broken down, there’s intense levels of communication and transparency that need to happen,” said Magrane.

In addition to increasing collaboration, AACN aims to identify patterns in client needs, capture SDoH, reduce duplication of efforts, identify gaps in services for unmet needs, and gather cross-sector evidence.

The community network also seeks further funding for community organizations. While organizations are currently funded through grants, the money is not robust enough to impact bigger system change, causing CBOs to remain dependent on funders, state systems, and local systems, she explained. To provide another source of income for organizations solving for SDoH, AACN aims to implement and impact Centers for Medicare & Medicaid Services (CMS) billing codes to ensure resources funnel down to CBOs.

While AACN just launched in September 2020, it could not have come at a better time amid the COVID-19 pandemic. As part of the San Antonio’s community recovery resiliency plan, the city was mandated to create an electronic platform for CBOs to connect people to services, which AACN was promptly able to provide, allowing the city to amplify and onboard an additional 50 organizations.

Humana’s Bold Goal

To double down on its commitment to improve the health of its members, Humana launched its Bold Goal strategy in a handful of selected markets, starting with the San Antonio community, which led to a collaborative partnership with the AACN and Signify, explained Jackie Rivera, population health strategy lead, Humana.

The goal: To improve the health of the communities Humana serves 20 percent by making it easier for people to achieve their best health.

“We’ve learned the significance of looking at social and economic factors and what impact those have on a person’s health. So, if 60 to 80 percent of what makes a person healthy is impacted by nonclinical factors, we have to look at the whole picture,” she said, noting the priority to focus on the integration of clinical and social care in the same ecosystem became very obvious. “Humana realized and recognized it wasn’t enough to just support community work as they address social health, but we really needed to look internally at our own workflows and processes and operations to figure out what we needed to do to change in order to be part of that conversation.”

In its approach to address social health, Humana sought programs and interventions that incorporated a social health lens to the work they do on an enterprise level. Six years after launching the Bold Goal strategy, the health plan has expanded to 16 communities, and by 2020 conducted 3.5 million SDoH screenings, provided 816,000 more healthy days for Medicare Advantage (MA) members in Bold Goal communities, launched strategic academic partnerships to support physicians, and delivered more than 1.1 million meals from March 2020 through the end of the year as a response to the COVID-19 pandemic.

Additionally, to ensure a closed-loop referral system, Humana launched its Social Health Access Referral Platform (SHARP) project, a technology that allows care coordinators to screen for SDoH, better connect members to community resources that address social health, and then understand the impacts on members’ clinical health outcomes, explained Rivera. Through its partnership with the AACN and Signify, Humana was able to implement SHARP throughout the San Antonio community.

Rivera credits Humana’s partnership with the AACN and Signify for the progress made so far. “We can’t do it alone; so, health care can’t drive this change just within the health care segment, community can’t drive that change just within the community segment,” she said.

“This approach truly does allow us to keep the member at the center of everything we do because we’re untangling this current disconnect our members face when it comes to achieving their best health. Instead of putting responsibility on members to seek assistance and guide their own path, through the partnership with AACN and Signify, we are better able to direct our members to community resources.”

Independence Blue Cross’ CommunityLink

Similarly, Independence Blue Cross launched its CommunityLink network in partnership with Signify in June 2020 to connect community organizations that aim to address SDoH in the Philadelphia area.

As one of the poorest major cities in the United States, Philadelphia has many challenges, including SDoH, said Julia Weatherly Sr., GM Stars program analyst, Independence Blue Cross, noting many people struggle with social issues beyond financial restriction. “People knew SDoH existed in Philadelphia, but people weren’t so convinced that they existed for people who had private insurance.”

Recognizing many of its Medicare members weren’t compliant with care measures such as mammograms or colonoscopies due to SDoH, Independence Blue Cross aimed to address the social and economic factors members faced. By developing its own SDoH questionnaire, the health plan was able to gain a deeper understanding of members’ social needs.

The CommunityLink network currently consists of 16 organizations, composed of smaller and local organizations as well as those on a national scale. These organizations are among those that Independence Blue Cross Medicare members would be likely be referred to as well as the organizations that the community turned to in times of need, said Weatherly.

“As we work through our members and we assess their needs, we’re starting to understand just how diverse people’s needs are in the Philadelphia area,” she said, noting the launch of CommunityLink amid the pandemic brought key social issues such as loneliness and mental health to light.  

So far, the community network has identified 3,200 needs and made 2,200 referrals to local organizations.

In addition to supporting the people throughout the Philadelphia community, CommunityLink also aims to support the organizations, said Weatherly. “We really want to understand the needs of our community organizations and find ways that we can support them in either opening up and doing more services or what they need kind of on the back end, what they’d like to see from the platform, how we can enhance their overall processes to help people in the communities.”