Many health care organizations are establishing programs to address the social needs of their patients and members in response to the growing recognition that personal, social, economic and environmental factors have a greater influence on health status than medical care. RISE looks at some of these efforts, including the Centers for Medicare & Medicaid Services’ data-collection initiatives, and Kaiser Permanente’s rollout of a social health network to address needs on a broad scale.
CMS urges use of new resources and existing tools to address social needs
Last year Alex Azar, secretary of the Department of Health & Human Services, made headlines when he announced that the federal agency was interested in paying for services that address social determinants of health. CMS has since issued new guidance that allows Medicare Advantage plans to offer chronically ill patients supplemental benefits tailored to their specific needs, such as providing meals and offering transportation for non-medical needs like grocery shopping.
Before organizations can address the social determinants of health of their patient population, they must first identify patient needs and measure their impact. To do so, Cara V. James, Ph.D., director of the CMS Office of Minority Health, wrote in a recent blog post that clinicians should use existing tools and resources to help identify patient needs, such as:
- ICD-10-CM Z codes, which include codes for problems related to education and literacy, housing and economic circumstances, and certain psychosocial circumstances
- The Accountable Health Communities (AHC) Health-Related Social Needs Screening Tool
- The PRAPARE tool (Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences), developed by the National Association of Community Health Centers
- Health Leads Screening Toolkit
“Data collection will help us strengthen our understanding of the relationship between social determinants of health and healthcare use across diverse populations, allowing us to develop solutions and better connect patients to much needed services,” wrote James.
CMS is also testing an Accountable Health Communities Model, which aims to promote clinical-community collaboration to support connections between care, food, and housing for patients in need. Thirty communities are testing the model over a five-year period to determine whether identifying and addressing social needs can reduce costs and healthcare utilization among Medicare and Medicaid beneficiaries.
Kaiser Permanente, Unite Us launch social health network
Kaiser Permanente recently announced it will join forces with Unite Us, a social care coordination platform, to connect healthcare and social services providers to help address patient needs for housing, food, safety, and utilities.
The new Thrive Local network will roll out this summer and the non-profit, integrated health system predicts that within three years it will be available to all its 12.3 million members as well as the 68 million people who live in the community that Kaiser Permanente services. The network will track community partner referrals and service outcomes to measure the degree to which participants’ needs are met, gathering data to continuously improve service delivery and better address community conditions for health.
In addition to being integrated into Kaiser Permanente’s electronic health record system, community-based organizations will also have access to Thrive Local’s resources so they can reach the broadest possible group of those in need.
“By integrating this network into our clinical care, our members with unmet social needs will be connected to community services more efficiently,” Bechara Choucair, M.D., chief community health officer, Kaiser Permanente, said in the announcement. “In addition, Thrive Local will be open to community health centers and community-based organizations to improve social health access for the entire community.”
RISE examines partnerships, resources that impact health outcomes at national summit
RISE will take an in-depth look at successful collaborative projects that address members’ social needs at the National Summit on Social Determinants of Health, June 23-25, in Washington, D.C.
Speakers will include:
- Eric Epley, executive director, Southwest Texas Regional Advisory Council for Trauma, which has partnered with local law enforcement, EMS, and behavioral health facilities in the San Antonia area to develop a program to help navigate medically stable psychiatric emergency detention patients to the nearest, most appropriate facility
- Sandra Viera, associate program director, Prevention Institute, and Jason Lacsamana, senior program officer of Joseph’s Health Community Partnership Fund, who will discuss how to address social determinants of health through policy and systems change
- Douglas Jutte, executive director, Build Healthy Places Network, who will present on community health and revitalization through housing partnerships
- Eileen Evert, senior director of health and wellness, Geisinger, and Rich Farr, Rabbit Transportation, who will provide a joint presentation on collaboration to implement a transportation pilot
- Michael Monson, senior vice president of Medicaid and complex care, Centene, who will discuss how to create and secure a sustainable financial model for social determinants of health.
For more information on the agenda and speakers, click here.