Lessons from a National Health Initiative that Helps Address Social Needs

[NATALIA BAROLÍN]

I think that there's increasing recognition, and certainly here at CMS, that if we want to have meaningful impact toward health equity, we need to take the lessons from the Accountable Health Communities Model and other areas to look at the bigger picture of how we address the demand for these services upstream.

[J.B. WOGAN]

I'm J.B. Wogan from Mathematica and welcome back to "On the Evidence," a show that examines what we know about today's most urgent challenges and how we can make progress in addressing them.

On this episode, we're going to talk about a national initiative aimed at improving people's health by practically identifying and addressing factors besides a medical condition that still affect a person's health. Some background is in order here. It is widely recognized that structural and contextual factors --the conditions in which people live, learn, work, and play – have a profound effect on people's health and wellbeing.

As a result of these so-called social determinants of health, many Americans have unmet health-related needs such as housing instability, safety needs, and food insecurity. Unmet health-related social needs can contribute to poor health outcomes, such as uncontrolled diabetes or cardiovascular disease, which in turn leads to avoidable health care use and increased health care spending.

Historically, these social determinants of health have put doctors, nurses, and other clinicians in a bind. They aren’t trained to treat social ills like homelessness or high unemployment. When their patients face these challenges, it can be difficult for clinicians to address the root causes of their patients' health care issues. Because addressing social conditions can improve patients' health, it is both in the best interests of the patients and the clinicians to do something about them.

One option is using a screening tool, like a questionnaire, which can surface the patient's health-related social needs. Providers can then refer patients to community-based organizations with the resources and expertise to help. The Centers for Medicare and Medicaid Services, or CMS, developed such a screening tool as well as a guide to assist providers who use that tool. The guide has been developed for a program called the Accountable Health Communities Model, which includes 28 organizations across the country.

But screening for health-related social needs has applicability beyond the Accountable Health Communities Model. To reach an even broader audience, CMS and Mathematica developed a public-facing version of the screening guide with promising practices for universal screening. In the show notes for this episode, I will include a link to that guide, which is also available on the website for CMS.

For this episode, my guests are Natalia Barolín from CMS; Maureen Kirkwood and Rafael Castañon of Health Net of West Michigan; and my Mathematica colleagues, Lee-Lee Ellis and Rachel Kogan. I hope you enjoy our conversation.

[J.B. WOGAN]

Today we're going to discuss the use of screening, referral, and community navigation to address the social determinants of health. Before we get too far into this discussion though, would each of you mind introducing yourselves? Say your job title, where you work, and what you do.

Natalia, let's start with you.

[NATALIA BAROLÍN]

Thanks, J.B.

I'm Natalia Barolín. I am the co-lead for the Accountable Health Communities Model here at the Centers for Medicare and Medicaid Innovation Center. In that role, I provide strategic leadership for model implementation and monitoring, as well as stakeholder engagement on addressing social determinants of health. I also have the privilege of serving as a Projects Officer to a few of our participant organizations, including Health Net.

[J.B. WOGAN]

Fantastic.

How about we'll go now to our folks from Health Net West Michigan, Maureen and Rafael.

[MAUREEN KIRKWOOD]

Hi, I'm Maureen Kirkwood. I'm the Executive Director of Health Net of West Michigan, and I serve as the Project Director for our Accountable Health Communities grant.

My name is Rafael Castañon, and I am the Partner Engagement Manager at Health Net and also a Project Manager. So I help work with the team that supports our partner sites through the Accountable Health Communities program.

[J.B. WOGAN]

Okay, great.

Lee-Lee and Rachel, why don't you finish up introductions.

[LEE-LEE ELLIS]

I'm Lee-Lee Ellis. I'm a Health Researcher at Mathematica, where I study delivery system reforms that aim to improve health. I work on the Learning System for the Accountable Health Communities Model, which aims to facilitate peer learning among the organizations that are participating in this model.

[RACHEL KOGAN]

I'm Rachel Kogan. I'm a Survey Researcher at Mathematica, and I work on a variety of health-related projects that include data collection and technical assistance. For the AHC model, I oversaw a revision of the Health-Related Social Needs screening guide that we geared towards the bridge organizations and, more recently, the version of the screening guide that's available to the broader public.

[J.B. WOGAN]

Okay, fantastic.

Rachel, let's stick with you; and let's start by explaining a little bit more about what a screening tool for unmet health-related social needs is. I think I've actually filled out one of these myself. So as you start describing it, maybe some listeners will discover that they too have encountered one of these screening tools in their health care experience.

[RACHEL KOGAN]

Yeah, J.B., they're actually pretty common. I've also completed a screening tool like this at my doctor's office. It's essentially a short questionnaire or survey that takes a couple of minutes to fill out. So you might see a question like, "In the last 12 months, have you worried that your food would run out before you had money to buy more food," or "How hard is it for you to pay for the very basics like food, housing, medical care, and heating?"

The responses to these questions will ideally enable your health care provider to pretty quickly see if you have any social needs that might be affecting your health.

There are a bunch of different ways that a person could complete the screening. You might complete it by using pen or paper or a tablet that your doctor's office provides while you're in the waiting room. Somebody could actually administer the screening to you and enter your responses into a database or your medical records. I don't think there's really a standard approach. Providers might use your responses in different ways, but the idea is that it could inform how your doctor provides care; or it might prompt a referral to help resolve your needs, like a referral to a food bank.

We don't have a clear picture on how common it is for providers to screen for health-related social needs like food and housing; but we do think it's becoming more common, especially as the evidence continues to show the value of addressing social determinants of health.

[J.B. WOGAN]

Okay, that's a great background about the general practice of using a screening tool to address unmet health-related social needs; but the folks on this call have had the benefit of direct experience implementing one of these screening tools in the field. In my intro, I mentioned the Accountable Health Communities Model.

Natalia, would you mind providing a little bit more background on the model and its use of the screening tool to address health-related social needs?

[NATALIA BAROLÍN]

Of course, thanks, J.B.

CMS launched the Accountable Health Communities Model in 20107. It's really a five-year model aimed to test whether systemically identifying and addressing health-related social needs among Medicare and Medicaid beneficiaries will impact health care costs and reduce health care utilization.

I wanted to also clarify that we refer to patients in our model as beneficiaries because they are enrolled in either Medicare and/or Medicaid.

When the model began, there was a rising interest in asking these questions in clinical settings; but as Rachel already mentioned, there were few options for standardized protocols or instruments to do this kind of work. So CMS developed a screening tool for our participating organizations to use as part of the model that would allow them to assess the health-related social needs of our patients or beneficiaries as part of the clinical visit.

As you mentioned in your introduction, we have 28 organizations participating including Health Net of West Michigan. We refer to them as "bridge organizations" because they really are the center of bridging the gap between clinical care and the community services to resolve those social needs. We're really proud that our organizations represent a diverse set of populations and types of organizations including several health plans, health information exchanges. We have a city health department participating, community-based organizations, and integrated health systems. They really do represent a good cross section of rural, urban, and suburban communities around the country.

One of the ways these bridge organizations work is to partner with clinical sites such as emergency departments, labor and delivery units, primary care practices, and really other places where people and patients access health care. In these settings, they screen beneficiaries for health-related social needs using the Accountable Health Communities screening tool that we developed.

When these needs are identified through the screening, then these clinical sites will refer the beneficiaries to resources in the community that can help resolve those needs – again, like Rachel mentioned, foodbanks with pantries, housing programs, transportation services, and things like that.

Then for our highest-risk beneficiaries, which we define as having two or more emergency department visits in the past year as well as one health-related social need or more, we connect them with community navigators who can really assist those beneficiaries in not just accessing those services but really helping them navigate them and get to a place where those needs can be resolved.

[J.B. WOGAN]

Okay, and then, Natalia, let me ask you another question – a little bit bigger picture here. Why is there such interest – more generally, even beyond this specific model – why is there such interest in identifying health-related social needs; and then, how does that relate to CMS's motivations for developing the Accountable Health Communities Model?

[NATALIA BAROLÍN]

Great question. I think many of us who have been in healthcare and doing this kind of work for a long time has seen that over the past ten years there's been an increased focus on the impact of social needs and, as you described, social determinants of health on health outcomes.

So combined with the alignment of financial incentives to encourage the healthcare system to address social needs through programs like value-based payments, we really felt that the environment was primed to experiment with reducing costs and improving quality by addressing social needs. So CMS really wanted to be a catalyst for this kind of innovation and help build the evidence base for addressing social needs.

Based on early findings from our first evaluation report, which is available on our website, the AHC model is really successfully reaching vulnerable populations. Our eligibility criteria that I described earlier is really targeting a high-use/high-cost population, and our navigation-eligible beneficiaries are also disproportionately likely to be low-income racial and ethnic minorities and, among our Medicare beneficiaries, disabled.

So we hypothesized that by addressing these needs, we can impact health outcomes and improve the overall wellbeing of this population while also decreasing the unnecessary health care utilization and increased costs.

[J.B. WOGAN]

Okay, Maureen, speaking from your perspective as the Executive Director of Health Net of West Michigan, why was it important for your organization to get involved in this model – in the Accountable Health Communities Model?

[MAUREEN KIRKWOOD]

Thanks, J.B.

Well, it was really a perfect fit with our mission. Our mission is pretty succinct. It's navigating care/connecting resources.

We are sort of a medium-sized, nonprofit organization, community-based, within a sort of medium-sized city and county in Western Michigan. Our vision is actually the actual definition of health equity. So our vision is creating community where everyone has a fair and just opportunity to be as healthy as possible, which is the literal definition.

We also have been doing this work for a number of years in our community, and this was really an opportunity to scale the work. So we pulled together a whole bunch of partners -- all of our health systems, we have three acute care health systems in our community; a bunch of community-based organizations; system partners, like the County Health Department and Community Mental Health. We held a big community meeting, and we presented the AHC opportunity and basically called the question – is this something that the community would like to apply for, do we all agree; and, number two, should Health Net be the applicant?

Really, the results to both of those questions were a resounding, "Yes!" Some of that is because of the relationship equity and the trust that we have built over the years with so many of the healthcare and community-based organization partners. But it really did seem like a perfect opportunity for us to really dive even deeper into this work.

[J.B. WOGAN]

Rafael, I think you mentioned earlier you're a Partner Engagement Manager at Health Net of West Michigan with Maureen. What does that partner engagement look like when it comes to working with clinical sites to screen for health-related social needs?

[RAFAEL CASTAÑON]

Thanks, J.B.

Health Net has 16 clinical partner sites. That includes emergency departments, primary care physician sites, behavioral health, labor and delivery, and dental sites. So to support our clinical partners in this process, Health Net has two staff members dedicated to supporting our clinical sites. These dedicated staff members develop the onboarding training for clinical staff. They develop the scripting used to offer the screening and the resource referrals. Health Net staff also created and printed paper resource packets organized by need for clinical sites to handout to patients with identified needs.

Health Net staff also visits sites monthly to review the processes at each site. We provide verbal support and encouragement to clinical staff. We also bring snacks because we like to show appreciation for our clinical partners. During those site visits, we also review data with supervisors; and we discuss any issues or roadblocks that that site might be having.

Health Net staff also organized quarterly consortium meetings with our clinical partners. In those meetings, we share data; we discuss successes and challenges. We also thought partnership around common issues, and we like to recognize the individual and specific clinical sites for their exceptional work during that specific quarter. So these are all efforts to support and uplift our clinical partners and their staff during this process.

[J.B. WOGAN]

Okay, and then we've talked a little bit about what a screening tool looks like. I'm curious what it looks like specifically in your experience with Health Net of West Michigan. So for the clinical sites that you partner with, Rafa, what does screening for these health-related social needs entail?

[RAFAEL CASTAÑON]

So screenings are offered by the clinical site staff, so they're not offered by Health Net staff. Screenings can be offered by patient registration staff, registered nurses, community health workers, AmeriCorps staff. It really depends on the resources available at each site. In any instance, the screening tool is going to be available in multiple languages; and screenings are either self-administered by the client, or staff read the questions to clients and then record their answers.

I should mention that during the public health emergency, many sites read the questions to clients and then recorded their responses either pre or post visit by telephone.

[J.B. WOGAN]

Now, when you say "client," we're talking about patients here or beneficiaries?

[RAFAEL CASTAÑON]

Yeah, so while the patient is meeting with their provider, the clinical site staff would then score the screening tool and gather the resource packets for any of those needs identified. Then before the patient leaves, the clinical site staff review the results of the screening tool with the patient and then offer those resource packets. Then eligible patients are offered navigation assistance through Help Net, and they receive a postcard kind of detailing that a Health Net navigator is going to be reaching out for assistance with any of the identified needs. It also provides Health Net's direct phone number if they want to reach out to us directly.

Clinical staff then send us the completed screening tool, and our Health Net navigation team follows up with the client in one to two days for navigation assistance.

[J.B. WOGAN]

Great, I'll give you a break here, Rafael, and turn to Rachel.

Rachel, I was hoping you could speak to what Mathematica's role has been in supporting screening for the Accountable Health Communities Model.

[RACHEL KOGAN]

Sure, well, I'll actually back out a little bit more, J.B., and tell you that Mathematica is the AHC model implementation learning system technical assistance and monitoring contractor. What that means is that we create various opportunities for learning from subject matter experts and for peer learning between the bridge organizations to help the bridge organizations think through how they're implementing the model to meet their patients' or clients' needs and to meet CMS project requirements.

So as part of this work, we've held annual meetings to bring together the bridge organizations. We did that in person pre-pandemic; now we are doing that virtually. We host other virtual events, like webinars; we conduct site visits; and we have developed a range of resources, some for bridge organizations and some for the general public. As part of that, our learning system work has really focused a lot on screening to help the bridge organizations think about how they want to do their screening; learning from learning best practices; and then kind of capitalizing or leveraging what other bridge organizations have determined are best practices for screening, whether that's workflows or COVID-19-related adjustments that they've had to make.

Another thing that we've done is we've developed case studies and spotlight reports that highlight the lessons learned and successes of bridge organizations. One of our recent spotlights described how a bridge organization launched an e-Campaign to screen their patients remotely via e-mail during the COVID-19 public health emergency. The spotlight described how this organization designed and implemented the state-of-the-art approach to continuing screening and addressing health-related social needs while people were avoiding in-person clinical visits and how they planned to continue this form of outreach. You can see more about this screening model on the CMS AHC model website.

[J.B. WOGAN]

I think we've established that AHC is the shorthand acronym for the Accountable Health Communities Model for listeners to just know that whenever we say "AHC," that's what we're referring to.

Rachel, I want to stick with you for one more question. Earlier in this year, as I mentioned in the introduction, Mathematica and CMS released a guide on how to use the screening tool developed for the Accountable Health Communities Model. Why was there a need for such a guide, and how can it inform ways in which the tool is used?

[RACHEL KOGAN]

Screening for health-related social needs is really the crux of the Accountable Health Communities Model, the AHC model. We know that screening can be applied much more broadly. We think that the lessons from the AHC model can be useful to any provider really, and we created the screening guide to share promising practices from the AHC model about how to screen people for health-related social needs.

J.B., I think I mentioned earlier that one thing that the new guide emphasizes is that there are really a lot of different ways to administer the tool. Patients can complete the screening on their own; they can have a proxy, like a parent or a caregiver complete it on their behalf; or they can have questions read to them by a staff person administering the screening. Really, anyone can be trained to administer it.

In the AHC model, bridge organizations are using different approaches to fit the needs of their particular setting and staff availability. So I think Rafa referred to this earlier. Some sites are training community members while others are using patient representatives, registration staff, community health workers, nurses, or student interns. Screeners really have a very wide range of backgrounds, and the screening tool can be administered in-person during a clinical visit; electronically through a secure system. It could be administered by phone – I know Rafa referred to that – before or after a clinical visit.

The flexibility for screening administration has really allowed us to be adaptable in the model during the pandemic, and that's been super important for keeping the work going.

[J.B. WOGAN]

Natalia, let me turn back to you. Why was CMS interested in releasing this new version of the screening guide, which is intended for public consumption?

[NATALIA BAROLÍN]

Sure, you know I think Rachel really covered a lot of that. What I'll add is that since we announced the Accountable Health Communities Model in 2016, the healthcare system has really evolved significantly in incorporating social needs screening referral and navigation activities. We've also seen that many payors outside of CMS are starting to provide incentives for providers to focus on population health and individual social needs. We also get a ton of requests from other stakeholders for using the screening tool and for lessons learned around how things have been going in terms of our implementation.

So it really felt like our responsibility to share those lessons and to really share that out with the public and other folks who are interested in doing this work. Although CMS originally developed the tool specifically for use within our model, it really is appropriate and widely applicable for broader use, like I said. I think Rachel and Rafa have shared some examples of that already.

The questions we use for our AHC tool come from a variety of other validated tools that are out in the public domain. Our tool we just feel really facilitates the ability to screen patients who are seen in clinics, hospitals, and other health care settings; but it's really applicable to screen patients/beneficiaries with any type of insurance status, not just the Medicare and Medicaid beneficiaries, and even in other settings outside of healthcare.

We've already provided and learned valuable learnings and learned so much from our four-and-a-half years of implementation that we really wanted to help put this information out there to inform practice in other areas. That's a real big priority for us at CMS. So we really see the screening guide itself as a vehicle to share those lessons learned from our model implementation – including the promising practices for screening for social needs; considerations for special populations; and highlighting some of the adaptability of the screening and referral for different settings, populations, and workflows.

I think one of the greatest lessons learned we've had has been in terms of its adaptability through the COVID-19 public health emergency.

[J.B. WOGAN]

Okay, that's really interesting. One of the things you said that I picked up on was that this might be used in contexts outside of the Medicare/Medicaid programs or even outside of the health care context. Are there such screening tools in practice right now that are in a non-healthcare setting?

[NATALIA BAROLÍN]

The AHC model screening tool – and our model was designed to only be used in a clinical or healthcare setting. There are other tools out there that I think are being integrated in community-based settings. I do think that there is increasing interest and I think focus, and rightfully so, to bridge the gap between those community organizations and healthcare and helping to ensure too that healthcare settings are able to understand the impact of social needs on the wellbeing and the health of the patients that we're working with.

So while I do think there are probably some settings that are using tools outside of healthcare, I think one of the areas we really look to address in the AHC model is in bridging the gap between those community services and providing holistic and health care that really looks at the bigger picture of a patient's life and wellbeing.

[MAUREEN KIRKWOOD]

J.B., could I add something to that answer?

[J.B. WOGAN]

Please do.

[MAUREEN KIRKWOOD]

Thanks, this is Maureen. We actually do do screenings in a variety of different settings in our community. There is certainly some overlap in the types of questions that are asked; but often, we will have community-based organizations screen and ask questions about health care access or dental or other things that would, again, have us as the bridge organization help people navigate the healthcare system itself. So there's in our community a great deal of this type of screening for social needs going on. It hasn't been maybe as systematized as what we're implementing in healthcare clinical delivery sites, but it certainly is happening frequently in our community.

One thing that strikes me as this conversation is going on is that this is a tool for getting at the whole person and what's happening, not just medical conditions but other factors that could affect a person's health. You could also look at it from the other side. Like if you were asking students or parents of students to fill out a questionnaire, you might find out that there are health issues that are affecting a student's academic performance or behavioral issues. So it seems like a questionnaire that's getting at beyond just the one-policy area to figure out what other parts of their lives are affecting education or health or wellbeing overall.

I think that – I mean, you speak about parents filling out on behalf of children. One of the parts of our work is really focused on the early childhood space in our community. Of course when parents are answering, they're answering for the family. So what we're finding is that even if they're answering screening questions about a child, what we end up doing is providing navigation services for the entire family because of course the health of the caregiver or the parents is going to be tied to the health of the child in terms of living situation, mental health issues, et cetera. So it really does end up being a more holistic approach in a variety of different settings.

[J.B. WOGAN]

Gotcha.

Lee-Lee, I have not had a chance to ask you a question yet. As one of the health researchers leading Mathematica's work on the screening tool and guide, I was wondering if you would mind sharing more about some of the promising practices described in the screening guide and how Mathematica identified them.

[LEE-LEE ELLIS]

Sure, I'll start by talking a little bit about how we identified the promising practices; and then I can talk more about what we cover in a screening guide.

Now, as Rafa alluded to earlier, when bridge organizations began working on the AHC model back in 2017, they really had to navigate a lot of new territory in terms of thinking about what staff they were going to hire and how they were going to train staff and developing workflows around screening and then of course figuring out how to engage patients in screening. So in many ways, the bridge organizations that are participating in the AHC model were pioneers; and there's a lot that we think other organizations that are interested in screening could learn from them.

So we put together the screening guide by drawing on all this feedback that we have gathered at Mathematica from working with bridge organizations over the last several years and hearing about their experiences with screening. For example, during one of our annual meetings with bridge organizations, we conducted a brief survey to learn about their experiences using the AHC screening tool. We wanted to know what was working well and what were some of the unforeseen challenges that they've encountered.

The results showed that some of the organizations wanted more guidance on inclusive practices for screening. As a result of that survey, we added some gender-inclusive language into two of the versions of the screening tool; and the screening guide includes a section on inclusive practices. We think that screening guide is really a great venue to share some of these learnings and insights to support health-related social needs screening outside of the AHC model and really elevate the importance of screening.

I think as Natalia and others have already mentioned, these learnings and insights would apply whether or not an organization is using the AHC model screening tool or one of the other social needs screening tools out there. So we do think that these learnings have pretty broad applicability to other organizations that are interested in screening.

Now I can talk a little bit more about the promising practices we cover in the screening guide. The promising practices in the guide include tips for getting screening off the ground -- like how to cultivate staff buy-in and develop staffing models and train staff on screening, as well as how to create a safe space for patients to respond to questions.

For example, we discussed the importance of sharing patient success stories specifically around screening and referral to Social Services and how by sharing those stories, this can motivate staff to offer screening; and it can help patients engage in screening.

Another example that's related to some of the comments that others have already made is around developing staffing models for screening. Some organizations use existing staff; others use volunteers; and some hire new staff that are specifically dedicated to screening. There are certainly pros and cons of each of these staffing models. Hiring dedicated staff does require time and funding; but it can also help avoid overburdening existing staff, which be really critical for staff that are already stretched thin. So we offer some guidance that organizations can think through in terms of thinking about what staffing model might work best for their organization, given their organization's strengths and resources.

The guide also discusses how to develop tailored scripts to engage patients and help patients feel comfortable to participate in screening. We discuss creating an inclusive and welcoming environment for screening. We also talk about anticipating the needs of particular patient populations, including patients that speak languages other than English; people with disabilities; patients with behavioral needs; and sexual and gender minorities.

Finally, the guide includes strategies for assessing and improving the screening process. This really draws off what we've learned from bridge organizations that have been working to improve their own screening efforts over the course of the AHC model.

One example we share in the guide is how one bridge organization used a quality improvement process to improve screening in one of its emergency departments. This organization wanted to improve low screening rates at this emergency department. So they used quality improvement methods to try to determine why they had low screening rates, and they found that many of the patients that were coming into the emergency department weren't being offered screening.

So they did some more investigation. They realized that it was because the schedules of the screening staff did not align with the hours of highest patient volumes in that emergency department. So through this quality improvement process, they were able to shift the hours of their staff to align with the times that the emergency department was busiest. That allowed them to see and observe more increase in offers to screen and then, in turn, in their screening rates.

So these are some, but not all, of the promising practices we cover in the guide.

[J.B. WOGAN]

Rafael, as you heard Lee-Lee providing that overview of best practices across grantees participating in the Accountable Health Communities Model, did any resonate with you and your experience in Michigan? What screening strategies have worked particularly well for Health Net of West Michigan?

[RAFAEL CASTAÑON]

Thanks, J.B. So many of them did resonate with me, and one was around cultivating staff buy-in. I think that's very important, especially as the newness of the process goes away and it can start to feel kind of repetitive. One way to maintain engagement is by sharing client outcome data and some of those clients' successes with your clinical partner sites at all levels of the organization. So that includes managers but also frontline staff. It's just so everyone can kind of see the positive impact that this work is having on their clients.

I think another important one that Lee-Lee mentioned was around continuous improvement. I think that's also very critical. It's great to have an opportunity to talk to clinical sites about the issues that they're having and kind of thought partner with sites to kind of overcome their challenges and really turn those challenges into successes for the sites that are screening.

Some of the things that we've seen success with is sites that have dedicated staff offering the screening, scoring, and resources to clients. They have a lot of success in building trust and creating that safe space for clients because the screening questions can be personal.

Screening patients by phone or post visit has been a very successful tool during the public health emergency for screening patients at clinical sites.

[J.B. WOGAN]

Then, Rafael and Maureen, sticking with the theme of what worked well for you and your partners, can you think of any cases where the screening tool made a positive difference in the life of a client?

[RAFAEL CASTAÑON]

Sure, so there was a client – we'll call her Patty for our purposes. Patty was a mother who was referred to Health Net through one of our AHC partner sites. Patty had some identified needs around food and nutrition, financial strain, and some environmental concerns with her current housing. When Patty was speaking to her Health Net navigator, the Health Net navigator said that Patty had mentioned that her biggest challenge was not having enough knowledge about available resources in the community.

So as Patty and her Health Net navigator worked together, our navigator recognized that Patty was driven to be very self-sufficient. Patty requested info about budgeting and financial counseling so she could work towards financial stability. Our Health Net navigator completed some referrals to Patty. One was for a local food club that had healthy food options, and another was a community service provider that specialized in home inspections and repairs.

So Patty contacted and followed up with each of these agencies after the referrals were sent. Our Health Net navigator provided the info about budgeting and finances to Patty, and Patty organized that info so that she could find it later. Patty was able to apply for budgeting classes by herself.

So at the beginning of our first meeting with her Health Net navigator, Patty was really overwhelmed and concerned about available resources; but through working with Health Net, Patty's confidence increased as she became more and more financially stable. Our Health Net navigator walked alongside Patty and witnessed her growth, determination, and confidence increase through the process. Patty was able to move towards self-sufficiency, and she was able to care for her family.

[J.B. WOGAN]

Thank you, Rafael.

Not to pick on you all too much but, Rafael and Maureen, I'm hoping you'll take one more question. This one is about the future. Given that the Accountable Health Communities Model is coming to a close, what does that mean for organizations like Health Net of West Michigan; or what does it mean specifically for Health Net of West Michigan and continuing your work on addressing health-related social needs?

[MAUREEN KIRKWOOD]

Well, we are definitely going to be continuing. As I mentioned earlier, this is work that we had been engaged prior to this funding opportunity; and it's definitely allowed us to scale, but we're continuing and even expanding. Right now, we're working actively with our Advisory Board for this project to look at ways to sustain. We're basically asking all of our clinical delivery sites, "Would you like to continue this work; if so, what would you like to see done differently or improved?"

We have great enthusiasm from our partners to want to continue this work because they've really seen the value over the last three-and-a-half years that we've been actively doing the screening. Some of the things that our clinical delivery sites would like to do is expand to do the screening with additional populations beyond just Medicaid and Medicare beneficiaries.

One of the things that’s a challenge in a busy emergency department is patient flow, and having to determine who the patient's insurer is takes time away from just being able to universally administer the screening. So that's one of the things that one of our partners are pretty excited about.

So, yes, we're definitely continuing; and I think this is really moved the work forward significantly here in Kent County.

[J.B. WOGAN]

Natalia, as the Accountable Health Communities Model winds down, how are learnings from the model informing the way CMS thinks about health-related social needs and the broader social determinants of health; and can we anticipate the development of similar models in the future?

[NATALIA BAROLÍN]

Sure, you know this is such an exciting time as I think the importance of social needs and the bigger picture related to equity and taking care of our most vulnerable -- that conversation has really been elevated. So I think it's a really great opportunity for the Accountable Health Communities Model to help inform how we do this work. It will be really exciting as we get our final evaluation results in the coming years.

In the meantime, we hope that the screening tool or guide, as well as other products and things that we are disseminating with lessons learned, are really going to help inform how health care providers, payors, and our community-based partners address these social needs and that the learnings really help spark more coordination between these traditionally siloed systems.

I can say that addressing health-related social needs and equity is truly a CMS priority. HHS at the broader level is planning to use our evaluation results and lessons learned to inform how the Department addresses social needs and health equity across all of its programs – so not just restricted to CMS.

Here at CMS, we're also exploring opportunities to incorporate these lessons into the models implemented by the Intervention Center and as we develop the lessons we've learned through AHC to apply a lens of kind of a more holistic approach to health care and looking at what we can take from AHC to really inform and drive how we do all of our work.

I will add that one way that CMS is trying to drive change in this area is through alternative payment models. Those are models or ways of paying for health care services that differ and take us away from the traditional fee-for-service reimbursement that tends to promote volume over value. So through these alternative payment models and value-based payment models, CMS and commercial and private payors are able to incentivize this kind of transformation.

For example, I'm going to refer them as APMs, alternative payment models, can be the link between the traditional healthcare system and broader social service delivery systems. Often these two systems are driving toward the same goal but operating separately, right? So historically as a healthcare system, we haven't done a great job connecting these two; and we see APMs as a way to fund and reward a stronger integration of these systems incentivizing greater coordination of healthcare, social services, and really bringing better quality and value to our patients.

I'll also add that early results from the AHC model – again, very preliminary and we have a lot more data to get from our partners and also to process – but early results are encouraging. We are showing a 9% reduction in emergency department visits among our Medicare fee-for-service beneficiaries and our assistance track. I think as we mentioned earlier, the first evaluation report is available on the website. We'll have additional quantitative and qualitative evaluation results that will be available in 2022 after the model comes to a close.

[J.B. WOGAN]

Okay, great.

We've run through my battery of questions. I want to give everyone an opportunity to offer parting thoughts for the listeners. Anything else that they should know or should be thinking about in terms of the future of using a screening tool like this to address the social determinants of health and health-related social needs? Maybe you can – other tools that should be in our arsenal beyond just the screening tool.

Natalia, do you want to kick us off?

[NATALIA BAROLÍN]

Sure, I guess one thing that I want to make sure to highlight here is that while addressing social needs is really necessary, and the work of AHC model I think has been really critical to advancing this work, it's not sufficient. I think that there's increasing recognition, and certainly here at CMS, that if we want to have meaningful impact toward health equity, we need to take the lessons from the Accountable Health Communities Model and other areas to look at the bigger picture of how we address the demand for these services upstream – meaning how can we examine the structure of systemic factors that create and exacerbate these social needs and really start to change the way that we do this work, the way that we structure the work that we do and that we serve our patients so that we're not only putting Band-Aids on the problems, but we're actually helping to resolve the problems before they even occur?

We're really encouraged by the commitment that we're hearing from our new CMS Administrator Chiquita Brooks-LaSure. She and our Innovation Center Director Liz Fowler recently were on Health Affairs sharing the strategy, which they've shared publicly; and we really feel that this is providing the wind in our sails to rethink how we do our work that really helps address those broader systemic drivers of inequity.

[J.B. WOGAN]

Terrific.

Any other parting thoughts from the rest of the guests?

[MAUREEN KIRKWOOD]

This is Maureen. I definitely heartily, heartily second all of Natalia's comments that, yes, this is a major step, the screening and the navigation; but it is not really addressing the root causes. So anything that we can do to move it upstream is absolutely necessary.

I guess my thought is that it's so important – this podcast is focused on the screening process. But one of the things that we've really learned in our years of working with health care providers is that it's important to not just screen but of course also have those resources in place for the navigation to social needs services because healthcare providers are not going to want to screen if they don't have anyplace to send people. Because then it's sort of like, "Well, here, tell us all your problems. Well, thank you very much and see you later." Of course that's not the message that any of us wants delivered.

So it's so important to have the process for navigation to the resources after the screening happens in place in order to have this be an effective method to add to the health care providers' menu of services they can provide.

[J.B. WOGAN]

Lee-Lee and Rachel, anything from Mathematica's perspective?

[RACHEL KOGAN]

This is Rachel. I don't have a whole lot to add that Natalia and Maureen haven't already said. We're very excited that the screening guide will be publicly available and that community services providers and clinical providers will be able to use it. But it's really a Band-Aid approach; it's not a systems approach. It helps providers think about what health-related social needs are that can impact the health of individuals. It's not addressing the larger upstream inequities that Natalia and Maureen have already talked about.

[J.B. WOGAN]

Okay, but it is at least a first step in a way of documenting what some of these social issues/social needs, are and giving us a sense of the extent to which there are demands that need to be addressed upstream.

[RACHEL KOGAN]

Absolutely, and we're really excited about the screening guide and the screening tool because we think it can be used very broadly; and we think that identifying, referring, and navigating to community service providers to address those needs will improve individuals' health outcomes.

[LEE-LEE ELLIS]

Yeah, this is Lee-Lee. I'm just going to add that I think at the very least we've found that screening itself can help communities identify what social needs exist in the community, and it's an important step towards that process of then identifying where there are gaps in services and where we might be able to strengthen community resources to then refer people to. So it's exciting to see this guide out there as a way that organizations at sort of any step of the process – maybe they haven't really thought about screening or it seems too onerous to take on – can really approach this and have some guidance to meet them where they are to try to move the needle forward in this area.

[NATALIA BAROLÍN]

J.B., I wanted to say one last thing to your point – that we absolutely have to address these. We are talking about these further upstream systemic issues that create these problems. We can't just abandon these individuals who are struggling and have needs that have really been created and exacerbated by an inequitable system. So we do absolutely have to be meeting those needs while simultaneously exploring and doing better at resolving the systemic and structural inequities that exist.

[J.B. WOGAN]

All right, that's a great note to end on.

Thank you, everyone, for your time today and for talking about the screening tool, the guide to the screening tool, and the larger issues that they're designed to address.

[J.B. WOGAN]

Thanks to my guests, Natalia Barolín, Maureen Kirkwood, Rafael Castañon, Lee-Lee Ellis, and Rachel Kogan.

In the short notes for this episode, I'll include links to the screening tool and guide and other related resources so you can learn more about the screening tool and guide that we discussed.

As always, thank you for listening to another episode of "On the Evidence," the Mathematica podcast. If you enjoyed this episode, there are a few ways you can keep up with the show. You can subscribe wherever you find podcasts, or you can follow us on Twitter. I'm @JBWogan. Mathematica is @MathematicaNow.