Uncovering and Addressing Disparities in Health-Related Social Needs, Social Needs Screening and Navigation
Using Data to Drive Change
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Associated Project
Accountable Health Communities: Identifying and Addressing Social Determinants of Health
Prepared for:
U.S. Department of Health and Human Services
U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services, Center for Medicare & Medicaid Innovation
Key Findings
- An AHC Project Officer shared that an early analysis of the AHC Model shows that racial and ethnic minorities are overrepresented in the navigation-eligible population.
- A staff member from Allina Health System shared how its screening data revealed that despite Black, Somali, and Latinx patients having twice the need for HRSN services, they were offered HRSN screening at 10% lower rates than White, non-Hispanic patients who spoke English as their first language.
- Allina Health System used these data as a launching point to engage with an equity team for process improvement and took lessons from the AHC Model to inform its system-wide efforts to effectively engage community partners and members to drive health equity.
- A staff member from Open Path Resources (OPR), a community-based organization serving local East African immigrant families and community members, described OPR’s partnership with Allina to address disparities in colorectal cancer screening through a multipronged intervention.
The Accountable Health Communities Model (AHC) from the Centers for Medicare and Medicaid Services (CMS) tests whether addressing Medicare and Medicaid beneficiaries’ health-related social needs (HRSNs) through screening, referral, and navigation services will reduce health care costs and use. The model addresses the gap between clinical care and community services and, over five years, has helped its participants test service delivery approaches meant to link beneficiaries with community services that address their HRSNs (that is, needs related to housing, food, utilities, interpersonal violence, and transportation). The presentation shares model-wide racial and ethnic evaluation findings regarding screening and navigation and ways to address them, highlights how one participant and its partners tried to reduce bias and discrimination in social needs screening, and explains how lessons from that experience inform the organization’s efforts to engage community partners to drive health equity.
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