October 10, 2017

Addressing Social Determinants of Health in the Medicaid ACO Program

Medicaid ACO Social Determinants

Primary care offices provide resources on a variety of topics that connect patients to helpful services offered across the state.

Social determinants of health, which are defined as the conditions in which people are born, grow, live, work, and age, play a major role in impacting health. Over the last two decades, a growing body of evidence has shown that social and economic factors, such as education, food security, housing, and income, as well as the environment can affect the risk of disease and health outcomes. They can even play a role in premature death. These factors, combined with health behaviors, have been estimated to account for eighty percent of a person’s health outcomes. With the rollout of the new Medicaid ACO program, Partners is developing a network-wide strategy to better screen patients for social determinants of health, and for those who need it, provide more tailored care with additional targeted resources and support services.

Partners is currently one of six organizations in the state participating in the Medicaid ACO pilot. Similar to federal ACO programs, the MassHealth ACO aims to move from a fee-for-service model, where providers are paid for each service, to an accountable care model where care is better coordinated and physicians are rewarded for providing high quality care while keeping costs under a target. Over the past nine months, Partners has built out existing population health programs in care managementbehavioral health, and substance use disorders and has expanded the role of community health workers, social workers, and recovery coaches to provide more tailored and individualized care to MassHealth patients. The pilot will likely end December 2017 and the full program will begin in March 2018 – this means Partners will be expanding its coverage from 20,000 MassHealth patients to more than 100,000 patients across the system.

“We look forward to offering these expanded population health services to our entire Medicaid population,” says Eric Weil, MD, Chief Medical Officer for Primary Care at Partners Center for Population Health. “As we continue to build out these resources, we are shifting our focus to areas that we know are still lacking – like addressing social and economic barriers.”

One of the requirements of the Medicaid ACO, which is called ‘Partners HealthCare Choice,’ is to screen patients for social determinants of health and to provide appropriate follow-up services. Although many community health centers and practices across Partners already address social determinants of health, there is no formalized system-level strategy in place. With the Medicaid ACO, and anticipated funding received from the state, Partners is leveraging existing resources to create an infrastructure with support services that will benefit not only patients, but providers and primary care practices as well.

The social determinants questionnaire, initially developed under the leadership of Drs. Cheryl Clark and Anne Thorndike, funded through the Brigham Care Redesign Incubator Startup (BCRISP) program, has already been used to screen patients at Southern Jamaica Plain Health Center and Brookside Health Center. It is now being piloted, as part of the Medicaid ACO, at several Massachusetts General Hospital (MGH) primary care practices including Revere HealthCare Center, Everett Family Care, and Charlestown HealthCare Center. The questionnaire asks patients if they are experiencing barriers with housing, transportation, child care, food security, community safety concerns, and other areas. To make it easier for both patients to fill out and for providers to respond to and track positive screens, the social determinants questionnaire has been incorporated into the Primary Care Annual Visit Questionnaire, which patients can complete from home using our secure patient portal or in the clinic on a tablet prior to the appointment.

“Once the patient completes the questionnaire, the data flows directly into our electronic health record – this is key because it frees up more time for providers to talk about the results of the screening and arrange resources if needed, rather than manually documenting their responses,” says Alex Sheff, Senior Program Manager for Medicaid Strategies, Partners Center for Population Health.

However, identifying patients is just one step in the process. To help support patients who screen positive for social determinants, Partners is developing a range of services that vary depending on the complexity of the social and medical needs of the patient. For patients with significant needs, hands-on support may be provided in the clinics. This typically involves culturally competent community health workers who address non-medical needs and serve as a bridge between medical and social providers.

“We provide informal counseling, social support, care coordination, and promote the importance of health screenings,” says Maria Mojica, a Community Health Worker caring for high risk patients at Brigham and Women’s Hospital. “This may include making appointments at social service agencies, filling out paperwork for food or housing assistance, and, in some cases, going to the patient’s home to better understand what their needs are.” For patients who are able to navigate social services systems on their own, a printed resource is available with a list of support services.

For practices who may not have a community health worker or patient navigator available, Massachusetts General Hospital will be piloting a centralized resource person who can help triage and connect patients who screened positive for social determinants with services. “We are exploring whether this type of model could eventually be made available more widely across the Partners network,” says Mary Neagle, Program Director for Primary Care ACO Strategy at Massachusetts General Hospital. Partners also has a web-based tool, called the Community Resource Connector, that any member of the care team can use to link up patients with social services and community agencies in their home community.

Over the next few months, several new sites including the MGH Chelsea HealthCare Center and MGH Revere Broadway HealthCare Center, will start screening for social determinants of health. The goal is to get all primary care practices at Partners up and running by the end of 2018. Although the initial program is focused on MassHealth patients, the long-term plan is to expand screening to all patients regardless of insurer.

Although a lot of this work is still being defined, it will continue to be more formalized with the launch of the full Medicaid ACO program. “One of the greatest things about this initiative is that the Medicaid ACOs and hospital organizations across the state are coming together to learn from each other and share best practices,” says Dr. Weil. “There is an effort underway to align screening domains and questions across institutions so that data can be collected across the region – this will not only benefit our patients at Partners, but it will help inform public policy and the care and resources available to patients across the state.

© 2022 My CMS All rights reserved.