As
health care payment models become more value-based, health care systems are
increasingly interested in approaches that address both medical needs and
social determinants of health.
This
isn’t surprising. Services delivered in the home and in the community that
prevent falls, address food insecurity and transportation issues, manage
chronic disease, support employment and economic independence, reduce social isolation,
and address other non-medical risk factors have been shown to improve health outcomes and reduce the cost of care.
This is particularly true for “high-need, high-cost” people who have complex
health conditions and social risk factors and who often have significant
functional limitations.
Integrating
these services into health care requires robust planning and assessment, expert
knowledge and navigation of a complicated social service system, ongoing case
management, and accountability for service delivery and outcomes. Incorporating
these services requires health care payers and providers to “build” internal
organizational capacity or “buy” it from existing service providers. When
making that decision, there are many factors for health care organizations to take
into consideration, not the least of which are local factors in the communities
and markets they serve.
For
many organizations, however, partnering with the existing infrastructure of
community-based organizations (CBOs) in the aging and disability network—buying
rather than building—is the more cost-effective strategy for delivering the
full continuum of quality care and support for their most high-risk and
high-need patient populations. Federal and state governments have made
significant investments in this network, which includes over 20,000 CBOs. Since
1965, the network has been a trusted resource, delivering home- and
community-based care to one in five of America’s older adults, as well as
people of all ages with disabilities.
As
described below, partnerships between CBO networks and health care
organizations have produced great progress in addressing the social needs of
patients. We believe the next step is to scale these partnerships across the
country, with shared investment from both health care and social services. We
envision collaborations between CBO networks and health care organizations
within and across states, organized by health care markets. We discuss how this
expansion would work, and conclude by calling on stakeholders to work with the
Administration for Community Living on a nationwide approach for integrating
medical and social care.
CBOs
And Social Determinants: Where We Are Now
CBOs in
the aging and disability network are present in every community across the U.S.
and have unmatched expertise in local culture and needs; service coordination
and delivery; and securing benefits, services and supports that maximize
independence and functioning. With extensive reach into peoples’ homes, the
network also has a unique ability to identify risks and connect people to
interventions before their situations reach crisis levels. These unique
capabilities can and should be strategically leveraged by health care
organizations through partnerships with CBOs in the aging and disability
network.
Health
care systems tend to focus on chronic conditions as the guidepost for targeting
high-cost, high-needs adults, but the data are clear: this view is too myopic.
Per capita Medicare spending roughly doubles for adults
with two or more functional limitations, regardless of the number of chronic
conditions they have.
CBOs
are critical partners in responding to these
challenges and are increasingly contracting with health care systems and plans,
including Medicare Accountable Care Organizations, to provide direct services,
like meal delivery; care and services coordination; and care transitions as
people return home from hospitals and avoid further institutional care. These
contractual relationships seek to cost-effectively help adults with complex
needs thrive in the community.
These
partnerships are succeeding. Collaboration between health care organizations
and social service networks in the community have been associated with higher
performance and reduced health care costs, and some partnerships
have substantially improved workforce shortages. For example:
·
VAAACares,® a statewide one-stop coalition
providing care coordination, care transitions, and other services, reduced the
30-day readmission rate from 18.2 to 8.9 percent through their partnership with
four health systems, 69 skilled nursing facilities, and 3 health plans.
·
Elder Services of the Merrimack Valley, an
Area Agency on Aging (AAA) in northeast Massachusetts, and their network of
community partners have shown an 11 percent reduction in total cost of care
through their collaboration with health care organizations.
·
The Veterans Health Administration, through the Veteran
Directed Care program, has had purchasing agreements over the last
decade with CBO network organizations across 37 states to provide nursing-home-eligible
veterans with a counselor and a monthly budget to obtain the long-term services
and supports they need to live in the community—at about one-third of the cost
of a nursing home.
·
Ability360, a center for independent living in
Arizona, has contracted with Medicaid and managed care organizations to serve
individuals across the state by providing home modifications, state-of-the-art
exercise facilities, and 2,300 personal care assistants to support independent
living in the home and community of each person’s choice.
·
A rural Medicare Shared Savings Program ACO partnered with local
faith-based organizations to establish a “buddy” program. Volunteers visit
regularly with beneficiaries who opt into the program, which is offered by
primary care practices to older patients who had high emergency department (ED)
use. Though small, the program has reduced unnecessary visits to EDs by 50
percent for elderly patients who are lonely or anxious but do not have emergent
medical conditions. Based on these results, the ACO plans to expand the
program.
·
Those are just a few examples, and leaders across the aging and
disability network are actively increasing capacity and creating new models to
meet the needs of health care organizations. For example, many CBOs have formed
cohesive networks with “hubs” or “network brokers” that manage referrals and
maintain relationships with many different community providers. These hubs act
as a single point of accountability for health care systems and plans,
increasingly across entire states or multi-state regions.
We also
are excited about the combination of innovation and policy changes in Medicare
that address social needs. For example, Medicare Advantage plans now can test
value-based insurance design and offer supplemental benefits that are not
primarily medical in nature for chronically ill beneficiaries, which gives them
flexibility to offer social services and supports to qualified beneficiaries.
In addition, the Center for Medicare and Medicaid Innovation’s Accountable
Health Communities Model is formally testing the extent to which
health care costs and utilization can be reduced by systematically identifying
and addressing the health-related social needs of Medicare and Medicaid
beneficiaries’ through screening, referral, and community navigation services.
These initiatives will yield ongoing insights that can inform future policy and
practice.
What’s
Next?
The
greatest opportunity lies in partnerships that go beyond individual health care
organizations and individual CBOs or CBO networks. We believe that the future
lies in scaling the CBO network model across the country, organized to
correspond to markets for health care delivery and payment. This means
establishing a system of CBO networks, with hubs at local, state and
multi-state levels. Each CBO network hub could individually contract with
multiple health plans and health systems in a given geographic region, as well
as partner with other CBO network hubs to contract with health care
organizations that have a broader geographic footprint. This would provide a
single point of accountability for health care partners, whether local hospital
systems, state-level managed care organizations, or multi-state or national
health plans and health systems.
The
Administration for Community Living is working with CBO leaders, states,
philanthropies, and health care organizations to accelerate the development of
this nationwide CBO network model. To that end, ACL is collaborating with
stakeholders to 1) clarify the role of the CBO network hub at each level and 2)
define the core competencies to coordinate with health care partners and
perform in-person centered planning and assessments, referrals, activation,
service delivery, data driven improvement, and financial management.
One
thing is clear: strategic collaboration and shared investment between the
health and social service sectors is needed. A collective effort would bring
together the different expertise found in these sectors, allow for innovation
to be replicated and scaled, enable efficient investment in technology that can
integrate workflows, and support expansion of the workforce needed to support
older adults and people with disabilities. It would also avoid using scarce
resources to duplicate efforts.
Fleshing
Out The Way Forward
Replicate
CBO Networks With Hubs
CBOs
are well-positioned and uniquely skilled to act as the hubs that curate and
manage networks of community service providers, given their expertise in
service navigation and their existing relationships in their communities. In
fact, a recent study found that AAAs (one type of
CBO), are consistently the most centrally positioned organization in a network,
leading the authors to conclude that "as policy makers and health care
managers engage in efforts to foster cross-sector partnerships, the AAAs could
be leveraged as brokers."
ACL is
supporting replication of CBO networks through a learning collaborative for
network hubs and will be administering grants to support their enhancement and
expansion. As these networks are replicated and scaled, maintaining their trust
in the community, flexibility to evolve, and ability to implement
evidence-based interventions to achieve performance benchmarks will be
essential.
Shared
Investment In CBO Networks And Services
CBO
networks and their hubs will strengthen as there is predictable payment for
their services. Experience to date has shown individual contracts between CBOs
and health care organizations don't provide enough referral volume to justify
the hiring of the new staff that would be dedicated to contracted services. As
network hubs contract with health plans and health systems at local, state and
regional levels, they'll secure payment that will build and sustain their
operations along with the workforce needed at the hub and CBO levels. Over
time, health systems and plans will have a go-to, reliable resource to
integrate social care into health care delivery.
Establish
A Shared Technology Infrastructure
Without
deliberate collaboration, we risk proliferation of siloed, technology systems
that only connect individual health systems and health plans with their CBO
partners and create walled gardens within communities. There are growing number
of examples of health systems and health plans in the same market implementing
different referral management platforms that create complexity and burden for
the CBO partners that must accommodate them all. North Carolina, Virginia,
Oregon and Pennsylvania are in various stages of planning and implementing
statewide solutions to avoid this complexity.
A
multi-stakeholder, standards-based approach to financing and implementing
information technology to integrate medical and social care will enable
efficient adoption of referral management, case management and analytic
platforms that can interoperate with the existing health IT infrastructure
across payers, health care providers and CBO networks. CBO network hubs can
work with their state and community stakeholders to plan for collaborative
technology investments that can scale across CBO networks and the health care
organizations they serve.
A Call
To Action
Of
course, there are unanswered questions we’ll need to address as we proceed. We
need transparency around the cost of providing community-based services and
better measurement of the health and economic impacts of various services.
Given the competing demands on primary care clinicians’ time, we also need to
determine who is best positioned to screen for social risks and refer to
community services. We need to find ways to expand access to affordable housing
and transportation, and to benchmark our progress over time, so that all
stakeholders can gauge our progress towards integrating medical and social care
nationwide.
In the
coming months, ACL will be meeting with key stakeholders to work on shared
goals, principles and strategies that we can all embrace and that can guide us
as we work across sectors to improve outcomes for the people we serve. We are
calling on health care system and health plan executives to partner with us to
develop business models for social care through CBO networks, evaluate what
works best, and incorporate private sector innovation. Together, we can achieve
a sustainable, integrated system of social service and health care delivery.
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