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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