Accountable Healthcare Community Model: Accounting for Key Social Determinants
Here’s a statistic you might find surprising. According to recent studies, clinical care affects only about 20% of health outcomes. The remaining 80% is influenced by a variety of lifestyle and social determinants. Examples of social needs include: housing instability and quality, food insecurity, utility assistance, interpersonal violence, and transportation. With this in mind, it’s easy to see how any strategy focused exclusively on the medical system will be less than effective in improving health outcomes, particularly among our most vulnerable populations.
At the same time, healthcare providers are increasingly assuming financial risk for clinical outcomes, patient experience, performance against quality goals, and total cost of care. Payment reform is no longer an academic discussion. These days we see purchasers—both private and public—aggressively pursuing a value-based purchasing agenda. Certainly each healthcare organization can and should pay greater attention to social determinants than ever before. However, this is also one of those areas where everyone is better off working together.
That’s why The Health Collaborative recently coordinated a regional planning process to connect hospitals and other providers to community-based resources that address patients’ “non-medical” needs. The resulting, forward-looking plan has a number of innovative features, including: 1) an integrated electronic information technology platform, which enables clinical delivery sites to perform seamless, consistent screening and referral to social service providers; 2) a partnership with the United Way to create and maintain a comprehensive Community Resource Inventory, integrated into the Electronic Health Record or other clinical management systems; 3) the replication of existing best practice navigation models to connect high-risk patients with community resources; 4) the substantive participation of nationally acclaimed experts in quality improvement and social determinants to design, test and scale solutions across Greater Cincinnati.
The work product from this planning effort resulted in an Accountable Health Community proposal submitted to the Center for Medicare and Medicaid Innovation. The Greater Cincinnati region brings a set of unique assets to support the stated aims of the Accountable Health Communities model. A history of collaboration across the community, strong and engaged executive leadership, a highly effective bridge organization, a nationally-recognized regional health data platform, and expertise in improvement science and the social determinants of health all set the stage for a robust model design, deployment and ongoing continuous improvement. We won’t know if our community won this highly competitive funding opportunity until next year, but are excited that local leaders are committed to continuing the effort regardless of Federal funding decisions. Better linking medical and social services in Greater Cincinnati is part of the region’s Collective Impact on Health agenda, and we are excited to see the progress in this important area.