5 minute read

Is the Healthcare System Ready?

Our current integrated care models break down silos between physical and behavioral health, allowing for comprehensive screening, warm handoffs, care coordination, and streamlined referrals.

Many patients, though, have unmet social, material, AND behavioral health needs. Here are some examples.

•           A 40-year-old man experiencing homelessness struggles to access medical care due to lack of documentation or transportation, even though he has chronic health conditions.

•           A family facing food insecurity struggles to connect their nutritional needs to their child’s developmental delays, impacting their overall health.

•           A 65-year-old woman grappling with social isolation does not recognize the link between her loneliness and depression, neglecting to seek or accept mental health support.

Is the healthcare system ready to identify and address all these needs? My brain says “no”, but my heart says, “not yet”.  

Health-Related Social Needs

Addressing health-related social needs (HRSN) during clinical appointments is an important factor in leveraging health promoting social determinants of health (SDH) and reducing health disparities.¹

Clinics can screen for HRSNs, document screening results, make referrals to community-based organizations (CBOs) providing food, housing, or income assistance, and establish medical‐legal partnerships and food pantries.^2-3

HRSN interventions in healthcare are associated with improvements in SDH, child health or health behaviors, adult physical health or quality of life, adult health-related behaviors, adult mental health outcomes, preventive care utilization, and healthcare recovery dollars.^2-5

Care and Community Fragmentation

Healthcare is not integrated well with CBOs that address HRSNs. They represent different systems with different regulations, funding streams, missions, and cadences.

Healthcare organizations can improve health equity and outcomes by partnering or even integrating with CBOs to identify and address HRSNs.⁶

The Centers for Medicare and Medicaid Services (CMS) Framework for Health Equity 2022-2032 includes priorities to build capacity of healthcare organizations to reduce disparities and increase all forms of accessibility. The CMS Accountable Health Communities (AHC) model seeks to address the fragmentation between clinical care and community services.

Using a data-driven and process-focused transformation strategy, healthcare organizations can enhance clinical workflows, implement new services, and integrate new staff (e.g., community health workers, navigators) to better address HRSNs. This primarily occurs by referring patients to community services and following up.

Integrating Integrated Care: A New Model?

One of the next evolutionary steps in advancing integrated care is integrating the healthcare and social care systems.

What would it look like to combine our integrated care models with the CMS Accountable Health Communities model? Such a hybrid or meta-model would leverage strengths from both models and fill in the inherent gaps.

We could call this new, meta-model the Community-Empowered Collaborative Care (CECC) Model. The CECC:

• Leverages the structured approach of integrated care.
• Integrates behavioral health specialists within primary care teams to address mental health comorbidities often linked to social needs.
• Incorporates the AHC model’s focus on HRSN screening, referral, and navigation services, utilizing its community partnerships and resource networks.
• Expands beyond individual interventions to address broader community-level determinants of health through policy advocacy, resource development, and social service system integration.
• Empowers communities to actively participate in designing and implementing solutions, ensuring cultural relevance and long-term sustainability.
• Fosters strong collaborations between healthcare providers, social service organizations, community leaders, and policymakers.

I am clearly spit-balling here. A new model would need to overcome challenges including funding and reimbursement, workforce development, performance metrics, and data sharing and privacy.

The benefits are clear though: improved patient outcomes, reduced healthcare costs, enhanced population health, and sustainable models.

There are facilities (e.g., Federally Qualified Health Centers) in my home state that are already integrating their clinical services with onsite food banks, legal aid, and housing vouchers. We can replicate their innovations.

What about your clinic? Are you screening for HRSNs? Do you have an onsite health navigator or CHW? Are you using Z codes?

If you already have integrated services, then you are already an early adopter or in the early majority. Integrated care prepares clinics to be more team-based and collaborative. Early adopters will be ready for the next, highly evolved healthcare model.

References

1. Gottlieb, Laura MD; Fichtenberg, Caroline PhD; Alderwick, Hugh; Adler, Nancy PhD. Social Determinants of Health: What’s a Healthcare System to Do?. Journal of Healthcare Management 64(4):p 243-257, July-August 2019. | DOI: 10.1097/JHM-D-18-00160
2. Gottlieb LM, Wing H, Adler NE. A systematic review of interventions on patients’ social and economic needs. American journal of preventive medicine. 2017 Nov 1;53(5):719-29.
3. Friedman NL, Banegas MP. Toward addressing social determinants of health: a health care system strategy. The Permanente Journal. 2018;22.
4. Shekelle, P.G., Begashaw, M.M., Miake-Lye, I.M. et al. Effect of interventions for non-emergent medical transportation: a systematic review and meta-analysis. BMC Public Health 22, 799 (2022). https://doi.org/10.1186/s12889-022-13149-1
5. Gottlieb LM, Hessler D, Long D, et al. Effects of Social Needs Screening and In-Person Service Navigation on Child Health: A Randomized Clinical Trial. JAMA Pediatr. 2016;170(11):e162521. doi:10.1001/jamapediatrics.2016.2521
6. 2022 National Healthcare Quality and Disparities Report. Rockville, MD: Agency for Healthcare Research and Quality; October 2022. AHRQ Pub. No. 22(23)-0030.