By Lance Robertson and Bruce Chernof | FEBRUARY 24, 2020 | HealthAffairs.org
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.