In the new and constantly evolving healthcare landscape, patient care organization leaders are now coming to a near universal acceptance that paying more attention to social determinants of health data has become vital to improving care and lowering costs. Indeed, across the country, there are countless projects that are examining, in various ways, how health outcomes are influenced by factors such as social circumstances, behavioral patterns and environmental exposures.
One example of this is in Chicago, where a group of healthcare leaders have been working on creating a seamless and purposeful link for sharing health and other information between social services agencies and patient-centered medical homes (PCMHs) to improve the health of those most at-risk and address social determinants of health.
Medical Home Network (MHN) is an organization that manages a Medicaid ACO (accountable care organization), comprised of nine federally qualified health centers (FQHCs) and three hospital systems serving approximately 80,000 Chicago area Medicaid beneficiaries. Earlier this year, MHN and the National Committee for Quality Assurance (NCQA) launched a joint research project to study the effects of connections between Medicaid patient-centered medical homes and community-based organizations (CBOs) that provide social services. For this project, a CBO is defined as any social service provider organization that serves an individual but is not responsible for providing “whole person care” in the same way that a PCMH or a hospital is held responsible, officials noted.
One of the driving factors for the research grant—managed by the Systems for Action National Program Office with support from the Robert Wood Johnson Foundation—according to officials, is that addressing social risk factors has been challenging for medical homes as most do not have adequate mechanisms for referring patients to services. Additionally, most CBOs do not have electronic health records (EHRs) and cannot easily communicate with medical home EHRs. Issues of protected health information and privacy have also blocked progress in this area, according to NCQA and MHN executives.
As such, through this research, the organizations set out to investigate the impact of connecting medical homes and CBOs using a web-based system. More specifically, NCQA, MHN and Cook County Health & Hospitals System (CCHHS) are partnering in this effort with medical homes and CBOs in Cook County, Illinois. As many as 200 medical homes and 25 hospitals will link to a variety of CBOs using a web-based communication and care management platform, known as MHNConnect.
“We want to see how connecting medical and social service care teams can help people with social risks,” Sarah Hudson Scholle, vice president of research and analysis, NCQA, said at the time of the project launch. “For example, if the medical care team and social service agencies coordinate to help people with immediate problems (substance abuse, food, housing, jobs), will that help them manage their health needs better or keep them out of the hospital?”
Cheryl Lulias, president and executive director of Medical Home Network, notes that the need for this connectivity is an outgrowth of MHN’s core premise of creating a community care record across all venues, while being able to communicate and collaborate between the agencies caring for its patients, and the care teams at the primary care practices who are managing the population throughout the continuum. So the question became, Lulias, says, “How do we connect and communicate, and enable communication in a meaningful way?”
Prior to this project, MHN had built foundational connectivity, and was exchanging real-time alerts and a longitudinal record between 27 hospitals and about 200 medical homes in Chicago. “We connected the acute system, but that wasn’t enough,” says Lulias. “Then we moved to start to connect the sub-acute [system], the behavioral health [facilities] and the community agencies. There are a lot of great systems on the market that do referrals to social service agencies from the medical home primary care practice, but we want to enable conversations and share relevant information on the patient to enable seamless transitions and ongoing communication between care teams serving the patients, as well as provide a more coordinated expedience,” she says.
As an organization, MHN is no stranger to researching how social determinants of health affect patient outcomes. A prior study done by researchers at MHN, and others, found that many risk factors outside of the traditional medical model may be associated with higher utilization and costs. That research, published last year in the Journal of Community Medicine and Public Health Care, found that some addressable factors are associated with greater medical and pharmacy spending, such as needing help getting food, clothing or housing, reporting fair or poor health status, and experiencing transportation challenges. The six most common addressable factors were all associated with higher hospital readmissions; most of them were linked significantly to greater subsequent inpatient stays and ED visits, according to the study’s results.
“We’ve proved that these social issues are critical to predicting the rising risk patients and predicting prospective cost and utilization,” Lulias asserts. “We now know that someone with transportation issues is X percent more likely to have a readmission or to go the ER within three months.” As such, the next step of MHN’s work, she adds, is to analyze how connecting medical homes and CBOs affect the use of hospital and ED services, and affect health outcomes of at-risk populations.
This project is currently in phase one, in which 12 behavioral health agencies and a home health agency in Cook County have access to the Community Care Connect tool—which is a module within MHNConnect—to simply search for patients and better coordinate care for those that are seeking services at their facility, says Sana Syal, project manager, Medical Home Network.
“What we are building out now, and finalizing the requirements for, is opening the messaging center to share that information and coordinate care between care managers at primary care settings and a case manager on the other end, which is likely a behavioral health or home health agency,” Syal explains. She notes that while there are plenty of good resources that provide social service directories for care managers to be able to refer patients, oftentimes, those referrals happen on paper or by phone, which in turn creates a gap in truly knowing what happened to that patient. “Did the patient have a good experience when I referred him or her to the food pantry, for instance? We can track those referrals and close the loop so that we are coordinating care in the best way,” she says.
Syal adds that referrals “have been happening since there were patients,” but the interest in what has happened at that service or that agency, and knowing how to track that, has long been a gap in care. “And the [providers] wouldn’t know unless the patient comes back and tells them. Maybe the patient says that he or she wasn’t eligible for what the [provider] referred him or her to, or the patient was turned away, or the wait time was three months. We are looking to fill that gap by connecting these different entities together,” she says.
What’s more, in addition to doing quantitative analysis, by comparing pre- and post-implementation of the web-based platform, MHN and NCQA will also be conducting interviews of patients and their providers, offers Keri Christensen, director for research innovation at NCQA, and formerly at Medical Home Network. This will involve interviewing a patient, a community-based organization staff member, and a medical home staff member, she says. “The patient will be at the center of the interview and we’ll also be interviewing the two care providers from the two different organizations that are caring for him or her. We want to understand how the connectivity has assisted in their workflows and how they have seen things change over time—both for the specific patient we are talking about and for the organization as a whole,” says Christensen.
Going forward, both MHN and NCQA leaders believe that this project will further prove the value in this new paradigm of connectivity to enable better coordination and better health. “It’s a simple concept, but not one replicated in many places today,” Lulias attests. “And it’s all part of the need for better coordination to drive better care. I hope that this connectivity becomes a ‘need,’ as opposed to a ‘nice to have’ when it comes to population health, and connecting the social with the medical,” she says.