The social determinants of health have quickly become the new focus in population health, with health systems and health plans showing increasing interest in the role social determinants play in health outcomes, especially with the rising burden of chronic care and the shift toward providers and payers taking on more risk.
The leaders of one North Carolina accountable care organization (ACO) give more than just lip service to the concept of social determinants, as the organization’s population health strategy centers on a community-based model for addressing social determinants of health by aligning appropriate community resources around its highest risk patients. Mission Health Partners (MHP), a clinically integrated network and Medicare ACO, has seen success through these efforts, as care managers are better able to identify the most vulnerable patients and provide those patients with a support system.
Formed in 2015 and affiliated with the Asheville, North Carolina-based Mission Health healthcare system, MHP is a physician-led ACO with a network of eight hospitals, 1,100 physicians and 90,000 covered lives across 18 counties in western North Carolina, or about 10 percent of the region’s population. The ACO's hospital network includes six Mission Health hospitals as well as Murphy Medical Center, part of the Erlanger Health System, and Pardee Hospital. The second largest ACO in North Carolina, MHP participates in the Centers for Medicare and Medicaid Services’ (CMS) Medicare Shared Savings Program (MSSP) ACO program, covering approximately 58,000 Medicare beneficiaries. MHP also covers 18,000 lives through the Mission Health employee benefits plan and about 8,500 patients attributed through Humana Medicare Advantage. In 2017, MHP added 4,700 United Medicare Advantage member and 1,500 Healthy State beneficiaries, through both Medicare Advantage and direct to employer offerings.
MHP leaders have found that the ACO’s unique care coordination approach—focusing on the social and environmental factors impacting patients’ health—has proven successful. In late October, CMS released data on the 2016 quality and financial performance results for Medicare ACOs, and that data indicated MHP achieved a quality score of 97.6 percent, up from 95 percent the previous year, and realized $11 million worth of cost savings, despite having one of the lowest spending benchmarks in the nation, according to MHP leaders.
“I think what makes us unique is that we are a very heavily social determinants-driven ACO, in that we compile social determinants data for predictive analytics, and then use that to drive our care management operations,” Robert Fields, M.D., Mission Health Partners’ medical director, says.
According to Fields, MHP puts an emphasis on identifying social barriers to better health, and has developed a network of community partners and non-profit organizations and a process for referrals and tracking that streamlines the limited resources available to meet these members’ needs. By working with community organizations such as local food banks, the local YMCA, legal aid and substance abuse organizations, MHP connects patients with resources to address the underlying causes of members’ health problems.
“We enable community partners to engage in the members’ care plan in the same way that typically only medical providers would engage in the care plan. We hold our team accountable for closing those social determinants gaps, with the idea that if we help patients meet their most critical basic needs, then the healthcare pieces will fall into place,” Fields says. “We feel that we have proven that through the success of our value-based contracts.”
As a primary care physician, Fields says he has witnessed firsthand the impact of social and environmental factors on patients’ health, and the need for healthcare organizations to address these gaps. “My biggest frustration as a provider at the front line is that I would write prescriptions for hypertension or diabetes, knowing there was a reasonable chance that the patient couldn’t afford it, or didn’t know how to take it effectively,” he says.
He continues, “My experience would tell me that those barriers are social determinants-driven, and so when we started doing this work, it seemed clear to me that it’s honestly ridiculous to talk about patients managing diabetes if that patient has zero control over their ability to access food or their ability to get to a pharmacy to a grocery store, or to talk about someone’s COPD [chronic obstructive pulmonary disease] when the house they are renting is infested with mold; it’s about the expectations we place on people when their lives are that chaotic. It seems to me that if we’re going to manage the population we have to think enough upstream to solve those basic needs first before we can even talk about the healthcare pieces.”
Leveraging health IT tools and data analytics has been key to this effort, Fields says, as it enables data to be aggregated from multiple, disparate sources. The organization worked with health IT vendor athenahealth to drive improvements in its population health strategy.
“A big challenge was to find a care management tool that supports social determinants,” Field says. “We were able to work with athenahealth to build that tool, and that has been the biggest value—operationalizing this social determinants model to create a community care plan.”
Historically, the only way to gather social determinants data is through nurse care managers performing member assessments. “This involves having fairly intense conversations with patients and hoping they will share intimate details about their lives with a nurse care manager, and they often do, but it takes a long time, because it takes a level of relationship and trust,” Field says. He stresses that building relationships with patients is the backbone of the organization’s care coordination approach, and while assessments continue to be an important step in the process, the use of technology has improved care coordinators’ ability to close gaps in care.
“We feel pretty strongly that any way we have of automating the collection of social determinants of health data for a significant portion of our population and then using that in a codified way to predict when an intervention is needed, is the right way to go. So rather than having to collect it by purely assessment, we can automate the process and make our clinical operations much more efficient,” he says.
As a result of the care coordination technology platform, care managers can see a visualization of social determinants gaps in the same hierarchy as clinical gaps. “A typical care plan might have heart failure, hypertension, diabetes, condition-focused care plans, but, in that same hierarchy, we’ll also see housing or transportation or food insecurity within the care plan as an equal need,” Field explains.
Community partner organizations also can log-in to the digital care management tool, view referrals sent from the care managers, conduct outreach to the patients and then report the closing of those gaps in the same tool. “We can track how many of those social determinant pathways we were able to close, and that helps us in a number of ways,” Field says. “One is to look at the productivity of our care managers, but it also helps us to identify community needs for housing or food insecurity for the purposes of advocacy and policy.”
The use of the technology tool also frees up MHP staff to focus on higher priority duties and to deliver better quality care, organization leaders say. What’s more, Field says the combination of the community approach model and the technology tools enables care managers to have a 360-degree view of the patient and better insight into the overall picture of the patients’ lives.
Mission Health Partners also utilizes athenahealth’s outreach manager tool which enables automated outreach campaigns, and that has increased efficiency in reaching patients for Medicare Annual Wellness Screenings, cancer screenings, fall risk prevention programs and other preventive care, Field says. Those programs now average a 40 percent schedule rate. The organization also utilizes athenaWell, a patient engagement smartphone app to gather patient-reported data. Patients who use the app can receive reminders of tasks in self-care, input blood glucose levels, and record their daily diets and exercise. That patient-reported data is then converted into a graph so that both patients and care coordinators can track their progress.
Beyond utilizing technology platforms to just collect data on patients, Field and his team at Mission Health Partners are focused on harnessing the data to drive timely interventions and behavioral change at the individual patient level.
“One of the things we are most excited about is that we have partnered with an analytics vendor that has created, using artificial intelligence, a predictive model for predicting who of our 90,000 patients will end up in the hospital in the next 30-days, based on social determinants data that is either publicly available or that they have purchased, so anything from credit scores, bankruptcy rates, etc.,” Field says, noting that the predictive analytics model utilizes social determinants and claims data. “That’s been a new path of analytics that we have embarked on, and that will help us prioritize our patients that we perform outreach on to an even greater degree.”
What’s more, MHP leaders are interested in leveraging patient engagement tools to drive behavioral change in patients. “How do we get patients from point A to point B, based on their ability to self-manage and how do we motivate that? How do we give appropriate feedback to patients when they are doing the right things, or the ‘wrong’ things?”
Field continues, “And, then, if we can figure out how to affect behavior change appropriately, how might we actually design health plan benefits around a patient’s behavior change? If a patient is doing what they need to do to manage their conditions, can that positively affect their premiums as an added motivator? I’m interested in how the work that we’re doing translates into benefit design.”
The harnessing and leveraging of data will continue to be a big area of focus for the organization, Field says, including the ongoing integration of social determinants predictive analytics into care coordination tools and the integration of clinical data from across the provider network.