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.”
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