Testing a model for better coordination of care in the community

Main article: How data provides vital insight into the social determinants of health

Can bridging the gap between clinical and community service providers help meet the social needs of Medicare and Medicaid beneficiaries and, in turn, improve health and financial outcomes? 

That’s the question driving the Accountable Health Communities (AHC) model, launched in 2017 by the Centers for Medicare & Medicaid Services. One of the participating organizations is Oregon Health & Science University (OHSU) in Portland.

Leaders at OHSU aim to use data analytics to help coordinate care among 50 clinical sites, community organizations and health departments. Their goal: to better meet the social needs of about 75,000 Medicare and Medicaid beneficiaries. 

“In Oregon, we understand that addressing many of the social factors is an important and necessary part of lowering healthcare costs,” says Bruce Goldberg, MD (pictured at right), senior associate director for the Oregon Rural Practice-based Research Network, a statewide coalition of primary care clinicians that will serve as OHSU’s command center for the model. 

Specifically, the network will leverage data to help high-risk patients access community services and to foster greater alignment among community partners. “Having robust data and information and being able to analyze community need is important for our participating organizations,”  Goldberg says. 

Through participation in the AHC model, leaders at OHSU aim to address five specific social needs among the patient population:

• Housing
• Transportation
• Interpersonal violence
• Food insecurity
• Utility needs 

Using data to improve community health

During the next 12 months, network leaders will gather and analyze patient data to understand social needs in specific geographic areas. “We haven’t had good data on those needs and the epidemiology of those needs,” Goldberg says.

Using the data, they will provide feedback to policymakers to help address social issues at the local level, he says. For example, if the data shows high numbers of homeless in a ZIP code, the network can work with community leaders to improve the availability of housing in that area. If data reveals that some communities are lacking resources to address interpersonal violence and its potential impact on health, the network can work with policymakers on solutions for those communities.

When targeting social determinants of health, Goldberg says, one of the challenges is establishing the best way to screen patients and obtain the data. “This is sensitive information, and we still don’t know the best way to ask questions or the best setting in which to ask those questions,” he says.

Where finance leaders can help

If an organization is involved in the AHC model or another value-based arrangement, finance leaders can support clinicians by building bridges with community organizations that can help meet patients’ social needs, Goldberg says. “This can’t be done alone by clinicians,” he says. “It requires strong partnerships with the community.” 

In these partnerships, he says, providers need to create a closed-loop system of referrals so they can direct patients to the right community resources and make sure patients are not lost in the shuffle.

But creating greater alignment across provider and community organizations takes time. “We’re just in our infancy in a lot of this work,” Goldberg says.

Interviewed for this article:

Bruce Goldberg, MD, senior associate director, Oregon Rural Practice-based Research Network, Portland.