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Working With ACOs To Address Social Determinants Of Health


Social, behavioral, and economic factors are important determinants of health and health outcomes. Many health care organizations are beginning to assess the social risks of their patients and facilitate interventions to address health-related social needs. Improving the integration of medical and social services is also central to the Biden administration’s health policy agenda. Organizations participating in payment models in which they are responsible for managing the total cost of care for assigned or enrolled populations, such as accountable care organizations (ACOs), may be particularly interested in integrating medical and social services.

A recent study by Genevra F. Murray and colleagues examined 22 ACOs that were early adopters of initiatives to address the social determinants of heath (SDOH). The study, based on interviews conducted in 2015–18, concluded that despite strong interest, these organizations encountered significant difficulties integrating medical and social services. The principal challenges included: lack of data on their patient’s social needs and the capabilities of potential community partners; lack of mature partnerships between ACOs and community-based organizations (CBOs); and difficulty determining how to assess the return on investment of this work.

There are no comprehensive data describing ACOs’ investments in addressing SDOH, but the level of activity is growing. The Institute for Accountable Care with the support of several foundations organized a learning collaborative to help ACOs develop strategies to address SDOH. Fifteen ACOs participated in eight learning sessions (described here) between September 2021 and September 2022. We found that the challenges identified by Murray and colleagues remain today and that future funding sources for new initiatives remains uncertain. Although health system demand for social service referrals is growing, many communities lack sufficient capacity to accommodate the new demand.

In this Forefront article, we discuss lessons learned from a group of ACO managers tasked with advancing their organizations’ efforts to integrate medical and social care.

Lesson 1: Collecting Data On Patients’ Social Needs Is Essential But Costly

Strategies to address SDOH begin with collecting data on community needs and local social service resources. ACOs need a systematic approach to screen patients for social risk factors and a strategy for responsibly using the data. Many ACOs already screen for SDOH. In a 2019 survey of ACOs, we found that of 133 respondents, 47 percent reported screening patients enrolled in care management, 14 percent reported screening all patients, and 36 percent said they plan to screen patients in the near future.

The Centers for Medicare and Medicaid Services (CMS) has begun developing policies to expand screening. In 2023, it will add two new measures to the inpatient quality reporting system: screening for social drivers of health and screen positive rate for social drivers of health. Reporting will become mandatory in 2024, and hospitals that fail to report would be subject to a reduction in their annual payment update factor beginning in 2026. CMS also requested comments on adding the same measures to quality reporting in the Medicare Shared Savings Program.

ACOs must determine when and how to screen patients. Multiple screening tools may already be in use across the organization so a process will be required to build consensus around a single screening tool and a uniform method for collecting the data. Large organizations will likely need to establish policies and a governance structure that includes staff and patient representatives to guide these policies. Staff will need training to collect this information in a compassionate, respectful, and culturally appropriate manner.

Ideally, ACOs will integrate screening information into their electronic health records (EHRs) so it can be easily accessed by appropriate clinicians and clinical team members. EHR vendors are beginning to offer tools to facilitate this work. The patient perspective is critical when designing these systems. For example, patients should be given the option to decline to answer questions they are uncomfortable with. Those that identify a need should be given choices about how their need could be addressed.

Lesson 2: Health System Investments Are Needed To Build Effective Partnerships With Community-Based Organizations

Once ACOs establish a process to screen patients, they must decide how to use the information. The steps in building a comprehensive approach include developing an inventory of community resources, building relationships with local CBOs, and establishing a reliable process for referring patients to CBOs.

Establishing an effective social service referral process requires ACOs to invest in building relationships with CBOs, understanding their service offerings, and assessing their capacity to collaborate. Preferred partners can be identified through open calls for applications to fill particular social service needs or more targeted outreach to specific organizations. This will help ACOs identify CBOs that can fulfill their business requirements such as accepting electronic referrals, meeting minimum referral acceptance rates and referral response times, sharing data, and maintaining HIPPA compliant data systems.

One collaborative participant, the Mount Sinai Health System, has formally aligned with selected CBOs by bringing them into its clinically integrated network. This creates opportunities for these CBOs to participate in Mount Sinai’s payer contracts and potentially earn shared savings payments or be reimbursed directly for services. Mount Sinai established a formal CBO credentialing policy, application process, and clear vetting criteria. The policy and process were reviewed and approved by the same committee and board of managers that oversee Mount Sinai’s clinically integrated provider network. This work is intended to ensure patients are connected to high-quality CBO services and to acknowledge the integral role CBOs play in addressing health disparities.

“Closed-loop” referrals are a preferred way to connect patients with CBOs. These are electronic referrals that include bi-directional communication to document that services were provided and to report on outcomes. While some ACOs have home grown systems, many contract with community resource referral platforms. Participants in the collaborative that use referral platforms said that along with the cost of licensing agreements they also incurred costs to train staff, modify clinic workflows, customize the platforms, and integrate them with their EHR.

The value of platforms depends on the degree to which CBOs use them. ACOs were concerned about the administrative burden these platforms may create for CBOs. We heard numerous anecdotes about insurers and providers selecting different vendors so that CBOs are forced to work with multiple platforms. Some states, such as North Carolina, contract with a single vendor to offer a statewide resource referral platform for their Medicaid program. While this solves the multi-platform problem, users have limited leverage to push for platform improvements because they no longer own the vendor contract.

Lesson 3: Many CBOs Lack Funding To Meet The Increasing Demand From Health Care Organizations

Recent attention in policy circles has focused on options for adjusting Medicare payments to account for social risk factors, which could direct more resources to underserved areas. The Center for Medicare and Medicaid Innovation (the Innovation Center) has adopted this concept in its new ACO Realizing Equity, Access, and Community Health (REACH) Model through a “health equity benchmark adjustment to ACO spending targets. The policy discussions around social risk adjustment often fail to acknowledge the large gaps in social service capacity that exists in many areas of the country. Efforts to enhance payments to providers that care for underserved communities will be less effective without sufficient CBO capacity to address their patients’ social needs.

CBOs range from sophisticated organizations with strong administrative capacity, to small charities with dedicated staff but limited resources. Demand from health plans and providers is growing, and there is a desire to scale up these partnerships. CBOs frequently rely on a mix of time-limited donations, grants, and government support. To substantially scale services, CBOs need sustainable funding—ideally through direct payment for the services they provide.

One promising development is the establishment of community care hubs (hubs), entities that organize and support networks of CBOs that provide an array of client services and that facilitate contracting with payers and health systems. Two examples of are VAAACares in Virginia and AgeSpan in Massachusetts. For payers and providers, hubs offer a one-stop shop to access a broad array of services across relatively large geographic areas. For CBOs, the hubs offer contracting, billing, referral management, and data management services, as well as access to payer contracts. The Administration for Community Living (ACL) awarded grants to 12 organizations to support the development of hubs, and it recently announced a national learning community with 58 organizations to accelerate hub development.

Lesson 4: More Direct Payment for Social Care Is Needed To Accelerate The Integration Of Health And Social Services

Despite growing evidence that some social service interventions can lower health care use, it remains difficult for most health care organizations to demonstrate that funding these interventions will generate an immediate return on investment. The two CBO networks mentioned above were able to scale their services because they secured a base of health plan contracts. Governments can directly fund health-related social services and local capacity development through block grants or other mechanisms, but these efforts may face political opposition.

A growing number of states such as Massachusetts, North Carolina, and New York are using Medicaid 1115 waivers to increase funding for health and social service partnerships. Medicaid has flexibility to pay directly for health-related social services and to invest in infrastructure. North Carolina’s 1115 waiver includes up to $650 million to pay for social services through the state’s Healthy Opportunities Pilots. States can also require Medicaid managed care organizations to partner with CBOs. According to the Henry J. Kaiser Family Foundation, this has been adopted by 27 states. AgeSpan, one of the country’s most successful CBO networks, traces the origins of its cross-sector partnerships to a state requirement for special needs plans to partner with Area Agencies on Aging.

Medicare Advantage (MA) is another potential funding source. MA plans have recently been granted flexibility to offer non-medical supplemental benefits. A recent analysis found that about 20 percent of general MA plans offered at least one non-medical benefit; the most common were food and produce (offered to 8.8 percent of enrollees), home-delivered meals (7.4 percent), and non-medical transportation (4.9 percent). Some health plan executives have said they would devote more resources to SDOH if they were allowed to include expenditures in the numerator of their medical loss ratio.

Traditional Medicare has limited authority to pay for health-related social services. CMMI, however, has substantial flexibility to support CBO services in its model tests. For example, the Community-based Care Transition Program (CCTP) paid participating CBOs an all-inclusive payment for care transition services totaling $300 million between 2011 and 2015. Although numerous CCTP sites reduced readmissions, the evaluation contractor was unable to demonstrate a statistically significant change in aggregate hospital readmission rates, and the program was discontinued. The evaluation has been criticized on the basis that evidence-based improvements in care transitions that reduce readmissions also reduce hospitalizations so that the evaluation’s focus on readmission rates likely obscured more positive results of the intervention.

Moving Forward

Many ACOs are already screening patients for social risks, developing partnerships with CBOs, and establishing processes for closed-loop referrals. But well-designed screening programs are costly to build. CMS officials are considering both incentives and requirements for ACOs to screen patients for SDOH. The overall goal is to guide better care and investment in community resources. But it is not clear how much data need to be collected before policy will pivot toward direct investments in community-based services.

While advancing health equity is a major focus of the Biden administration, we believe that the policy discussions have not paid sufficient attention to addressing gaps in community social service resources. Additional federal investment in hubs is needed. CMS should continue working with states to develop Medicaid waivers that include funding for community-based social services providers and consider options to encourage MA plans to invest in these services.

Finally, we believe the Innovation Center has an immediate opportunity to develop an updated model based on the community-based care transition program that incorporates learnings from successful CCTP sites. Doing so would help CBOs build the infrastructure to contract with providers and health plans, and it would create synergies with the ACL’s investments in community care hubs to accelerate the scaling of health and social services partnerships.

Authors’ Note

Funding for the ACO Learning Collaborative on Addressing the Social Drivers of Health was provided by a grant from the Commonwealth Fund, the Scan Foundation, the Robert Wood Johnson Foundation, and the John A. Hartford Foundation.



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