What does one’s method of transportation to and from work have to do with their health? Quite a bit, according to a growing body of evidence showing that social and economic factors—such as education, food security, housing, and income, and the environment—along with health behaviors can account for a full 80 percent of a person’s health outcomes. That is why these “social determinants” of health are the focus of a Partners-wide strategy, in coordination with the Partners Medicaid Accountable Care Organization (ACO) pilot, to provide more tailored care based on patients’ lifestyles and environments.

Partners is one of six organizations in Massachusetts participating in the Medicaid ACO pilot, aimed at evolving care delivery from payments for individual services to compensation based on overall care quality, value, and outcomes. One requirement of the Partners HealthCare Choice ACO is to screen patients for social determinants linked to health, and provide follow-up services accordingly. Bolstered by the ACO, along with anticipated state funding, Partners is building on its existing efforts through community health centers and practices to develop a system-wide screening and support infrastructure that addresses patients’ social determinants.

This infrastructure employs a social determinants questionnaire, initially developed by Drs. Cheryl Clark and Anne Thorndike through the Brigham Care Redesign Incubator Startup Program (BCRISP), which asks patients if they are experiencing barriers with housing, transportation, childcare, food security, safety, and other concerns. The questionnaire is incorporated into standard care through the Primary Care Annual Visit Questionnaire, which flows into the electronic health record and flags patients screening positive for social determinants. Those patients will be matched with a range of services, from hands-on support from culturally competent community health workers who can assist with paperwork for food or housing assistance, to printed referrals for such services. For practices without a patient navigator, a web-based tool is available, and Massachusetts General Hospital will pilot a centralized triage resource to similarly connect patients with the services they need.

With screening underway at pilot sites such as the Mass. General Chelsea HealthCare Center and Mass. General Revere Broadway HealthCare Center, the ultimate goal is to institute screening across Partners primary care practices by the end of 2018. Although initially focused on MassHealth patients, the program could eventually be expanded to all patients, regardless of insurer, to enhance outcomes for everyone whose health is impacted by their circumstances.

“Medicaid ACOs and hospital organizations across the state are coming together to learn from each other and share best practices,” says Eric Weil, MD, chief medical officer for primary care at the Partners Center for Population Health. “With screenings aligned across institutions, data can be collected across the region—which will not only benefit our patients, but will inform public policy and the care and resources available to those across the state.”

Read more about the initiative here.

Topics: Medicare/Medicaid, Economic Impact

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