Accounting for Social Risk Factors in Medicare Payment (2017) / Chapter Skim
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B2: Improving Care for Socially At-Risk Populations
B2: Improving Care for Socially At-Risk Populations
Pages 237-302
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From page 237... ...
. Although these populations receive care from a wide range of providers, they are disproportionately represented among the patients treated by a small subset of providers, including safety-net hospitals, minority-serving institutions, critical access hospitals, and community health centers (CHCs)
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From page 238... ...
. Studies of providers serving high proportions of Hispanics, Asians, and other racial and ethnic minority patients show similar patterns of disparity (Hasnain-Wynia et al., 2010; Jha et al., 2008; Rangrass et al., 2014)
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From page 239... ...
Safety-net primary care providers include community health centers and minority-serving providers. CHCs, also known as federally qualified health centers, and federally funded health centers provide primary care and preventive services to socially at-risk populations such as Medicaid patients, uninsured patients, migrants, and the homeless.
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From page 240... ...
Publicly Reported Performance Data The committee considered using publicly reported performance data from providers relevant to Medicare beneficiaries -- Medicare Hospital Compare hospital data and Medicare Advantage and Medicare Part D Star Ratings health plan data -- to identify high-performing providers disproportionately serving socially at-risk populations. To do so would have engaged the committee in original empirical research, uncommon in reports from the National Academies of Sciences, Engineering, and Medicine, especially given the time frame the committee faces.
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From page 241... ...
. Likewise, one study used a composite measure covering multiple domains (quality/process of care measures for AMI, heart failure, and pneumonia; 30-day readmission rates; in-hospital mortality; efficiency; patient satisfaction; and two survey-based assessments of patient care quality by chief quality officers and frontline physicians)
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From page 242... ...
. Mechanisms driving disparities in health care outcomes that lie outside of provider settings include barriers to access and financial constraints for disadvantaged persons and differences in case-mix, including patient clinical characteristics and social risk factors (Chien et al., 2007; Jha and Zaslavsky, 2014; Karve et al., 2008; NASEM, 2016)
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From page 243... ...
The committee reviewed both the peer-reviewed and grey literature in order to identify inno vations, interventions, and other strategies providers disproportionately serving socially at-risk populations have implemented to improve care and outcomes for their patients. As described in Appendix B1, the committee reached out to organizations known to conduct research or represent providers disproportionately serving socially at-risk populations (Alliance of Community Health Plans, America's Essential Hospitals, America's Health Insurance Plans, and The Commonwealth Fund)
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From page 244... ...
Note that "system" as used here is not limited to a single health care organization, but refers more generally to a set of interconnected a ctors who work together to accomplish a common purpose -- in this case to improve health equity and outcomes for socially at-risk populations. In this approach, the system is mainly composed of medical providers as well as partnering social service agencies, public health agencies, commu
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From page 245... ...
It is important to note that these practices together constitute a general approach to identifying and developing best practices for a specific community context and given specific resources. Unlike clinical best practices that are applied to all individuals in a given population and that are derived from systematic reviews of the evidence to identify causal associations, these systems practices are not interventions that can be applied wholesale in every practice setting for every patient and in every community context and be expected to improve quality and outcomes for socially at-risk populations.
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From page 246... ...
For example, a system may already conduct a comprehensive needs assessment, but this assessment will be fundamentally different when driven by a commitment to health equity and when it includes social needs in addition to clinical needs. The value and resources that flow from this commitment drive changes in other processes, such as collaborating with social service agencies in the community, which support enhanced planning for care transitions.
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From page 247... ...
, these are typically limited to clinical teams, whereas this model also incorporates collaborative partnerships with external organizations, including not only other clinical care providers, but also community organizations and social service and public health agencies to address social risk factors. In sum, these practices make up an approach by which health care systems can promote equitable health outcomes by using data to reveal unmet needs, which are then addressed through collaborative partnerships that coordinate care across time, sites of care, and intensity of needed services to support patients living in the community to engage in their health care in the context of patient goals and community resources.
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248 ACCOUNTING FOR SOCIAL RISK FACTORS IN MEDICARE PAYMENT TABLE B2-1a Description of Systems Practices to Improve Care for Socially At-Risk Populations and Implementation Considerations: Commitment to Health Equity Systems Practice Description Commitment to health equity: Health care leaders and staff at all levels Value and promote health equity and hold express a core commitment to valuing yourself accountable and promoting health equity. Health care providers accept accountability for reducing inequities.
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From page 249... ...
activities and practices to achieve equityi o Incorporation of health equity into compensation or incentivesj • Financial and non-financial resources aligned and allocated to promote health equityk SOURCES: a Chin et al., 2012; Jones et al., 2010; Taylor et al., 2015. b Chin et al., 2012; IOM, 2001; Taylor et al., 2015.
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250 ACCOUNTING FOR SOCIAL RISK FACTORS IN MEDICARE PAYMENT TABLE B2-1b Description of Systems Practices to Improve Care for Socially At-Risk Populations and Implementation Considerations: Data and Measurement Systems Practice Description Data and measurement: Health care providers understand their Understand your population's health, risk patterns of performance across different factors, and patterns of care indicators of social risk. Providers know how their performance for socially at-risk populations compares with top-performing peers.
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APPENDIX B 251 Implementation Example Implementation Strategies Considerations Regular, standardized collection of social risk factor dataa • The concentration • Analysis and monitoring of performance data of socially at-risk disaggregated by indicators of social risk to identify patients among a small existing health disparities within organizationsb subset of health care o Enhanced risk prediction modelsc providers means that • Comparison of performance to top performers and peers many providers will be unable to reliably assess disparities with internal data alone. Providers may need to benchmark their performance against peer organizations or population-based measures.
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252 ACCOUNTING FOR SOCIAL RISK FACTORS IN MEDICARE PAYMENT TABLE B2-1c Description of Systems Practices to Improve Care for Socially At-Risk Populations and Implementation Considerations: Comprehensive Needs Assessment Systems Practice Description Comprehensive needs assessment: Providers analyze performance data, as well Identify, anticipate, and respond to clinical as directly engage patients, to identify unmet and social needs clinical or social needs. Providers also review the literature and the experiences of peers to identify lessons and anticipate their patient population's needs.
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program results when • Data sharing with other providers, public health and social important contextual service agencies, and community organizations to identify features differ. patients' social needsb o Information exchange portal for clinical providers, social service agencies, public health agencies, and community organizations to share information (with patient permission)
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254 ACCOUNTING FOR SOCIAL RISK FACTORS IN MEDICARE PAYMENT TABLE B2-1d Description of Systems Practices to Improve Care for Socially At-Risk Populations and Implementation Considerations: Collaborative Partnerships Systems Practice Description Collaborative partnerships: Providers create collaborative teams to deliver Collaborate within and across provider services with scope, intensity, and scale teams and external partners to deliver matched to population needs. Collaborations integrated, coordinated care will often need to span multiple service sectors, such as housing, transportation, and nutrition.
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Regional collaborations with other health care providersd • Collaborations may evolve • Involvement and collaboration with social service and over time as needs and public health agencies and community organizationse obstacles become clearer. In addition, effective models of collaboration will differ based on the specific patient needs and community context.
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256 ACCOUNTING FOR SOCIAL RISK FACTORS IN MEDICARE PAYMENT TABLE B2-1e Description of Systems Practices to Improve Care for Socially At-Risk Populations and Implementation Considerations: Care Continuity Systems Practice Description Care continuity: Health care providers anticipate and carefully Plan care and care transitions to prepare plan patient trajectories through illness for patients' changing clinical and social progression, across sites of clinical care, needs between clinical care teams, between health care providers and social service agencies and community organizations, and differing intensity of needed services. Providers design transitions and hand-offs to maintain patient engagement and avoid losses to follow up.
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to coordinate care between clinical and social intervention, providers service providersc may need to monitor Collocating clinical, behavioral health, and social servicesd • patients to ensure that Patient education about care transitionse • progress is maintained, as well as to detect relapse and re-intensify services as needed. SOURCES: a Chin et al., 2012; Davis et al., 2015.
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could be realized through different forms (e.g., nurse care manager or community health worker) depending on the level of severity and desired site of care (office visits versus phone consultation versus home visits)
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instrumental support to promote healthy behaviors and reduce health risksd (e.g., transportation) , • Reach patients through community centers, homeless undiagnosed behavioral shelters, religious organizations, schools illness, or both.
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. Additionally, providers reduce F barriers to accessing care and coordinate care across care settings (and with external partners)
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Finally, health care organizations may identify social risk factors that the medical or clinical health system cannot address or should not address. For certain social risk factors, presuming that primary solutions lie within the health care sector risks "medicalizing" the factors in undesirable ways if the health care sector acts on them, because they may be better addressed through social policies or interventions rather than through individual medical interventions (Lantz et al., 2007; Woolf and Braveman, 2011)
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From page 262... ...
Kaiser Permanente is a large, nonprofit integrated managed care organization that provides a case study of a community-informed health system. Kaiser's comprehensive, multifaceted approach to improving communitylevel health uses ethnography and interviewing to understand drivers of health disparities; reduces barriers to receiving coordinated, culturally, and linguistically appropriate clinical care; promotes healthy behaviors in the community through targeted dissemination and interventions (e.g., farmers' markets, partnering with community activists to promote healthy eating and physical activity)
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. However, achieving health equity requires more than providing equitable health care, or the same type of care to all patients regardless of social risk, because this may not be sufficient to reduce health inequities.
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. Specific activities into which leaders can incorporate the aim of achieving health equity to support organizational transformation to achieve a culture of equity may include • investing in a diverse workforce to provide culturally concordant and culturally competent care and improved communication; • designing interventions to reduce health disparities; • redesigning care to incorporate equity goals; and • setting measurable goals to reduce health disparities and holding staff accountable.
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A study identifying themes from systematic reviews of interventions to reduce racial and ethnic disparities found that successful interventions involved the active design of interventions to reduce disparities that were targeted to specific contexts, patient populations, and organizational settings (Chin et al., 2012)
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In response, the organization's executive leadership and governance recognized changes to its patient population, acknowledged and accepted accountability for existing health disparities, and acknowledged that providing equitable care was a strategic issue and part of its organizational vision. In addition, the organiza tion believed that there were business, legal, and quality improvement rationales to provide equitable care.
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From page 267... ...
These tools include language train ings accompanying the expansion of interpreter staff, educational forums about s ocial risk factors for poor health, and cultural competence training. In addition, HealthPartners developed the HealthPartners Equitable Care and Service intranet site, which provides access to resources and information to provide language- concordant health information (including translated materials)
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. A study synthesizing lessons from successful interventions to reduce racial and ethnic disparities based on a series of systematic reviews noted that effective interventions must be integrated with overall quality improvement efforts, rather than be a separate, discrete initiative (Chin et al., 2012)
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. To consider and address social risk factors for poor health care outcomes, organizations may need to go beyond providing equitable care within the walls of their health systems to understand, partner with, and in some cases invest in the community in which they are embedded to support health outcomes of the communities they serve (Bachrach et al., 2014; Chin et al., 2012; Schor et al., 2011)
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. However, a systematic review of interventions to reduce racial and ethnic disparities in diabetes found that providing in-person feedback to providers about their performance improved diabetes outcomes for African-American patients (Peek et al., 2007)
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Studies have found that regularly collecting consistent race, ethnicity, and language data among a provider's patient population and analyzing performance data disaggregated by race, ethnicity, and language to identify existing health disparities within their organizations are critical to effective interventions to reduce disparities (Ayanian and Williams, 2007; Chin et al., 2012; CMS, 2015; HHS, 2011a; Jones et al., 2010; Thorlby et al., 2011)
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that may not be identified through clinical data alone. Thus, comprehensive needs assessments may need to include not only consideration of clinical and behavioral risk factors as is done for the general population, but also social risks that may be related to health care outcomes.
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Denver Health is continuing to refine the tool, including developing rules to better account for patients' social risk factors (Hostetter and Klein, 2015; Johnson et al., 2015)
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For example, under the Patient Protection and Affordable Care Act of 2010, nonprofit (tax-exempt) hospitals must conduct a community health needs assessment every 3 years.
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Collaborative Partnerships Improving health and health care outcomes for socially at-risk populations will require collaboration within and between care teams within health systems, across clinical settings, and between health systems and external partners, such as community organizations and public health and social service agencies (Bachrach et al., 2014; Schor et al., 2011)
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For example, a systematic review of interventions to reduce racial and ethnic disparities in diabetes found that nurse- and pharmacist-led interventions showed promise to improve quality of care and health outcomes and potential to reduce disparities (Peek et al., 2007)
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, promoting shared accountability (through both performance measurement/public reporting and financial accountability) , and by facilitating enhanced funding for social risk factors related to health (e.g., through value-based purchasing methods, identifying and coordinating nonprofit community benefit funds, and by aligning non–health sector funding to promote population health)
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; invested in HIT infrastructure to integrate information from and facilitate coordination across clinical, behavioral and social services; and expanded its workforce to include specialized nurse care coordinators, pharmacists, dentists, behavioral health staff, social workers, community health workers, housing and social services navigators, vocational counselors, emergency medical services staff, and HIT professionals (Sandberg et al., 2014)
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From page 279... ...
Expected funding from Colorado's Medicaid expansion under the Patient Protection and Affordable Care Act of 2010 was key to the coali tion's long-term funding. Stout Street Health Center provides health care services, including primary care, mental health care, substance abuse treatment, dental and vision care, and social services to about 18,000 current homeless persons, formerly homeless persons residing in coalition residences, and formerly home less persons who no longer live in coalition residences.
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From page 280... ...
, such as through the use of coordinated care teams, trained care coordinators, and patient navigators, or through collocating services. A review of randomized controlled trials of interventions to improve care transitions among chronically ill adults found that all but one trial showed positive effects on at least one outcome -- clinical outcomes, patient experience, quality of life, health care use, and costs -- regardless of the specific type of intervention (e.g., discharge planning and follow up, case management, coaching, patient education, peer support, telehealth)
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From page 281... ...
CHOICE Health Plans, Fallon Health's NaviCare and Summit ElderCare, and Geisinger Health Plan's Medically Complex Medical Home provide examples of health care providers actively managing care transitions across care settings, across a patient's illness trajectory, and across a patient's needed intensity of services. VNS Choice Health Plans is a managed care organization serving New York City residents who are eligible for Medicare, Medicaid, or both that assigns a care manager to coordinate services across members of the patient's care team using a variety of tailored interventions.
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Once identified, a patient is as signed a care team consisting of a nurse care manager and a trained community health worker. The team visits patients before discharge to introduce themselves and to schedule a home visit within 2 days of discharge.
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From page 283... ...
to ensure the provider can find the patient. Specific types of activities providers may practice to engage patients in their care and to support individuals in the community include educating patients about self-management, healthy behaviors, and care coordination; providing culturally sensitive, targeted, and tailored patient education; providing tailored care plans easily understood by patients; employing patient navigators or health navigators to facili ate access to and to t coordinate care between clinical and social services; using new technologies (e.g., telephone consultation, videoconference, mobile screenings, smartphone apps)
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From page 284... ...
. With respect to patient navigators alone, studies have shown that employing patient navigators or care managers to facilitate access to clinical and social services, coordinate care, and support self-management has shown promise to improve care for high-cost Medicare beneficiaries and to reduce racial and ethnic disparities (Chin et al., 2012; Davis et al., 2015; Itzkowitz et al., 2016; Naylor et al., 2012)
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From page 285... ...
Importantly, these case examples are hypothetical and illustrative of how an organization might implement a systems approach to achieving health equity, but are not intended as a one-size-fits-all approach. As described in detail in the preceding sections, the specific interventions appropriate to a given care setting will depend on the specific needs of a provider's patient population, each individual health care provider's available resources, and the local community context.
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From page 286... ...
As part of the model, Genesys HealthWorks implemented an integrated self-management support program using health navigators to support patients to adopt healthy be haviors such as physical activity and healthy eating and to reduce health risks like tobacco use. The health navigator program began as a variety of pilot programs and research projects in 1997 and evolved to target patients receiving care at a Genesys Health System patient-centered medical home practice and low-income, uninsured enrollees of the Genesee Health Plan.
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As health care systems increasingly partner with external organizations (e.g., community organizations) and other sectors (e.g., social services and public health)
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From page 288... ...
Value and promote health equity and hold yourself accountable. Data and measurement: Hospital leaders compare performance in readmission rates Understand your across the spectrum of social risks.
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From page 289... ...
Bilingual and bicultural staff members are included in primary care teams and community health workers when appropriate. Dietary recommendations are tailored to reflect patient preferences.
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From page 290... ...
The hospital collaborates with external partners such as community organizations and public health and social service agencies to address issues beyond the reach of the health system such as housing and food insecurity, income support, and transportation needs. Care continuity: The hospital recognizes discharge not as a singular event but Plan care and care as a transitional period that the patient's hospital care team transitions to prepare must actively manage.
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From page 291... ...
The ACO or health plan employs community health workers linked to the primary care team to provide home-based health coaching related to nutrition and exercise. The ACO or health plan also partners with public health and social service agencies or community organizations to improve access to healthy foods and safe areas to exercise, as well as to identify and address competing priorities such as instability in housing or home utility services.
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n.d.-b. Geisinger Health Plan's medically complex medical home program.
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2013. Community health assessment for population health improvement: Resource of most frequently recommended health outcomes and determinants.
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2013. Health information technology capacity at federally qualified health centers: A mecha nism for improving quality of care.
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2012. Federally qualified health centers and private practice performance on ambulatory care measures.
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2016. New York Citywide Colon Cancer Control Coalition: A public health effort to increase colon cancer screening and address health disparities.
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2010. Factors influencing the effectiveness of interventions to reduce racial and ethnic disparities in health care.
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2015. Health literacy: A necessary element for achieving health equity.
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2008. Beyond equal care: How health systems can impact racial and ethnic health disparities.
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2016. Accounting for social risk factors in Medicare payment: Identifying social risk factors.
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2012. Interventions to improve decision making and reduce racial and ethnic disparities in the management of prostate cancer: A systematic review.
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2016. Building a culture of health equity at the federal level.
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