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Suggested Citation:"2 Overview of the Landscape: Tensions and Promise." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Suggested Citation:"2 Overview of the Landscape: Tensions and Promise." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Suggested Citation:"2 Overview of the Landscape: Tensions and Promise." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Suggested Citation:"2 Overview of the Landscape: Tensions and Promise." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Suggested Citation:"2 Overview of the Landscape: Tensions and Promise." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Suggested Citation:"2 Overview of the Landscape: Tensions and Promise." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Suggested Citation:"2 Overview of the Landscape: Tensions and Promise." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Page 11
Suggested Citation:"2 Overview of the Landscape: Tensions and Promise." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
×
Page 12
Suggested Citation:"2 Overview of the Landscape: Tensions and Promise." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Suggested Citation:"2 Overview of the Landscape: Tensions and Promise." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Page 14
Suggested Citation:"2 Overview of the Landscape: Tensions and Promise." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
×
Page 15
Suggested Citation:"2 Overview of the Landscape: Tensions and Promise." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
×
Page 16
Suggested Citation:"2 Overview of the Landscape: Tensions and Promise." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
×
Page 17
Suggested Citation:"2 Overview of the Landscape: Tensions and Promise." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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2 Overview of the Landscape: Tensions and Promise The workshop began with two keynote presentations that provided an overview of the landscape related to how actors in the health care delivery system are addressing health-related social needs and the social determinants of health (SDOH), and it explored some of the tensions and promise of those efforts. Highlights from the two presentations and sub- sequent discussion are provided in Box 2-1. Session moderator Marc Gourevitch of New York University Langone ­ Health began by sharing a simple diagram that he used to illustrate the workshop agenda. As Figure 2-1 shows, different categories of organizations may be better suited to assume a lead or a partner role when working to respond to the spectrum of social needs, depending on whether those needs are expressed by patients or by communities. Gourevitch pointed out that the gradient from downstream to upstream interventions is a continuum, and any single action such as screening or referral could be viewed as downstream or midstream depending on whether one is approaching it from the perspective of a health system or a community-based organization. The boundaries among categories are ­ fluid as well, and as one moves up or down in the figure, the role of any particular ­ ector shifts. For example, Gourevitch noted that health care s would be more likely to be in the lead on a downstream (e.g., clinically oriented) effort, and to assume a more supportive, collaborative role in an upstream effort, which may be better led by a social service agency. Gourevitch explained that one of the workshop’s tasks was to show- case examples of interventions from across the spectrum that feature dif- 5 PREPUBLICATION COPY—Uncorrected Proofs

6 MODELS FOR POPULATION HEALTH IMPROVEMENT BOX 2-1 Key Points Made by Individual Speakers and Participants •  ome organizations are best suited to lead and others to partner or col- S laborate in addressing downstream, midstream, and upstream factors re- garding health-related social needs or social determinants of health (SDOH). (Gourevitch) •  here is a lack of consensus regarding which social risk factors are most im- T portant to screen for in clinical settings, which measures to use in screening for those factors, and even whether conducting social risk screenings at the patient level is appropriate. (Gottlieb) •  here are five categories (five As) of SDOH-related health-sector activities— T awareness (which can be individually and/or community focused), adjustment and assistance (which are individually focused), and alignment and advocacy (which are community focused). (Gottlieb, in reference to NASEM, 2019a) •  s part of focusing on greater integration of social services in health care, A it is important to keep in mind potential unintended consequences (e.g., on patients, clinicians, the social sector), but early research indicates some of the feared negative consequences may be unlikely. (Gottlieb) •  afety net providers frequently adjust medical care to accommodate social S factors that could interfere with treatment, although this is not systematically built into all health care practices. (Gottlieb) •  orth Carolina’s Healthy Opportunities initiative pilots will allow the state to ex- N amine how contributions to social services may improve health care outcomes. (Money) • t is important to listen to communities and align activities with community I needs and priorities. An initiative is more likely to be successful when the community is invested in the solution and the outcome. (Money) FIGURE 2-1 Heuristic illustrating the roles of various sectors in downstream, midstream, and upstream interventions. SOURCE: Gourevitch presentation, September 19, 2019. PREPUBLICATION COPY—Uncorrected Proofs

OVERVIEW OF THE LANDSCAPE 7 ferent types of entities, including a public health agency, health system, and human services agency in the lead role. Much of the discussion would feature the perspectives of health systems or health care organizations. The examples are intended to illustrate the range of innovative work taking place across the country and elevate the types of governance, leadership, and institutional infrastructure that are needed to help health systems work with communities and other partners to address health and the nonhealth needs of their patients and communities. Gourevitch also described Figure 2-2 as a map of some of the lead conceptual models that situate health care’s contribution to population health on the downstream, midstream, and upstream continuum. He noted that the diagram references recent key publications from Alderwick and Gottlieb (2019), Auerbach (2016), Castrucci and Auerbach (2016), and Kindig and Isham (2014), and it aims to portray commonalities and highlight differences in language and framing across types of interven- tions. As he explained, moving from the bottom to the top, attention shifts Up/mid/downstream paradigms in advancing upstream. Fromhealth equity are from downstream to midstream to population health & left to right Locus of Action Prevention Approach Tactics Healthcare sector Sector-level and Infrastructure (adapted from Auerbach, “3 (adapted from Alderwick & (adapted from Castrucci & Auerbach) engagement cross-sector and system buckets of Gottlieb, Milbank Mission-centrality, capabilities, control (adapted engagement needs prevention”) 2019) from Kindig & Isham) UPSTREAM Total Improving SDoH at Shaping laws, policies, Mission-aligned; population or population (area) regulations & Limited capabilities; community- level through investments (public & Low control; wide collaboration w/ private sector) that Action through prevention other create community partnership sectors/services conditions supporting Cross- P cutting health for all people H u E e b d H Workforce? a l u o Prevention Community and Health-related social l i Org. services social service needs screening in c u t c structures? MIDSTREAM extend into partnerships to clinical settings; h a s community target care to CHW initiatives; t i Org. policies? (e.g., CHW- or identified needs of Closed-loop referrals w/ c H i n home-based) specific patients CBOs a e Data & o g technology r a n e l Metrics t Others? h Traditional Mission-central; clinical Social needs- Clinical preventive Many capabilities; preventive informed care services High control services DOWNSTREAM ***WORKING DRAFT – prepared by Marc Gourevitch with assistance from Alina Baciu to inform discussion at the September 19 workshop Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream FIGURE 2-2  Diagram displaying up/mid/downstream paradigms in advancing population health and health equity. NOTES: The bidirectional arrows illustrate the recognition that practices or activi- ties do not fall neatly in one category but occur on a spectrum. The gradations of color among the few sectors provided as illustration (health care, public health, education, and housing) are meant to signify the level of responsibility for a given sector (darker = greater; lighter = lesser). SOURCE: Gourevitch presentation, September 19, 2019. Prepared with assistance from Alina Baciu. PREPUBLICATION COPY—Uncorrected Proofs

8 MODELS FOR POPULATION HEALTH IMPROVEMENT various models or frameworks that address contributions of health care, public health, and other sectors (see narrow blue bands at right) along the spectrum from identifying and addressing an individual’s risk factors to tackling upstream SDOH. ACTIVITIES IN THE HEALTH CARE SECTOR TO IMPROVE SOCIAL CARE AND STRENGTHEN SOCIAL RESOURCES Via videoconference, Laura Gottlieb of the Social Interventions Research and Evaluation Network (SIREN), University of California, San Francisco, presented on ways health care systems are identifying and intervening in social conditions as part of efforts to improve health for individual patients and communities. She suggested that the recent emphasis on addressing SDOH and social risks within the health care delivery system is only one part of a comprehensive strategy necessary to achieve population health and health equity. Categories of Health Care Activities Related to Social Conditions Gottlieb explained that the National Academies of Sciences, Engineer- ing, and Medicine’s Committee on Integrating Social Needs Care into the Delivery of Health Care to Improve the Nation’s Health, of which she was a member, articulated five categories of health-sector activities related to providing social care or improving social conditions—the five As (aware- ness, adjustment, assistance, alignment, and advocacy; NASEM, 2019a). A foundational step for improving social conditions is increasing awareness of social risk and protective factors. As a result, an increasing number of health care systems are investing in ways to obtain that information at the patient and population levels. At the patient level, examples include standardized social risk screening tools such as measures proposed by the National Academies committee;1 the National Association of Commu­ ity n Health Centers and partners’ Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) tool;2 and the social risk domains included in a tool developed under the Center for Medi- care & Medicaid Innovation’s (CMMI’s) Accountable Health Communi- ties demonstration project. She noted that there is a lack of consensus regarding which social risk factors are most important to screen for in 1 The committee authored the report Integrating Social Needs Care into the Delivery of Health Care, available at https://www.nap.edu/25467 (accessed July 1, 2020). 2 The National Association of Community Health Centers’ PRAPARE assessment tool is avail- able at http://www.nachc.org/research-and-data/prapare/about-the-prapare-­ ssessment-tool a (accessed July 1, 2020). PREPUBLICATION COPY—Uncorrected Proofs

OVERVIEW OF THE LANDSCAPE 9 clinical settings, which measures to use in screening for those factors, and even whether conducting social risk screenings at the patient level is appropriate. One alternative to collecting patient information involves using c ­ommunity-level social risk data as a proxy for individual level risks, such as by linking a patient’s address or zip code with census tract data. As Gottlieb explained, several new technologies can be useful in display- ing community-level data. For example, HealthLandscape allows health systems to map data on where their patients live and the social resources that are available in that area. Just as awareness strategies span the spectrum from a focus on the individual patient to a focus on the whole community, Gottlieb high- lighted that health care system activities to intervene in social conditions are also wide ranging. Two categories of activities that focus on patients and the delivery of health care services are (1) the adjustment of medical care or treatment decisions based on information about social risk, and (2) interventions by health care systems to assist patients in improv- ing social conditions by providing social services onsite or connecting patients to social services offsite. Gottlieb explained that many providers working in safety net health care delivery systems already adjust medical care to accommodate individual-level social factors that could interfere with treatment, although these alterations are not always done systemati- cally. Adjustments can be made to improve access, diagnostics, or treat- ment. For example, to improve access to care, health care systems use mobile units, offer clinics on evenings and weekends, provide interpreter services, and adjust written resources for different literacy levels. The American College of Obstetricians and Gynecologists guideline on preeclampsia includes “low-income” as a moderate risk factor and suggests it be used to guide aspirin therapy. As another example, pro- viders may opt to avoid using diuretics when treating hypertension in homeless populations given challenges with restroom access. Gottlieb also described innovative work on diabetes care informed by social risk. For example, a 2019 paper explored ways in which providers change the way they care for patients with diabetes based on information about the patient’s social risk (Hessler et al., 2019). She noted the study found that providers reported changing blood sugar goals, engaging in more cost-sensitive prescribing, and making other treatment changes based on information about social risk. She suggested that this model could also help to inform chronic disease management in other areas. She pointed out that the health care system has not yet determined what interventions work best for which populations, and care informed by social risk is applied inconsistently. She specified that a major challenge to adjustment strategies is that the health care system has not clarified how PREPUBLICATION COPY—Uncorrected Proofs

10 MODELS FOR POPULATION HEALTH IMPROVEMENT to implement some of these recommendations and not elucidated what interventions work best for which populations. Gottlieb suggested that more research is needed to enable the use of social risk data to improve medical care, social risk data should be available to providers at the point of care, and effective interventions should be built into electronic health systems. Gottlieb went on to describe “social risk-targeted care,” which involves using health care system resources to improve patients’ social context. In the National Academies report, these activities are categorized as “assistance” strategies. Examples include helping patients obtain a refrigerator to be able to refrigerate medications, connecting patients to food programs, and helping patients obtain jobs paying a living wage. In addition to the patient-directed adjustment and assistance strate- gies, Gottlieb noted that the National Academies committee also consid- ered ways that the health care system can affect social conditions at the community level. Strategies include better aligning health care actions with community priorities and advocating for policy changes that change the resource and equity landscape. Examples include ways hospitals and health care systems align their own institutional practices around issues, such as procurement and hiring, with the needs of the surrounding com- munity. Another example is CMMI’s Accountable Health Communities demonstration project, in which 24 health systems are supported to con- vene intersectoral advisory committees to fill gaps in social service needs. Gottlieb used the issue of food security to illustrate how the five As could complement one another—and potentially be engaged simultane- ously. For example, screening for food insecurity in health care settings is increasingly common. Providers could use that information to adjust insulin doses for patients with food insecurity when food access is low. Community health workers could assist by providing support for meal programs or connect patients with existing programs. Hospitals could align their needs with those of the community by sourcing hospital food from local farms or hosting farmers’ markets. They could also advocate for increased or sustained food program benefits for low-income popula- tions. Figure 2-3 outlines these five categories of SDOH-related health- sector activities. Tensions on the Path Upstream Gottlieb stated that while both downstream and upstream approaches to increasing health care system engagement are critical, there are many obstacles to achieving them; just as importantly, there is the potential that such approaches may incur unintended consequences. One potential unintended consequence that Gottlieb highlighted is that PREPUBLICATION COPY—Uncorrected Proofs

OVERVIEW OF THE LANDSCAPE 11 FIGURE 2-3 The five As: A visual representation of the categories of SDOH- related health-sector activities. SOURCES: Gottlieb presentation, September 19, 2019; NASEM (2019a, Figure 2-1, p. 34). asking about social risk factors could offend patients, worsening rela- tionships with the health care system and exacerbating inequities in access to health care services or treatment adherence. She highlighted new work suggesting that this may be an unlikely effect, but she noted that this area demands more study. Another potential unintended con- sequence is the possibility that if not monitored, the availability of social risk data at the point of care could increase medical treatment bias and discrimination. Gottlieb also wondered “could the health care sector’s ­ sudden enthusiasm around SDOH actually end up exacerbating our underfunding crisis in the third sector?”3 She suggested that academics, patients, providers, community members, public health practitioners, and social services representatives work together to increase awareness of potential unintended consequences and invest in effectiveness and implementation research to understand how health care sector activities affect patients from different demographic groups, as well as caregivers, and the social sector. Gottlieb noted that initial research from SIREN has produced early evidence that some of the potential unintended consequences described are unlikely. For example, her research group has found that many, although not all, patients appreciate being asked about social risk in clinical settings. It also found that patients want to talk about social risks in health care settings, even if they do not expect health care providers to 3 The third sector, or social sector, is an umbrella term for organizations that are neither in the public nor private sectors, such as community volunteer organizations and other nonprofit organizations. PREPUBLICATION COPY—Uncorrected Proofs

12 MODELS FOR POPULATION HEALTH IMPROVEMENT resolve the issues. Also, health care providers in clinics that provide more social services are less likely to be burned out. Gottlieb noted that research from SIREN may be a resource for stake- holders working to improve the way health care systems engage around social conditions as a strategy for improving health. OPPORTUNITIES FOR HEALTH: ADDRESSING SOCIAL DETERMINANTS OF HEALTH E. Benjamin Money of the North Carolina Department of Health and Human Services (NCDHHS) spoke about the state’s approach to address- ing SDOH. He opened by noting that he is relatively new to his current role and previously led the primary care association in North Carolina, which was an early partner in addressing social determinants, or social drivers, of health. Money noted that most of the current work builds on successful past initiatives. Background on North Carolina and Its Approach to Addressing Social Drivers of Health Money provided background on the state of North Carolina, noting that it is the 10th most populous state in the United States and 37th in overall health status. Approximately one in five children experience food insecurity and a similar number have two or more adverse childhood events. Nearly half (47 percent) of women experience intimate partner violence. The state’s legislature has not expanded Medicaid, which would benefit more than 500,000 people. He noted that 29 percent of low-income adults have forgone needed care because of cost. Money pointed out that North Carolina also has challenges with affordable housing and growing gentrification in urban areas, which are particularly affecting people dis- placed from coastal areas due to hurricanes. Politically, North Carolina is “purple,” with a Democratic governor and a Republican-led legislature. The state is also racially diverse. As Money pointed out, the state of North Carolina has recognized the importance of buying health, rather than just health care, as health is driven by more than health care. In fact, Money stated that health care accounts for only 10 percent of health status, and health is instead largely deter- mined by behaviors, social circumstances, and environmental exposures. As most of the state’s health-related spending is on health care, there is a significant opportunity to increase attention to the other factors that influence health. The state’s vision for addressing social drivers of health involves opti- mizing health and well-being for all residents by bridging communities PREPUBLICATION COPY—Uncorrected Proofs

OVERVIEW OF THE LANDSCAPE 13 and the health care system. Money pointed out that achieving this vision will require partnerships and humility. The state is focused on partnering with community-engaged organizations and moving into managed care. As he explained, North Carolina is the largest state without a Medicaid managed care program. The state is moving from a fee-for-service model to one that is value based and takes a whole-person approach to care, integrates physical and behavioral health care, and seeks to buy health rather than health care. He noted that the state is taking a data-centered approach to this work. Medicaid Transformation As Money explained, Medicaid transformation is a key driver of the state’s work to address social factors that influence health. He noted that Medicaid transformation was originally scheduled to launch in February 2020, but political disagreements around Medicaid expansion between the governor and legislature are likely to delay that timeline.4 The state is intending to move toward a “whole-person care system” with ­ edicaid M managed care organizations, also called prepaid health plans. These pre- paid health plans will focus on physical health, behavioral health, and unmet social needs using a three-tiered provider structure. The system will move toward increased value by providing enhanced payments and supports for the provider to engage in case management and care coordi­ nation. Money outlined three components of the healthy opportunities landscape: (1) implementing Healthy Opportunity pilots that are part of the state’s 1115 waiver from the Centers for Medicare & Medicaid Services, (2) incorporating robust elements within Medicaid managed care, and (3) using a healthy opportunities framework for all popula- tions. Priority domains for case management and value-based payments include food security, housing stability, transportation, interpersonal envi- ronment, employment, toxic stress, and adverse childhood experiences. Money outlined the elements of the Medicaid managed care model, as shown in Figure 2-4. The Healthy Opportunities initiative pilots will allow the state to examine how contributions to discrete services may improve health care outcomes. In-depth analysis of the strategies and results will drive future adjustments to the Medicaid managed care model. A key component of the 4 The transition to Mediaid Managed Care is expected to take place in summer 2021. See https://files.nc.gov/ncdma/NCMT_Provider_FactSheet-NCMT-Overview_20210118. pdf (accessed May 4, 2021) and https://journalnow.com/governor-signs-medicaid-­ transformation-bill-new-format-projected-to-start-in-july-2021/article_7379d2f5-8830-5ffc- 8f67-7889d7fef742.html for more information (accessed May 4, 2021). PREPUBLICATION COPY—Uncorrected Proofs

Robust Elements within Medicaid Managed POPULATION HEALTH IMPROVEMENT 14 MODELS FOR Care Care Management Integration Quality with Address 4 Priority Domains: Department Strategy Housing Partners Food Healthy Interpersonal Opportunity Transportation Violence Pilots Value-Based Payment Contributions In Lieu of to Health- Services Related Resources FIGURE 2-4  Visual representation of the elements, including four priority do- mains, in North Carolina’s Medicare managed care program. 4 SOURCE: Money presentation, September 19, 2019. model will be care management that uses teams of care man­ gers focused a on navigating and providing resources for social services and trauma- informed care. As Money explained, the model will use an interdisciplin- ary team-based care approach that includes providers such as housing and legal specialists. Standardized screening tools and an electronic referral system will also be used. Increased focus will be given to high-needs cases, such as people experiencing homelessness or interpersonal violence. The program is also focused on aligning payments and incentives. Money pointed out that value-based payments for health and the delivery of social services create incentives for prepaid health plans to invest in those services, particularly in communities involved in the pilots. Infra- structure and elements of the program include • geo-mapping hotspots of social drivers across the state, • standardized statewide screening questions on SDOH that were adapted from existing tools such as PRAPARE and tested within the state, • a statewide coordinated network with a shared technology plat- form called NCCARE360, and PREPUBLICATION COPY—Uncorrected Proofs

OVERVIEW OF THE LANDSCAPE 15 • community health workers that are trained through community col- leges statewide to be employed by health systems and health plans. NCCARE360 is being implemented independent of Medicaid in 30 counties in the state, with a goal of statewide implementation by the end of 2020. In addition, Money noted that a statewide resource direc- tory is being developed. While a statewide call center has existed for several years, the resource directory will be integrated into the call center and data will be collected and analyzed. The Unite Us referral platform will also be made available and supported by county-level community engagement managers. In the future, Money explained, the state intends to be able to use data obtained through the resource platform on social needs and morbidity data through the health information exchange for data analytics and geo-mapping. Healthy Opportunities Pilot Program Money described the Healthy Opportunities pilot program, which will dedicate $650 million over 5 years to pay for discrete services to enhance health outcomes for Medicaid beneficiaries in managed care plans. The prepaid health plans would provide this funding through lead pilot enti- ties, which are organizations and communities that bridge the relationship between health care organizations and housing, food, and transportation service providers in the community. Money noted that it will be important to ensure that the pilot pays for nonhealth care interventions that will improve the health of the most vulnerable patients and that the services are used. To be eligible for the program, participants must have at least one physical or behavioral health condition and one social risk factor. Exam- ples of eligible physical or behavioral health conditions include pregnant women with multiple gestations, children in neonatal intensive care units, and adults with two or more chronic conditions. Social risk factors include homelessness, food insecurity, and transportation insecurity. Program ser- vices must address food, housing, transportation, or interpersonal vio- lence. For example, services to address housing could include assistance with 1 month’s rent, security deposit, utilities, or weatherization programs. Services to address food insecurity could include support with enrollment in the Special Supplemental Nutrition Program for Women, Infants, and Children or the Supplemental Nutrition Assistance Program, healthy food packages, and medically tailored meals for people with chronic disease. Transportation assistance could provide services for health care and social service visits. With respect to financing, Money explained, prepaid health plans will have a capitated rate and advanced care payments with incentives that PREPUBLICATION COPY—Uncorrected Proofs

16 MODELS FOR POPULATION HEALTH IMPROVEMENT move toward value and incorporate social drivers that influence health. To evaluate the effect, the state has partnered with the University of North Carolina and the Sheps Center for Health Services Research. The evalu- ation will involve rapid cycle assessments that quickly determine which strategies are working and allow for adjustments as needed. The goal is to ensure that the program works with communities and meets their needs. Models will be used to expand the approach statewide. The development of the program is under way, with review of the request for proposals (RFP) and final revisions to program details taking place during fall 2019. After the RFP is released, funding for lead pilot entities will be awarded in early 2020. For the next 5 years, the focus will be on building the capacity of the lead pilot entities, health services orga- nizations, and communities, as well as refining the model. The program is slated to end in October 2024. In addition to NCDHHS, other key partners include the state’s Medicaid ­ program, Blue Cross and Blue Shield of North Carolina, several health sys- tems within the state, and primary care providers that have already been participating in the Medicare Shared Savings Program and other value- based payment models. AUDIENCE DISCUSSION Gourevitch opened the audience discussion by asking Gottlieb if her research has found effective approaches based on the five As of care informed by social risk. Gottlieb responded that research has been primar- ily focused on awareness and assistance activities. Research on adjustment strategies exists in select medical disciplines but has not been collected and aggregated specifically under this bucket. Though there is consider- able interest and investment in alignment and advocacy strategies, there has not been much research done in these areas. This is in part because it is more difficult to conduct research in a multisectoral partnership, which is more common with those types of interventions. Gottlieb sug- gested that more health services research on all of these topics is needed. Gourevitch asked Money to what extent the health care sector is in support of, and engaged with, the programs in North Carolina that he described. Money responded that the health care sector has been engaged from the beginning. The Medicaid transformation initiative stems from an interest by the legislature during a prior administration to move Medicaid from fee-for-service to managed care. As he explained, the health care systems at that time indicated an interest in addressing factors outside their usual focus that improve health, as such factors influence health plans’ abilities to improve health outcomes, which is central to a capitated payment model. When the current governor began his administration, the PREPUBLICATION COPY—Uncorrected Proofs

OVERVIEW OF THE LANDSCAPE 17 model shifted to emphasize SDOH and the Healthy Opportunities pilot was developed. Health systems, providers, and other community mem- bers were invited to comment on the model for the Healthy Opportunities pilot, which was subsequently adjusted based on public feedback. Sanne Magnan of the HealthPartners Institute asked how to ensure that systems in communities address community needs rather than assess risk. Money responded by emphasizing the importance of listening to communities and aligning activities with community needs and priorities. He noted that public health often uses its own data sets, analytics, and geomaps to identify the problems and the solutions, ignoring the com- munity’s own perceived needs and proposed solutions. He pointed out that an initiative is more likely to be successful when the community is invested in the solution and the outcome. Money suggested that greater emphasis on ensuring that interventions meet the needs of the community and the public health agenda fits into the community’s agenda. He also pointed to the need for increased respect for the work that communities have done and leadership within the community. Gottlieb added that she agrees with Money that it is important to ensure that health care delivery interventions meet the needs of patients and communities. For example, she noted that some research has shown that people who agree with the idea of social risk factors do not consis- tently accept assistance from health care systems related to these risk fac- tors. Gottlieb noted that this reveals an important research question about how health care systems can ensure that any new activity meets patients’ needs and priorities. Jennifer Little of Klamath County Public Health in Oregon asked Money how the programs and frameworks that he described, such as the Healthy Opportunities pilots, may work differently in rural versus urban environments. Money responded by noting that North Carolina is both an urban and a rural state, and these types of communities have different needs. For example, a rural transportation system is different from an urban one. He noted that the state’s Office of Rural Health works with rural counties on approaches to address the four domains (see Fig- ure 2-4) at the county level. For example, Money described a community health center in the more rural eastern part of the state that has used existing resources, such as church and agency vans, to create a transporta- tion network. They also developed community gardens to address food i ­ nsecurity. A faith-based organization is supporting income development and sustainable agriculture by training community residents to become beekeepers. Money added that the closure of many critical access hospi- tals in rural areas provides an opportunity to determine what rural health care should look like, incorporating strategies that address the social drivers of health. Gottlieb noted that assistance is the one of the five As PREPUBLICATION COPY—Uncorrected Proofs

18 MODELS FOR POPULATION HEALTH IMPROVEMENT that would most likely differ between urban and rural populations, since urbanicity often affects resource availability. Lourdes Rodriguez of the Dell Medical School at The University of Texas at Austin asked for the panelists’ perspectives on moving from a pilot project to a scaled-up intervention. Money responded that data will be critical for demonstrating that investment in an intervention is cost saving. For example, he explained that the cost of a refrigerator for insulin is less than the cost of even an ambulance ride to the hospital for a diabetic who does not take his or her insulin. Gottlieb added that there could be many additional considerations, given that standard insulin does not need refrigeration if used within 28 days. An alternative cost-effective adjustment strategy for providers might be to prescribe a supply of insu- lin that does not require refrigeration, though the comparative effective- ness (e.g., on quality of life, adherence, and other health-related outcomes) and cost-effectiveness of these different types of interventions should be evaluated. She noted that the National Academies report on integrating social care into health care delivery includes content regarding financing strategies and how to scale up pilot projects (NASEM, 2019a). Alyssa Crawford of Mathematica stated that interventions in health care often target the easier problems first and she sees a similar pat- tern emerging with interventions to address SDOH. She said longer-term investments are needed that address more challenging issues such as systemic racism and social isolation. Crawford asked the presenters about promising practices that address these types of larger challenges. Money noted that some European countries may provide a model for the United States in promoting equity in health outcomes. He stated that income inequality is a particular challenge in the United States and stems from historic and systemic racism. PREPUBLICATION COPY—Uncorrected Proofs

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Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop Get This Book
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The Roundtable on Population Health Improvement of the National Academies of Sciences, Engineering, and Medicine hosted a public workshop on September 19, 2019 titled Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream. The term upstream refers to the higher levels of action to improve health. Medical services act downstream (i.e., at the patient level) in improving population health, while such activities as screening and referring to social and human services (e.g., for housing, food assistance) are situated midstream, and the work of changing laws, policies, and regulations (e.g., toward affordable housing, expanding healthy food access) to improve the community conditions for health represents upstream action.

The workshop explored the growing attention on population health, from health care delivery and health insurance organizations to the social determinants of health and their individual-level manifestation as health-related social needs, such as patients' needs. The workshop showcased collaborative population health improvement efforts, each of which included one or more health systems. This publication summarizes the presentations and discussions from the workshop.

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