Despite interest in addressing social determinants of health (SDOH) to improve patient outcomes, little progress has been made in integrating social services with medical care. Even for accountable care organizations (ACOs) that have been early adopters in addressing social needs, significant difficulties have been experienced in this area.
These findings were detailed in the February issue of Health Affairs, as researchers aimed to understand how healthcare providers with strong motivation (for example, operating under new payment models) and commitment (for example, early adopters) fared at addressing patients’ social needs.
For the study, the research team collected qualitative data from 22 ACOs that were early adopters and were working on initiatives to address social needs, including such common needs as transportation, housing, and food. However, the study’s authors noted, “even these ACOs faced significant difficulties in integrating social services with medical care.”
The study’s authors believe that little is known about how ACOs are actually working on social service integration. They noted, “This lack of data is due in part to the fact that despite the promise of new payment models to encourage providers to focus on population health and social determinants, relatively few are working in this area. Instead, many are focused on more basic factors of healthcare costs that are under providers’ direct control.”
The findings revealed that as expected, the set of ACOs analyzed were generally knowledgeable about and committed to social service integration work. In terms of the specific social needs that the ACOs in the sample reported working to address, the majority reported addressing transportation (95 percent), food (86 percent), and housing (77 percent) needs. A sizable minority reported addressing economic hardship (36 percent), challenges with health literacy (32 percent), and inadequate social support or loneliness (27 percent). Few ACOs reported working on safety issues (9 percent), legal services (9 percent), or underemployment and unemployment (5 percent).
However, few ACOs had formal programs or contracts that addressed social needs, and what contracts were in place were inadequately specified, the researchers stated. For example, three years into a study of one ACO, staff members working on community partnerships had only just started to talk with community-based organization partners about the number of ACO members they should be serving and about documentation requirements. Among the researchers’ phone interviews that were conducted, contracts with these partners were rare, and the majority of ACO respondents had not yet determined how better to formalize relationships with community partners.
The authors point to three key reasons as to why the implementation of social service and medical care integration was so challenging for organizations that were committed to that integration and on the leading edge of integration efforts:
1) The ACOs had few data related to social needs to use in making decision. One ACO had already built standard screening into its electronic health record (EHR) and had tailored software to feed screening data into a social services work flow that included care plans that both its own providers and relevant partnering community-based organization personnel could read and edit. But this ACO was a distinct outlier, having accomplished what its most sophisticated peers were still only considering for the future. Only half of the ACOs in our sample conducted standardized screening for social needs, and 45 percent used a standardized approach to documentation. What’s more, a minority of ACOs in the sample shared data with community partners, with only 14 percent planning to share and 9 percent currently sharing electronic data.
2) Partnerships between ACOs and community-based organizations were critical to developing programs but were often difficult to develop. The formality of partnerships between ACOs and community-based organizations varied widely, with most of the sample maintaining some kind of formal partnerships and 23 percent having only informal partnerships to complete social service integration work.
3) Implementation of innovations to address social needs was constrained by ACOs’ difficulties in determining how best to approach return on investment (ROI), given shorter funding cycles and longer time horizons to see returns on social determinants investments. ACOs in the sample also reported challenges with regulations determining how funds can be spent. Further challenging long-term sustainability was the fact that only about a quarter of the ACOs studied were thinking about social service integration work in the context of ROI. Among those ACOs that were doing so, most were uncertain of their capacity to calculate ROI, especially in the short run.
