Three years ago, the Pennsylvania-based Reading Health System (today Reading Hospital is a part of Tower Health System) received a $4.5 million federal grant from the Centers for Medicare & Medicaid Services (CMS) that positioned the health system as a "hub" aiming to help bridge the gap between medical care and social services for local Medicare and Medicaid patients.
Reading Health was one of 32 organizations across the U.S. to receive federal funding at the time, with the goal to help test CMS’ Accountable Health Communities (AHC) care model, designed to increase Medicare and Medicaid beneficiaries' access to and awareness of available services and to ensure that community partners are aligned to provide patients with necessary services and support.
Reading Health partnered with the Berks Community Health Center and numerous community social service agencies to create the Berks Accountable Health Communities Consortium. Under the five-year pilot program, Reading Health and the Berks Community Health Center has worked to identify Medicare and Medicaid patients who receive medical treatment and who also have unmet social needs. If they do, a Reading Health team comprised of care navigators and community health workers—who have been specifically dedicated to this initiative—works to link patients with the appropriate social services, according to health system officials.
Desha Dickson, associate vice president of community wellness at Reading Hospital, says that receiving the AHC grant provided the necessary resources for the patient care organization to focus on its vulnerable populations—specifically how they can better respond to patients with socioeconomic challenges.
But even before the grant work began, Reading Health had developed a comprehensive community needs assessment, designed to identify the region’s most pressing health issues and create a collective path forward. These issues include access to care—including to behavioral health—addressing social determinants of health (SDOH), and disease prevention and management. Dickson, who leads Tower Health System’s community health and wellness activity, notes that over the last seven years, the organization has been focused on moving beyond just “checking the box” with its needs assessment, but instead on “really understanding our vulnerable population, identifying who those patients are, connecting with our community, engaging with them, and finding out which external and internal barriers exist to get well and stay well.”
From there, the health system has built several educational programs aligned with homeless outreach, food insecurity, the workforce pipeline, and combating obesity, mostly focusing on vulnerable populations—those individuals who live in areas where the average unemployment or poverty rate might be double or triple the county average, Dickson explains.
One specific project that has been core to Reading Hospital’s community wellness work has been its Street Medicine Program, launched more than four years ago and created to help the underserved in some of Berks County’s most remote locations. Health system officials have pointed out that at any one point in time, more than 500 homeless men, women, and children can be found living on the streets of Reading, under bridges, in shelters, or in temporary camps. “So we wanted to deliver [care] to them where they would be most comfortable, which could be at their campsite, food kitchen, or shelter,” says Dickson.
One principal challenge in that program, notes Dickson, was identifying how many homeless patients were going to Reading Hospital’s emergency department (ED). Her team had tossed around the idea of conducting a survey to find out how many patients who were being admitted were homeless. “The reason why we did not move forward with that survey is because we didn’t have a mechanism to then connect those patients with [the right] services,” she recalls. “We noticed that was our gap; we had the ability to treat them and provide care for them in the community, and we certainly had the ability to ask questions around SDOH, but we didn’t have the linkage.”
Enter the AHC grant work, which Dickson contends closed that fundamental gap. “We thought we are already halfway there in terms of connecting with and engaging our community, so we looked at the alignment track for the AHC and we felt like we are working a lot with our community members, and that it wouldn’t be tough to engage and align our efforts. What we really needed was that closed-loop referral and the AHC gave us an opportunity to do that. We were able to improve upon what we were already doing and strengthen that work,” she says. According to CMS, the organizations in the AHC Alignment Track will provide community service navigation services, as well as encourage community-level partner alignment to ensure that needed services and supports are available and responsive to beneficiaries’ needs.
Screening for SDOH
Although there is growing evidence that a significant amount—upwards of 70 percent, according to some research—of a person’s health outcomes is driven by SDOH factors, a recent study in JAMA Open Network, inclusive of responses from more than 2,100 physician practices and nearly 800 hospitals across the country, found that just one-quarter of U.S. hospitals and 16 percent of physician practices self-report screening patients for social determinants of health such as food, housing, transportation, utilities, and interpersonal violence needs.
Dickson believes that the person who is delivering that SDOH screen needs to be well-trained in asking non-medically-related questions. “This is extremely sensitive information, and we continually train our screeners with motivational interviewing and understanding body language. We pride ourselves on the [notion] that you cannot teach anyone to be compassionate or empathetic. So that’s what I look for in my patient screeners; rather than the degree you have or how many years in the field you have, are you familiar with the patient population, can you display empathy and compassion, and do people feel warm, welcomed and open around you?”
Dickson contends that oftentimes, providers are not the best people to do this SDOH screen, but that they still need to have all the non-clinical information at their fingertips when meeting with patients. Looking at Reading Hospital’s Street Medicine Program, for example, she explains that the provider needs to know the patient he or she just cared for, who had a sprained ankle, and was told to go home and keep his or her leg elevated for two weeks, is actually homeless. “Now, if that patient is homeless, a provider’s discharge instructions may be different. That is what the provider needs to know; if this patient has a health-related social need that may prevent them from following your instructions. So the first thing is determining who the best person in the organization is to deliver the screen, and that has been a barrier,” Dickson acknowledges.
The next key steps are taking information from patients and ensuring they get connected immediately to the services they need, and then continuing to follow-up with them over the long-term, says Dickon. “We can very easily just give that patient a phone number, but the problem is, how many times is that patient actually getting connected with those human resources?” That’s where Reading Hospital’s navigation program comes in, and its strong connection with community members, as well as a strong data system—the health system has partnered with Healthify, a company that works with payers and providers to create SDOH infrastructures—that’s reliable to pull those community resources out of, Dickson says. To the point of engaging with community-based organizations, she touts how important that has been, and that the AHC grant work was not a Reading Hospital project—it was a Berks County project. “This was something we all had to come to the table around and invest in; Reading couldn’t do it alone.”
Health system officials have pointed out that Reading leveraged community relationships to screen and refer patients to appropriate social services and track referrals, and as a result, it was able to reduce unnecessary ER visits by 15 percent, improve overall quality of care, and saved $1 million in one year.