Statewide Networks Evolving to Meet Health-Related Social Needs

Nov. 20, 2020
Utah, Louisiana, Pennsylvania and Oregon among states making progress on expanding networks to meet social needs and track data

As the pandemic worsens, access to basic needs such as food, health care, and housing are strained more than ever. In response, health systems, community-based organizations and government entities are partnering to create statewide efforts to improve community health and social care and to track data statewide.

For example, Unite Louisiana uses the Unite Us technology platform to connect clinicians and social service providers to serve the health and social needs within communities and parishes statewide. Established in partnership with the Louisiana Association of United Ways and Louisiana 211, Unite Louisiana is currently in 14 parishes and growing. Since April 1, the network has grown by 70 percent. Unite Louisiana now extends into New Orleans, Baton Rouge and Shreveport with recently announced partnerships with CVS Health, Humana, and Ochsner Health. The Unite Louisiana network is also supported by Aetna Better Health of Louisiana and Louisiana Healthcare Connections.

Care managers at Aetna Better Health of Louisiana are using the platform to connect their Medicaid and Dual-eligible Special Needs Plan (DSNP) members with social services.

The Commonwealth of Pennsylvania has required patient-centered medical homes in its Medicaid managed care organizations to screen patients for social determinants. David Kelley, M.D., chief medical officer for the Pennsylvania Department of Human Services Office of Medical Assistance Programs, said the state is working on a request for proposals to get a statewide system set up to refer patients to community-based organizations and to track the data in a common system at the state level.

 The State of Oregon has created a statewide advisory group to develop a community information exchange at the state level. “A year ago, we begin to think about how to aggregate social and medical data — not to pick a platform or tool but to develop a roadmap of how to build this,” said Carly Hood-Ronick, M.P.A., M.P.H., director of CCO Strategy and Health Equity for the Oregon Primary Care Association. At the local level, she noted, there has been an explosion in the use of Social Services Resource Locator programs such as Aunt Bertha and Unite Us.

Expanding on pilots in Utah

Meanwhile, in Utah, several health systems have come together to extend work that Intermountain Healthcare piloted over the past two years in Ogden and St. George to drive better health outcomes by streamlining access to critical social services, and then removing barriers in areas such as housing, education, transportation, and jobs.

 The new partnership, supported by a $5 million commitment made from Intermountain in 2019, brings together state health systems and partners including Select Health, HCA MountainStar, Molina Healthcare, University of Utah Health, the University of Utah Health Plans, Steward Health Care, Health Choice, the Utah Hospital Association, the Association for Utah Community Health, Get Healthy Utah, the Utah Department of Health, the Utah Health Information Network (UHIN), the Governor’s Office of Management and Budget, and Cambia Health Foundation.

 “Prior to the pandemic, we recognized that poor health outcomes are not merely the result of individuals’ behaviors,” said Marc Harrison, president and CEO of Intermountain, in a statement. “They result from unrealized factors such as uneven economic opportunity or inequitable education and healthcare systems, and they create conditions that limit individuals’ choices. COVID-19 has merely served as a spotlight on the need for more equitable solutions that address the social needs of individuals and communities at large.”

United Way of Salt Lake (UWSL) has been building partnerships dedicated to transforming the systems that keep children and families from achieving their potential through health, financial stability, and education. By bringing together Utah’s leading health systems, community partners, and stakeholders across multiple sectors, UWSL and the Promise Partnership of Salt Lake will develop scalable solutions for addressing social determinants of health and establish an integrated plan for accelerated and equitable outcomes throughout its communities.

In 2019, Gene Smith, community health director at Intermountain, told Healthcare Innovation that one goal was to be able to have an electronic process to connect providers, while being able to follow patients longitudinally. “We wanted to be able to do that on the social services side. We were looking for a vendor that had the capability to collect the proper consent from individuals to share their information with partners and to follow the referral from start to finish, to help us measure outcomes,” he said. “We looked at about a dozen vendors, and a number focused on creating a resource directory. That wasn’t what was important to us.”

Intermountain also chose to work with Unite Us. “The software is great and nice to have,” Smith said, “but the real value was building a coordinated network of providers where you could share information about an individual and have user roles and security protections in place to protect sensitive data such as behavioral health and domestic violence information. We started out thinking about data sharing and software-related things and quickly learned that was a commodity across the applications. We were looking for someone who knew how to stand up a coordinated network of partners. Where Unite Us was strong was in showing a demonstrated ability to help organizations create partner networks and having a solid consent-gathering process.”

One lesson in this process, Smith said, “is that while we have been focused on external partners, we realized that our internal partners, our care management teams, our medical assistants, our ED managers, clinic managers, are very much a part of the network and have work flows to design. We need to spend as much time with them as with our external partners.”

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