The Alliance for the Determinants of Health is a three-year community-based demonstration that began January 2019 with support from a $12 million charitable contribution from Intermountain Healthcare. The Alliance is modeled after CMS’s Accountable Health Communities Model of awareness, assistance, alignment and is being piloted in two Utah counties among SelectHealth’s (ACO) Medicaid members. The chief aims are to scale best practices, reduce healthcare costs, and improve overall wellbeing of communities.
The Alliance is a community collaborative that seeks to improve physical, behavioral health, and social outcomes by addressing social need through connection to resources and improved coordination of care across the continuum. The main drivers being identified through screening are inadequate food, transportation, housing, safety, utilities, and access to care. Key performance indicators for the Alliance include reduction of avoidable emergency department utilization, implementation of screening and referral workflows across clinical sites, and the implementation of a digital platform to support better coordination of care across sectors. Outside evaluation is being performed by the PolicyLab team at Children’s Hospital of Philadelphia. Camden Coalition is studying patient and partner experiences, relationships between community organizations, and promising policies to sustain scaling.
Social screenings in clinical settings are targeted at high-risk members (based on emergency department utilization), but any SelectHealth Medicaid member indicating social need in designated geographies is eligible for services. Based on complexity of need, members are given information on community resources or assisted with resource coordination by an Alliance community health worker (CHW) in conjunction with the clinic’s care management team. The CHWs are funded by the Alliance and contracted through a not-for-profit primary care organization. A closed-loop, digital platform implemented by the Alliance is the preferred tool to send and receive referrals between organizations and improves accuracy of data collection. As the demonstration enters the final year, the focus is to improve the identification of high-risk members through social risk prediction analytics, allowing a more proactive, scalable, and targeted approach to identifying social needs and improving the in-person screening process.
A crucial lesson learned in the Alliance is support from both executive leadership and operational managers are needed for success; likewise, cultural adoption is just as crucial as workflow adoption. Screening for social need in a clinical setting is a cultural shift for both providers and patients, and simply asking the questions isn’t enough unless the intent is sincere. In terms of metrics, a variety of measures outside of ROI can demonstrate success, including health outcomes, engagement in one’s own health, improved coordination networks, and appropriate utilization. At the conclusion of 2020, avoidable emergency department utilization decreased 9 percent among the Alliance population. This can be partially attributed to COVID-19 and decreased utilization during stay-at home orders in the spring; however, the downward trend continued as patient volumes returned to normal levels. Since the Alliance is focused on a defined population it improves the likelihood of understanding causal factors like which interventions corelated with utilization.
From the onset, the Alliance was intended to model a community SDOH collaborative that could be scaled outside demonstration counties. 2021 marks the Alliance’s final year and the learnings are being folded into a new Utah SDOH Partnership, led by United Way of Salt Lake, with support from Leavitt Partners, which can provide a sustainable SDOH infrastructure. The partnership includes Utah Medicaid ACOs, health systems, and state government to develop a large-scale strategy for SDOH across payers and county lines. Intermountain Healthcare has provided funding to convene the partners and support the initial strategy deployment. The partnership aims to create a shared path with other key stakeholders using a collective impact approach to align strategies with the Alliance and other existing efforts.
Kaiser Permanente recognizes the importance of access to health-promoting environments (e.g. work, school, and diverse community settings where people spend much of their time) in addition to working on individual behavior changes to achieve “total health”. Kaiser Permanente utilizes a innovative framework to align its resources to maximize well-being for its beneficiaries and their communities.
There are 3 elements that support total health — and they’re all connected. Physical health is the health of your body. Mental health is the health of your mind. Social health is being able to take care of your basic needs — having a safe place to live, nutritious food, and positive relationships.
Kaiser Permanente’s focus on social health includes a variety of resources and case studies related to access to food, housing security, healthy relationships, and social connections. Kaiser’s social health focus fits into its innovative framework – “total health” – which uses and aligns all its resources to maximize physical, mental, and social well-being for its beneficiaries and the communities in which they live. These resources include sourcing and procurement, workforce pipeline development, training, investment capital, education programs, research, community health initiatives, environmental stewardship, and clinical prevention.
It emphasizes high-impact approaches like workforce wellness initiatives for employers and customers, increases access to healthy foods and physical activities in schools, and reduces Kaiser’s institutional carbon footprint through purchasing green energy. Kaiser also supports local economic development in communities of color through purchasing from women and minority-owned organizations. Kaiser Permanente actively pursues a “values- and mission-guided corporate strategy” in their effort to maximize and support the total health of their members and the communities they serve. The total health framework has three interrelated facets:
In order to address the social and non-medical needs, Kaiser Permanente also screens patients for unmet social needs and refers them to resources in their communities.