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The American Journal of Accountable Care March 2018
Medicare Accountable Care Spending Patterns: Shifting Expenditures Associated With Savings
David B. Muhlestein, PhD, JD; Spencer Q. Morrison, BA; Robert S. Saunders, PhD; William K. Bleser, PhD, MSPH; Mark B. McClellan, MD, PhD; and Lia D. Winfield, PhD
ACO Quality Over Time: The MSSP Experience and Opportunities for System-Wide Improvement
William K. Bleser, PhD, MSPH; Robert S. Saunders, PhD; David B. Muhlestein, PhD, JD; Spencer Q. Morrison, BA; Hoangmai H. Pham, MD, MPH; and Mark B. McClellan, MD, PhD
Chronic Pain as a Driver of Cost in ACO Arrangements
Joshua A. Rushakoff, BS; Ramana Naidu, MD; and Ami Parekh, MD, JD
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A Managed Care Organization's Call Center–Based Social Support Role
Zachary Pruitt, PhD; Pamme Lyons Taylor, MBA, MHCA; and Kristopher M. Bryant, BS
Thirty-Day Readmissions: Relationship to Physician Attending Type and Social Connectedness
Carey C. Thomson, MD, MPH; Nathalie Bloch, MD, MPA; Tafadzwa Muguwe, MD, MS; Kendell Clement, PhD; Shani Legore, BA; Orissa Viza, MSW, MPH; Joanne Kerwin, PhD; and Valerie E. Stone, MD, MPH
Outpatient Referral Rates in Family Medicine
Maribeth Porter, MD, MS; John Malaty, MD; Charlie Michaudet, MD; Paulette Blanc, MPH; Jonathan J. Shuster, PhD; and Peter J. Carek, MD, MS
Predictive Factors of Discharge Navigation Lag Time
Charles Walker, MD; Sayeh Bozorghadad, BS; Leah Scholtis, PA-C; Chung-Yin Sherman, CRNP; James Dove, BA; Marie Hunsinger, RN, BSHS; Jeffrey Wild, MD; Joseph Blansfield, MD; and Mohsen Shabahang, MD, PhD

A Managed Care Organization's Call Center–Based Social Support Role

Zachary Pruitt, PhD; Pamme Lyons Taylor, MBA, MHCA; and Kristopher M. Bryant, BS
This study describes an alternative approach to linking patients to community resources, such as food banks, housing, and medical transport, using a call center–based layperson role.

Objectives: We described the social support provided by CommUnity Liaisons, a layperson role that addresses participants’ unmet social needs with linkages to community resources. The call center–based role operates within HealthConnections, a managed care organization’s program responsible for developing a nationwide network of local community-based social service organizations.

Study Design: We utilized an explanatory case study approach to describe a new health layperson role.

Methods: Multiple evidentiary sources, including in-depth interviews, training documents, and program data, enabled analysis of the application of the CommUnity Liaison role to social support theory within a logic model framework.

Results: To alleviate the impacts of stress on participant health, the call center–based program created a social support layperson role. Consistent with social support theory, CommUnity Liaisons’ experiences enabled them to match participants’ unmet social needs with community resources not covered by their insurance benefits. Social service referrals most commonly included patient and family support, transportation, and housing assistance.

Conclusions: This study’s results demonstrated the feasibility of managed care organizations to address social determinants of health using a social support layperson role. Future study should investigate whether this form of social support protects population health and reduces healthcare spending.

The American Journal of Accountable Care. 2018;6(1):e16-e22
The presence of stress is related to increased morbidity and mortality,1,2 whereas social support from a person’s network, such as family, friends, and valued peers, may protect their health.3-6 A majority of physicians acknowledge that unmet social needs contribute to poor health outcomes, but most report a lack of time during the clinical appointment to address patients’ social needs in addition to their medical needs.7 They also may be unwilling or unable to address patients’ social determinants of health.8,9 Garg et al have suggested that when providers screen for issues, such as food insecurity, unemployment, and interpersonal violence, without the capacity to link to community resources, their effort becomes “ineffective and, arguably, unethical.”10

To more effectively address unmet social needs, most physicians want social service coordination to be funded by payers, such as managed care organizations (MCOs).7 Alternative social support roles have been introduced by MCOs but have not been formally studied. Existing literature describes layperson roles that leverage the advantages of social support to improve the delivery of medical care.11 These individuals, such as community health workers,12,13 care guides,14,15 and lay navigators,16 seek to achieve patient-specific clinical goals by improving access to social services, such as transportation, food, and housing.

This study describes the new social support role, CommUnity Liaisons, developed by WellCare Health Plans, an MCO based in Tampa, Florida, that serves Medicaid and Medicare beneficiaries nationwide.17 WellCare established HealthConnections to improve plan members’ health and reduce unnecessary healthcare services utilization. The program comprises multiple operational components, including CommUnity Liaisons who make referrals to social service organizations. Other program elements include a research team that identifies local community resources, a field-based community relations team, an outbound call team that confirms referral access, and an analytics team. According to Carman and McGladrey,18 HealthConnections acts as a public health facilitator by identifying gaps between needs and services in the community, encouraging collaboration among community health stakeholders, and expanding local public health and social services capacity.

Since September 2014, participants with unmet social needs have contacted a call center to obtain free referrals to a nationwide network of local community-based public assistance programs. The social services have been provided to participants outside of the health plan benefits package. The call center, called the CommUnity Assistance Line, is available through a toll-free number or video link on weekdays from 9 am to 6 pm Eastern Standard Time. Participants learn of the referral program through numerous sources, including the MCO customer service and case management units, member materials (eg, provider directories), advertisements, and healthcare service providers. CommUnity Liaisons support all participants, including members, family, and other individuals unaffiliated with the MCO.

The present case study investigated the role of the CommUnity Liaison at a single MCO.19 Consistent with social support theory constructs, we posited that CommUnity Liaisons supported individuals who faced stressful circumstances and needed information about community resources.5,6 In addition, we expected that CommUnity Liaisons would provide informational and emotional support, both enabled by personal experiences with the social services system.20


Case study research enables descriptions of the characteristics, patterns, structures, or processes of individuals or complex systems.19 A case study protocol, including propositions related to social support theory, logic linking the evidence to the propositions, an analytical approach, and criteria for interpretation, was developed to guide this investigation. According to social support theory, interactions with similar and valued peers can be protective of individuals’ health in times of stress.5,6 Four types of social support are distinguished in the literature: emotional, instrumental, informational, and appraisal.4 The 5 propositions related to social support theory advanced by Cohen and Wills,5 Hogan et al,3 Thoits,20 and House et al21  were: 1) participants sought informational support from CommUnity Liaisons; 2) a CommUnity Liaison’s main goal was to provide informational support through advice, suggestions, and information that participants could use to address their problems; 3) CommUnity Liaison interventions provided emotional support conveyed through empathy, love, trust, and caring; 4) participants contacted the CommUnity Assistance Line because they experienced adversity; and 5) CommUnity Liaisons’ life experiences enabled empathic understanding and delivery of tailored information.

In-depth interviews with CommUnity Liaisons and managers of the program were conducted by researchers using semi-structured interview instruments, provided in eAppendix 1 [eAppendices available at]. The questionnaires consisted of 26 questions for CommUnity Liaisons and 28 questions for program managers. The interviews were organized using a logic model that enabled systematic review of the CommUnity Liaison role.22 The Figure describes the logic model used for the evaluation. Using purposeful sampling, 9 study participants were selected by a HealthConnections administrative staff member from the total of 28 CommUnity Liaisons. Each of HealthConnections’ 4 managers were interviewed. All interviews were conducted in December 2016 at the MCO headquarters. Additional information supplied by the MCO included number of referrals given, number of referrals accessed, call statistics, and training materials.

The analytic strategy of the interviews involved 3 key steps: 1) transcription, 2) analysis, and 3) interpretation. After the audio-​recorded interviews were transcribed, responses were coded by multiple researchers. These coded responses then were categorized according to theoretical propositions, and patterns of responses were analyzed. We interpreted the explanatory evidence according to consistency with the 5 social support theory–based propositions.19


Interviews revealed that CommUnity Liaisons mostly worked part time in the call center and were recruited through a variety of sources, including the state vocational rehabilitation agency, recruitment firms specializing in employment for people with disabilities, and the MCO’s employment website. Many CommUnity Liaisons had a variety of disabilities, including deafness and physical limitations. The ideal qualities of a CommUnity Liaison included being empathetic, engaging, and investigatory and having similar “lived experiences” as participants. Required skills included interpersonal communication, computer aptitude, and knowledge of social service programs. CommUnity Liaisons completed 2 weeks of training, including education on compliance, software, motivational interviewing, observational learning, and mock calls. Table 112-16 identifies distinguishing functions of the CommUnity Liaison role and other layperson roles.

CommUnity Liaisons utilized an extensive software suite that allowed them to locate more than 160,000 community resources in a database, identify service gaps in the local social services network, and manage referrals. The liaisons entered referral information into a dedicated “social services electronic health record” accessible by the liaisons and other MCO employees, such as nurse case managers. CommUnity Liaisons delivered referrals in 10 languages, including American Sign Language. Participants were responsible for making contact with the community organization directly. Table 2 indicates the most common types of social services that received referrals in 2016. The services were categorized consistent with the Nonprofit Program Classification System taxonomy developed for tax-exempt organizations by the National Center for Charitable Statistics.23 Table 3 shows the descriptive statistics of the CommUnity Assistance Line in 2016.

The following quotes were selected from the in-depth interviews as they related to the 5 social support theory propositions:

Proposition 1. Participants sought informational support from CommUnity Liaisons. Each of the respondents confirmed that participants sought informational support:
“We exist as an informational resource for what [social services] they can access in their communities.”

One respondent cited advice on social services as a reason participants called the CommUnity Assistance Line:
“[Participants] don’t know how to navigate the social service arena to get help. So, they’re looking for someone to guide them through that process.”
Proposition 2. A CommUnity Liaison’s main goal was to provide informational support through advice, suggestions, and information that participants could use to address their problems. All interviews with CommUnity Liaisons and CommUnity Assistance Line management confirmed this proposition. A CommUnity Liaison stated that the CommUnity Assistance Line’s purpose was to:
“… share knowledge and to empower people to be able to find help and to let them know that there may be help out there and it just may not be common knowledge.”

The information could be used to support participants’ medical and social needs:
“I love sharing information. People that don’t realize that there are a lot of different types of assistance programs out there, they may think, ‘Oh, I didn’t think of getting help for my utility bill to be able to pay for this surgery I’m supposed to get … or going to [a] food pantry and getting food, and then the money I would have spent on that food I can put toward this bill.’”

CommUnity Liaisons addressed more than 1 need:
“Even if they just call in for 1 issue, our [CommUnity Liaisons] are so good that they say, like, ‘Okay, is there anything else going on? Anything else we need to talk about? Okay, you need transportation to the grocery store or the pharmacy?’”

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