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The American Journal of Accountable Care June 2018
Amazing Grace: A Free Clinic's Transformation to the Patient-Centered Medical Home Model
Jason Alexander, BS, PCMH CCE; Jordon Schagrin, MHCI, PCMH CCE; Scott Langdon, BA; Meghan Hufstader Gabriel, PhD; Kendall Cortelyou-Ward, PhD; Kourtney Nieves, PhD; Lauren Thawley, MSHSA; and Vincent Pereira, MHA, PCMH CCE
Lessons Learned in Implementing Behavioral Screening and Intervention
Richard L. Brown, MD, MPH
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The Intersection of Health and Social Services: How to Leverage Community Partnerships to Deliver Whole-Person Care
Taylor Justice, MBA, President of Unite Us
Effects of an Integrated Medication Therapy Management Program in a Pioneer ACO
William R. Doucette, PhD; Yiran Zhang, PhD, BSPharm; Jane F. Pendergast, PhD; and John Witt, BS
Are Medical Offices Ready for Value-Based Reimbursement? Staff Perceptions of a Workplace Climate for Value and Efficiency
Rodney K. McCurdy, PhD, and William E. Encinosa, PhD
Utilizing Community Resources, New Payment Models, Technology to Deliver Accountable Care
Laura Joszt, MA
Cost-Effectiveness of Pharmacist Postdischarge Follow-Up to Prevent Medication-Related Admissions
Brennan Spiegel, MD, MSHS; Rita Shane, PharmD; Katherine Palmer, PharmD; and Duong Donna Luong, PharmD

The Intersection of Health and Social Services: How to Leverage Community Partnerships to Deliver Whole-Person Care

Taylor Justice, MBA, President of Unite Us
As the healthcare industry continues its transition from volume to value, it is critical for healthcare organizations to leverage existing community partnerships to improve outcomes. 
The American Journal of Accountable Care. 2018;6(2):e15-e17
As the healthcare industry continues its transition from volume to value, it is critical for healthcare organizations to foster partnerships with community organizations to move the needle on health outcomes. The growing challenge of rising healthcare costs and poor health outcomes transcends industry lines. This means that the solution requires commitment and collaboration across sectors on all fronts.

Over a short period of time, the social determinants of health have emerged as a top priority at the federal, state, county, and city levels. We know that the structures that exist in people’s lives have an unparalleled impact on overall well-being and happiness. With this undeniable acknowledgment from all sectors, the conversations have changed. In the hospital setting, we are seeing providers seek ways to facilitate care outside of their specialty, whether by incorporating it into their practice, implementing screening tools, or generating external referrals. Within the payer world, we are seeing more investments in social programs and physical infrastructure, as well as the expansion of coverage to include behavioral health and social services.1

While this significant work is happening in healthcare, just as much innovation is occurring in the community. To date, a significant amount of funding and pressure has been directed toward the healthcare industry to solve the problem, but as many can guess, it will take more than just healthcare to solve this problem. It will take a village.

On the nonprofit and social service side, there are discussions around how to better support healthcare in the transition to value-based care. State programs have already started to integrate care between community-based organizations and health systems, and this integration is increasing dramatically.

A standard framework that has been consistent across organizations for expanding service delivery to incorporate social and behavioral services is to identify social needs through screenings, refer to external providers and partners, and track the total health journey of every patient in the community. This commentary will dive into this framework and discuss some partnerships rooted in the community that aim to support the transition from volume to value. 

Identifying Social Needs

To develop systematic change within healthcare and social service delivery, there need to be tiers of service delivery that lead to a fully integrated system. With this shift toward delivering integrated care, there are 3 main categories through which healthcare organizations will navigate. Screening and identifying social needs is the first. With the implementation and successful adoption of accountable care organizations and other value-based initiatives, the use case for screening has been widely accepted. According to a  Deloitte report, 88% of hospitals are screening for social needs as of April 2017.2 Although the report also noted that only 66% of these hospitals have implemented screening for social needs as a standard practice, their openness to adopting such screening is a huge indication that, more often than not, healthcare organizations are aware of, and engaging their high-utilization populations to identify, co-occurring medical, social, and behavioral needs.

As healthcare providers and care navigators screen for social needs, the next question becomes: How do we address these needs? Building community partnerships and programs is the path forward for many organizations, but the coordination and efficiency of this path is challenging. In an effort to identify resources and refer patients out of the clinical setting into the community, many entities have leveraged resource directories. These partnerships have helped move the industry forward to deliver care outside of the hospital’s 4 walls through community referrals, but unfortunately there have been some major challenges with this approach, including lack of visibility into the full patient journey, patients who are still seeking clinical care for their social needs, no information to track and measure outcomes and improved health, and limited accountability around the patients due to the lack of transparency.

To move the needle, healthcare organizations must invest in programs that support screening, referring, and measuring, not just 1 piece of this continuum.

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