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Clinical Interventions Addressing Nonmedical Health Determinants in Medicaid Managed Care
Laura M. Gottlieb, MD, MPH; Kim Garcia, MPH; Holly Wing, MA; and Rishi Manchanda, MD, MPH
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Clinical Interventions Addressing Nonmedical Health Determinants in Medicaid Managed Care

Laura M. Gottlieb, MD, MPH; Kim Garcia, MPH; Holly Wing, MA; and Rishi Manchanda, MD, MPH
This review examines the breadth of published work on interventions addressing nonmedical determinants of health that are supported by Medicaid managed care organizations.
Target populations included specific demographically defined groups—primarily low-income individuals, children, or families. Other population groups included seniors, minority groups (racial, ethnic), those experiencing homelessness, and those who were broadly eligible for Medicaid. Some interventions defined target populations based on healthcare utilization patterns (eg, high-cost, high-utilizer), while others focused on patients with specific health conditions (eg, asthma, hypertension, diabetes and other dietary-related chronic health issues, HIV, multiple sclerosis, mental illness).

Seven interventions specifically targeted a single social issue, such as housing (4),12,21,23 food quality and availability (2),23 and employment (1).23 The remaining 18 interventions provided more comprehensive services to address multiple SDH. Interventions varied widely in how they addressed SDH within the clinical setting. Specific intervention components included variations on team-based approaches, including case managers, social workers, community health workers, and other nonprofessional staff integrated into clinical teams—although the degree of integration and communication with other clinical staff was rarely described. Intervention settings also differed across programs, including both training and education delivered on site, referrals to off-site programs, and home visits.

The majority of the programs identified were designed to address both social and medical needs of the patients being served. For example, asthma programs typically included elements focused on pharmacological management and specific housing risk factor reduction.21 Other case management programs were designed to facilitate pharmacy and appointment access in addition to social service linkages.17,20,27

Evaluation

Eleven program descriptions included some empirical evaluation indicating effects of the intervention on health system outcomes. Five program evaluations reported reductions in emergency department (ED) visits16-19 and reductions in hospital admissions.16,17,19,20 The impact of 1 home-based intervention targeting high-risk asthma patients on ED use and hospital admissions reported mixed results. Although the initial evaluation of enrollees’ pre- and post-utilization patterns showed significant reductions in hospital admissions and ED visits, a subsequent, more rigorous evaluation comparing an intervention group with an untreated control group found no overall differences in utilization patterns between the 2 groups.21 Several programs reported cost savings associated with changes in enrollee utilization patterns.16,17,19,20,22,23 Three studies described higher levels of patient satisfaction as a result of social intervention programs,18,22,23 and 1 study reported an increase in quality of care.18 The majority of program descriptions included no outcomes data or other return-on-investment information. The eAppendix includes a complete list of interventions and programs included in this review (eAppendix Table 1).

DISCUSSION
This study provides an overview of ways in which MMCOs help address patients’ nonmedical needs by using healthcare services as a venue for social needs screening and related social needs interventions. The 25 programs captured are geographically dispersed across the United States and across multiple MMCOs. The strong majority of programs identified target high healthcare–utilizing patients with specific chronic health conditions. Within target disease groups, programs frequently focus on specific racial or ethnic groups and low-income, homeless, or other specific sociodemographically defined populations. The existing literature provides no empirical data showing that MMCOs engage in universal social screening, needs assessments, or resource mobilization to address the social needs of all members. Based on our theoretical model, these findings suggest that MMCOs are making low, or at most, low to moderate investments in SDH interventions and are not yet systematically engaged in comprehensive SDH strategies to improve health or change healthcare utilization patterns of enrolled patients.

This review differs from previous reports examining SDH interventions in 2 important ways. First, it focuses exclusively on MMCOs because these organizations are relatively well-positioned and incentivized to address the social needs of their patient populations to improve healthcare outcomes and service utilization. Although we found many interventions and programs addressing SDH that serve Medicaid patients, this review focuses on the few that are financed or directly supported by MMCOs. Second, the review focuses on programs that have at least some degree of clinical integration, meaning that individual patients are being screened for social needs and connected with relevant services based on being patients in a clinical care delivery system. Understanding the degree to which SDH programs are clinically integrated is key for MMCOs, which must decide whether spending on SDH interventions will be linked to a plan’s patient care and quality improvement activities or to its community benefit activities. Previous reports describing and examining innovations in addressing SDH have either not been specific to MMCOs or have included both clinical and community-level interventions.7,9,13,23

The 25 program descriptions we identified provide little detail on key program characteristics or MMCO decision-making processes that could help establish and disseminate best practices, such as the role of internal or external financial or other drivers or barriers to undertaking these interventions; any relevant community needs assessments on which interventions are based; or the role of executive sponsors, project owners, and key stakeholders in shaping the interventions. Similarly absent are descriptions of the return-on-investment calculations required to sustain these types of programs. This lack of information on organizational decision making, “readiness” assessments, and management processes, combined with the lack of rigorous evaluation of the impacts that these types of interventions have on health outcomes or health services, limits the capacity to understand and disseminate best practices in SDH-related interventions among MMCOs. 

Our review revealed several reports of case management programs for high-risk patient populations that include both social and medical components. This blended approach of social and medical case management may be an important target for scaling nonmedical health interventions within MMCOs. A recent report from John Snow, Inc (JSI) suggests that these services elicit a better response from clients if initiated at the provider level rather than at the payer level, which could incentivize MMCOs to fund provider-delivered programs.13 Both the JSI report and a related Commonwealth Fund issue brief authored by the Center for Health Care Strategies further suggest that the absence of assured flexible use of Medicaid managed care capitation rates may prevent MMCOs from transitioning from traditional case management of medical services to case management that includes behavioral and social needs coordination.13,14

Ensuring flexible funding for managed care capitation rates could improve MMCO case management programs that address a combination of patient medical and social needs. This funding may be accessible via the Affordable Care Act’s Health Homes program, which does require both comprehensive care management and increased referrals to community and social support services28; the Health Homes program already supports intensive case management activities in 19 states,28 though only 1 was identified in this systematic review.29

Limitations

References meeting our inclusion criteria show wide variation in associated key words and terms, which made it difficult to develop a comprehensive, practical electronic search strategy. The WHO definition of SDH is very broad, and the process of translating that broad concept into meaningful search terms that capture specific social determinants interventions is complex. Furthermore, some MMCOs may choose not to publish information regarding successful programs in order to maintain advantage in a competitive marketplace. To minimize the challenges inherent to this search strategy, we supplemented the electronic search using references provided by national experts. Nevertheless, there could be programs that meet our inclusion criteria that were not identified by these methods.

Our methods included a hierarchical exclusion process: references were initially assessed based on whether or not they described an SDH program or other intervention. Those that referred to SDH but did not describe an intervention were excluded. Remaining articles were then reviewed to determine whether there was some degree of clinical integration for the intervention. In the 25 programs captured, there was a considerable range in the extent to which clinical integration was described. For example, one program simply said that a social worker was added to care teams (article not included), while another program more clearly described the integration, including information about how the social worker addressed patients’ social needs (article included). It is possible that some programs were clinically integrated, but the integration was insufficiently described in the reference article to justify inclusion. Future efforts should supplement available information via key informant interviews, organizations’ annual reports, or other data sources. The lack of existing information may negatively influence dissemination or quality improvement efforts.

Additionally, many references in the original search did not include a description of the funding mechanism for the program. In other cases, funding was from a source other than Medicaid managed care entities. Interventions that met the other inclusion criteria but were not clearly funded by MMCOs are listed in eAppendix Table 2. To improve scaling and dissemination efforts, journals may consider requiring reporting of funding mechanisms.

CONCLUSIONS
This review is an important first step toward understanding how MMCOs are making investments in clinical nonmedical health determinants. Although risk-based capitated payment systems serving low-income populations provide incentives for incorporating models to address SDH, real and perceived local, state, and federal barriers can dis-incentivize adoption. In the context of increasing federal and state funding experimentation supporting Medicaid investments in SDH, MMCOs hoping to invest in these interventions will require detailed implementation, operations, scaling, and sustainability descriptions from other programs that have begun to make these investments.

Acknowledgments

The authors wish to thank Stephanie Chernitskiy for her editing and assistance with the paper’s figures and Beena Patel for her assistance in the literature review. Support for this study was provided by the Commonwealth Fund.

Author Affiliations: Center for Health and Community (LMG, KG, HW) and Department of Family and Community Medicine (LMG), University of California, San Francisco, CA; HealthBegins (RM), Studio City, CA.

Source of Funding: Support for this study was provided by the Commonwealth Fund.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (LMG, RM); acquisition of data (LMG, KG, RM); analysis and interpretation of data (LMG, KG, HW, RM); drafting of the manuscript (LMG, KG, HW); critical revision of the manuscript for important intellectual content (LMG, HW, RM); obtaining funding (LMG); administrative, technical, or logistic support (HW, RM); and supervision (LMG).

Address correspondence to: Laura M. Gottlieb, MD, MPH, Center for Health and Community, University of California, San Francisco, 3333 California St, Ste 465, San Francisco, CA 94118. E-mail: laura.gottlieb@ucsf.edu.
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