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Ensuring Successful Interventions Once Social Determinants of Health Are Identified


During a session at the National Association of Accountable Care Organizations (ACOs), panelists offered perspectives on how ACOs can successfully address social and behavioral needs of their patients.

Whether it’s food insecurity, housing instability, or economic status, in order to successfully address social determinants of health (SDOH) for patients, it’s imperative to target the specific determinants you want to impact in the population and to foster partnerships to serve the community, said Andrea Cichra, director of population health, South Bend Clinic during a session at the National Association of Accountable Care Organizations (NAACOs).

“When you’re looking at SDOH, [it’s] really taking a broader view, more of a systems view in identifying what exactly it is that you want to address, who are the best people to address those problems, and then how do you build those partnerships over time?”

To this end, there are 5 key questions ACOs must ask, she explained. These questions include:

  • What are we trying to impact?
  • What can we impact?
  • What is the provider’s role?
  • What is the best way to approach this role?
  • How do we know when we are succeeding or failing?

The greater focus being placed on social determinants has led to awareness that genetics account for just 10% of the risk factors of early death, while social and economic factors and behaviors account for 60%. As a result, community partnerships are essential, not only to better reach patients but also to align services, manage outcomes, and track data, explained Cichra.

However, providers must still maintain focus on addressing the impact that clinical care has on health; while doing this, they must focus on outcomes measures.

“Process measures are no longer sufficient," Cichra said. For example, rather than being asked if they measured a patient’s glycated hemogloblin (A1C) level, providers should be asked if they controlled the patient’s diabetes.

ACOs should also educate both providers and patients on available social and behavioral resources and how they can access those resources, as well as lead patient engagement to get patients involved in their own healthcare and outcomes.

On the administrative side, ACOs should engage with CMS and other payers on patient access and benefit design that advances addressing SDOH, said Cichra. At the same time, ACOs need to leverage the community by partnering with community providers of SDOH services to align their work, as well as advocate and work with local schools, health departments, and governments to expand and/or address quality and alignment of SDOH in the community.

And how do ACOs know if they are succeeding in their efforts? Cichra warned that while there might be immediate “wins” individually, this is a long-term commitment and collective “wins” will take time. She also cited “Game Theory,” comparing finite and infinite perspective. “If you’re heading toward a goal—for example, the end of every fiscal year—the work won’t change a whole lot from 1 year to the next,” she said. “You need to think not just 1-year plan but look further into the future—5, 10, 20 years down the line.”

Offering more perspective, Debbie Welle-Powell, senior vice president of accountable care at Essentia Health, followed up with takeaways from Essentia Health and how the ACO is addressing the needs of patients in Minnesota, Wisconsin, and North Dakota. The ACO currently participates in 11 value-based contracts representing 45% of their revenue, 25% of which is down-sided risk.

“Risk was the stake in the ground that really allows us to actually move toward more value in a way that we can measure it and in a way that we can show the results of the work we’re doing,” she said.

The ACO, she said, is based on 3 pillars:

  • Innovating in clinical care: connecting services to extend care beyond the provider’s walls
  • Investing in the community: aligning funding and investment for the greatest impact, as well as volunteerism
  • Community health assessment: collaborating to reach the entire population

Laying the groundwork for successfully implementing initiatives requires the ACO knowing their population, she explained. In Minnesota, for example, there’s a health divide between the North and the South, with the North being primarily rural and having higher rates of obesity, opioid addiction, tobacco use and lower graduation rates. This, she said, requires Essentia Health to implement a vastly different strategy than they would implement in the South.

It’s also crucial to understand the priorities of the providers within the ACO, highlighting the importance of community health assessments. Results from Essentia Health’s latest assessment across its 17 hospitals, priorities were consistent across the board: mental well-being, substance use, and nutrition and physical activity.

Once these priorities are identified, Welle-Powell echoed Cichra in arguing that successful interventions will be based on outcomes-based measures and results-based accountability.

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