Our Power in Partnership series highlights our national and regional partners and the work they do with Unite Us to build healthier communities.

Tell us more about your organization.

211info is a private nonprofit serving Oregon and Southwest Washington that connects people with the help they need. We provide free, confidential information and referrals to services like food, housing, healthcare, childcare, utility assistance, and other essential support. Our team is available 24/7, ensuring that anyone can access support at any time. We offer live translation services in over 240 languages and can facilitate warm transfers to emergency and crisis lines when needed.

Beyond traditional information and referral (I&R) services, our Coordination Center offers enhanced support to help reduce barriers and improve access to care with more hands-on guidance to help individuals connect with the right support.

What are the needs of the individuals and families you serve?

The needs of people who contact 211info vary widely, but common themes include housing and shelter, food access, healthcare access, and utility assistance. Many individuals and families we serve face multiple challenges at once, so they require not just a quick referral, but a deeper level of support to navigate complex systems. Our staff is trained to go beyond providing a simple list of resources—they listen closely to each caller’s unique situation and ask the right questions to provide customized help.

We call this approach “asking the second question.” By digging deeper and fully understanding someone’s circumstances, we can offer comprehensive support, uncover options they may not have considered, and tailor solutions to their specific needs.

What are the main programs or offerings that your organization provides? How have these expanded or evolved over time?

211info provides a broad range of services, including traditional I&R services, specialized navigation for maternal and child health, foster parent support, SNAP and food access, and childcare assistance. We also collaborate with county and city agencies to manage waitlist access and conduct pre-screenings for various homeless services and coordinated access programs.

Since the COVID-19 pandemic, our emergency incident response has expanded from serving individual localities to providing statewide coverage. 211info is often one of the first points of contact for assistance during natural and human-made disasters, such as wildfires, severe weather events, and public health crises. We offer swift connections to essential resources, support services, and up-to-date local information, helping to ease the strain on 911 and emergency medical services.

Launched in 2020, our Coordination Center partners with coordinated care organizations (CCOs) and healthcare providers to offer a more personalized approach to resource navigation. Through community-based support, client-led care, and individual outcome tracking, we ensure that people are connected to the right services and receive follow-up support when needed.

Additionally, our Coordination Center now offers Health-Related Social Needs (HRSN) assistance, supporting CCOs with Medicaid Waiver implementation. We help with eligibility screenings and applications to promote a “no wrong door” approach for clients seeking assistance.

What led you to partner with Unite Us? Can you explain the nature of our partnership and how we work together?

We partnered with Unite Us as part of the natural evolution of our care model, moving beyond traditional I&R services to incorporate more comprehensive support and additional care services.

The Unite Us platform enables us to follow up with clients who need more in-depth assistance. This approach supports the integration of health care and social services through a secure closed-loop referral (CLR) system, ensuring that clients receive follow-up support and warm hand-offs for ongoing care.

“Our partnership with Unite Us also allows us to streamline collaboration with healthcare providers and community-based organizations, which helps improve the way we serve our local communities. While anonymous and traditional information and referral remains central to our work, Unite Us is a helpful tool to manage referrals and track outcomes within our Coordination Center.” – Dan Herman, CEO, 211info

How does collaborating with other organizations play a role in your work?

Collaboration is central to the work we do at 211info. By working closely with community-based organizations (CBOs), healthcare providers, and CCOs, we build strong networks that allow us to connect people with the right services more effectively. We also have a dedicated community outreach and engagement team who live and work across all of Oregon and Southwest Washington to build local community and partner relationships and ensure the accuracy of local resources.

In addition, as part of our expanded partner collaboration, 211info now hosts service provider roundtables throughout all of Oregon and Southwest Washington to bring local agencies together to work toward common goals. These roundtables help streamline service delivery, encourage inter-agency information sharing, help coordinate efforts, and reduce service fragmentation.

By collaborating in these spaces, we enhance the ability of local communities to respond to emerging needs, identify service gaps, and ensure a more connected and comprehensive service model. Whether it’s through coordinating referrals or facilitating information sharing, collaboration is essential in creating a network of support where all partners contribute to a unified system of care.

What is something you are excited about in terms of future projects and/or initiatives at your organization?

Using our partnership with Connect Oregon and Unite Us in our Coordination Center to assist Oregon’s Medicaid 1115 Waiver! We recently kicked off this project and will continue implementing more CCOs over time. 211info is screening members for climate devices, housing supports, and nutrition support, and we’re able to screen for eligibility in real-time on behalf of CCOs, as well as provide traditional I&R to clients for other needs.

We also look forward to deepening our role in emergency preparedness and incident response by becoming more integrated into state and regional emergency management plans. Our goal is to streamline how the public can quickly and reliably access real-time, localized support during times of crisis through our centralized contact center.

What excites you most about your partnership with Unite Us?

What excites us most about our partnership with Unite Us is our shared vision for integrating health care and social services in a way that truly benefits our communities. Both of our organizations understand that people’s needs are complex and dynamic and that a one-size-fits-all approach doesn’t work. This alignment allows us to build a more connected care system for those we serve.

We also genuinely enjoy working with the Unite Us team! Beyond their expertise, the Pacific Northwest group is collaborative, easygoing, and fun to work with—making the teamwork enjoyable.

Most importantly, our partnership delivers real, tangible outcomes for local communities. It’s exciting to see our progress and to know that we’re both working toward the same goal of making a meaningful difference in people’s lives.

Do you have any additional success stories or quotes you’d like to highlight?

When a CCO referred a client to our Coordination Center, he was in medical respite and needed assistance with a housing assessment, medical equipment, and basic household goods. One of our care coordinators connected him with resources such as the Aging and Disability Resource Center, local housing programs, and a nonprofit providing assistive technology. This organization recommended additional resources, including an agency for paralyzed veterans, The Lions Club, and others. The care coordinator reflected, “the impact of all of us working together will completely change his chances for a better, more productive life. With the wheelchair, he’ll gain mobility, and housing will take him off the streets, preventing further health issues—ultimately, this will save his life.”

Another client called our Coordination Center while their usual care coordinator was off and spoke with another coordinator about an urgent issue—they had accidentally locked their keys in their car, along with their medical equipment, including oxygen, inside. Unsure of who to contact, the client reached out to the Coordination Center, where they had built rapport with the team. The client later shared:

“I was panicking because I had locked my keys and all my important things in my car. The care coordinator was a huge help and dedicated to making sure I got help. They told me not to hang up until we found someone who could get me back into my car. They even made calls on my behalf to figure out which options would work and which wouldn’t. Ultimately, we were able to contact non-emergency services, and the fire department came quickly and got me back into my car at no charge. I’m so grateful for the help.”

The post Power in Partnership: 211info appeared first on uniteus.com.

How addressing social drivers of health (SDOH) improves health outcomes for those affected by opioid use disorder (OUD).

It is estimated that more than six million Americans ages 12 or older have an opioid use disorder (OUD) and that in 2023 there were more than 110,000 drug-involved overdose deaths. The opioid crisis is a multifaceted challenge that requires a comprehensive approach, integrating both medical and social support systems, to shape the recovery journey of affected individuals. To effectively combat OUD, interventions must target the underlying social drivers of health, as factors such as economic hardship, housing instability, and limited access to mental health services can exacerbate both the prevalence and severity of OUD.

Risk factors associated with opioid use, misuse, and overdose include:

• Younger age – Drug overdoses and poisonings are the third-leading cause of pediatric deaths in the U.S.
• History of adverse childhood experiences (ACEs) – Analysis of Behavioral Risk Factor Surveillance System (BRFSS) data found that individuals reporting three or more ACEs had increased odds of taking opioids more than prescribed or without a prescription.
• Polysubstance use – More than 90% of individuals with OUD used more than two other substances within the same year and the majority of OUD-related deaths involve multiple substances.
• Other untreated mental health issues – Individuals with mental health disorders (e.g. anxiety, depression, bipolar).

Strategies for Addressing the Opioid Epidemic

Considerable progress has been made at the federal, state, and local levels in deploying evidence-based strategies to address the opioid epidemic. These strategies include primary prevention (e.g., reducing clinically inappropriate prescribing), harm reduction (e.g., Narcan distribution), evidence-based treatment (e.g., buprenorphine access), and recovery support (e.g., via peer support services). Ensuring equitable access to these essential interventions will undoubtedly prevent overdoses and save lives. The Centers for Disease Control (CDC) identifies that clinicians, community leaders, education, criminal justice, social services, business, and government all have a role to play in increasing access and linkage to care.

The CDC also recommends that linkage to care is bundled with other services (e.g., housing support, transportation assistance) to alleviate common barriers to treatment success, as effectively addressing the opioid crisis requires acknowledging and addressing the social drivers of health (SDOH) that contribute to OUD. By focusing on these underlying community-level factors — such as economic stability, education, healthcare access, and social support systems — we can create more comprehensive and sustainable solutions for the prevention and treatment of OUD.

Social Care and Opioid Use Disorder: Insights from the Literature

SDOH refers to the social, economic, and environmental factors that influence an individual’s overall health and well-being. Health-related social needs (HRSN) are the specific, actionable needs an individual may have within the broader social drivers of health. In recent years, a growing number of studies have emphasized the value of addressing the social needs of individuals with substance use disorder (SUD), defined as the inability to control the use of legal or illegal substances (such as stimulants, opioids, alcohol, or medications). Given the high rates of morbidity and mortality among individuals with OUD, along with the common occurrence of multi-substance use in this population, it’s unsurprising that many of these studies focus on individuals affected by OUD.

• A 2023 evaluation of California’s Whole Person Care Pilot – designed to coordinate the health, behavioral, and social care needs of Medi-Cal beneficiaries – found that participants with SUD experienced fewer ED visits ($32 per beneficiary per year decrease) and fewer hospitalizations per 1,000 beneficiaries ($310 per beneficiary per year decrease). 
• A 2023 retrospective study to assess the impact of recovery housing for individuals with SUD found that providing housing helped reduce readmissions to inpatient substance use treatment and that housed individuals had reduced ED use and increased primary care use. 
• A 2021 study funded by the National Institute of Drug Abuse found that case management, including service linkage to address basic needs, reduced inpatient readmissions and ED visits among a sample of 400 adults with comorbid SUD (including OUD) 
• A 2020 study of a model that integrates maternity care, SUD treatment, and social service coordination for pregnant Medicaid beneficiaries with OUD found that participants experienced reductions in foster care placements, fewer reports of child maltreatment, and an increase in prenatal visits. 
• A 2023 qualitative study to explore the perspectives of community-based clinicians and staff highlighted the need for better bidirectional care coordination between healthcare and community settings to support individuals with OUD. Participants reiterated that medication was important, but solving unmet social needs associated with ongoing opioid use was equally important. One clinician offering wrap-around support service stated: “They don’t know that services like ours exist. They think, ‘I can get meds, but how is that gonna help me with a place to sleep? Help me get my food stamps?’”

The Data is Clear. But Are Individuals in Need Getting Connected to Vital Services?

Most adults with SUD (94.7%) report not seeking treatment because they perceive that they do not need it. However, of the more than two million people with an unmet need for treatment, nearly half report that they do not know how or where to get treatment. Additionally, disparities in access to evidence-based treatment exist across groups. Based on an analysis of 2021 Medicaid claims data, one in three Medicaid enrollees with OUD did not receive medication-assisted treatment. Black/African American individuals, youth ages 18 years and younger, and individuals with a disability were all less likely to receive treatment.

Interventions that identify patients with SUD, initiate treatment, and link patients to community-based organizations (CBOs) are increasingly common, however, a 2023 scoping review identified several barriers to intervention success, including difficulties with:

• Building partnerships between hospital and community-based SUD programs
• Managing logistics and communication between hospital and community treatment teams to coordinate follow-up care for patients

Care in the clinical setting alone is not sufficient to address prevention, treatment, and recovery. Individuals with substance use disorders need clear access to comprehensive services such as employment, childcare, and housing. Building a path to recovery requires shared infrastructure to support community participation, coordinate care across service areas, and identify and activate evidence-based programs that effectively address diverse needs.

Insights from a Cross-Sector Collaboration Platform

Unite Us is an integrated suite of social care solutions designed to streamline processes and foster collaboration across government, healthcare, health plans, and community organizations to address SDOH. Insights from the Unite Us platform demonstrate how community-based organizations across the nation are collaborating to fight the opioid epidemic.

Since 2018, care professionals (e.g., community health workers, care coordinators, social workers) have leveraged Unite Us to connect more than 11,000 individuals with services to support their SUD recovery journey (15,000+ substance use cases). The top service subtypes referred to included substance use treatment, substance use recovery support, substance use counseling, substance use assessment, and tobacco cessation.

Data shows that substance use needs often co-occur with other types of needs. For example, nearly 1 in 4 individuals with a substance use need also had a mental and behavioral health need, one in 5 had a housing and shelter need such as transitional or emergency housing, 10% needed food assistance, and 10% needed support with benefits navigation (e.g., applying to health insurance). Effectively addressing the opioid epidemic requires recognizing that individuals with opioid use disorder may have co-occurring unmet HSRN that impact their ability to connect with ongoing treatment.

We observed an overall need resolution rate of 59% for substance use assistance requests, with no difference in resolution by gender, age, or military affiliation. However, we did find that the presence of co-occurring need requests can significantly influence the likelihood of substance use need resolution. For instance, the co-occurring presence of requests related to housing or shelter, food, and utility assistance, reduced the likelihood of resolution by 18%, 51%, and 40%, respectively. Conversely, needs related to individual and family support, mental and behavioral health, and transportation increased the likelihood of resolution by 158%, 50%, and 57%, respectively.

Supporting Individuals with OUD: Where Do We Go from Here?

• Recognize that individuals with OUD may have co-occurring unmet health-related social needs that impact their ability to connect with affecting and ongoing treatment. When using validated tools to assess the presence of SUD, also consider assessing for unmet social needs (and vice versa).
• When designing and implementing interventions, consider the unique needs of specific populations, such as justice-involved individuals, pregnant and postpartum individuals, American Indians, and Alaska Natives. Include the voice of individuals with lived experience of substance use challenges to inform compassionate, practical, and responsive solutions to real-world barriers to recovery,
• Continue to deepen our understanding of how addressing social factors can improve outcomes for individuals with opioid use disorder (for example, how does access to stable transportation affect adherence to medication-assisted treatment? Or what combination of social services yields the best outcomes for individuals in OUD recovery?)

The post Integrating Social Care Delivery into the Opioid Epidemic Response appeared first on uniteus.com.

Is it a hospital’s responsibility to screen for and address a patient’s social care needs? 

The answer is “yes.” New CMS requirements are beginning to require that hospitals screen patients for social determinants of health (SDoH) needs such as food, transportation, and housing. 

With this in mind, CMS’ health equity data requirements will now motivate provider organizations to collect social risk measures the way they have long collected clinical risk measures, like elevated blood pressure readings. CMS-approved SDoH screening measures will help, but it can still be difficult to get a comprehensive understanding of a patient’s whole-person needs. 

While social care screenings are often a great first step towards providing whole-person care, healthcare providers also need to be properly equipped to address the needs that may be uncovered in those screenings. How can providers build an effective strategy for addressing SDoH to serve the non-clinical health needs of their patients and local communities? 

The Cost of Unaddressed SDoH 

Eighty to 90 percent of health outcomes are due to behavioral, social, or environmental factors that go beyond clinical care, including socioeconomic status, race, nutrition, housing security, transportation, and more. For this reason, health inequity has a powerful influence on factors that influence health. The consulting firm Deloitte estimates that health inequities cost the U.S. $320 billion per year and could rise to $1 trillion by 2040 if unaddressed. At an individual, family, or community level, the toll on health, quality of life, and well-being is just as profound. 

When physicians, nurses, public health officials, and others in the healthcare field encounter a patient or member who faces challenging environmental circumstances, they know it’s very likely the care they provide will not be enough to meet that person’s overall needs. After the appointment or care encounter, the patient may return to the same environment that caused or exacerbated their health problems in the first place, and that environment can present barriers to their recovery. 

Consider this example: A patient who is unable to manage his diabetes becomes a frequent visitor to the emergency department. Concerned, the physician takes the initiative to apply for a grant that enables him to assign a community health worker to the patient’s case. The health worker discovers the patient is experiencing homelessness and has no place to store his insulin. The community health worker can then connect the patient to a local shelter, where he is able to stay and store his insulin. 

Identifying that patient and connecting him to the right social resources helped improve his health outcomes and reduce the burden on the local hospital. The bigger challenge, however, is achieving that kind of impact systematically and at scale.

5 Barriers to Addressing SDoH 

Here are five common barriers to addressing SDoH needs, and how healthcare practices can overcome them: 

1. Determining where to begin – One of the biggest challenges with addressing social care needs is not knowing quite how, or where, to start. Partnering with industry experts gives providers the guidance, support, and peace of mind they need to get this initiative off the ground. 
2. De-siloing information – When patient data is siloed in disparate systems and inaccessible across different organizations, delivering whole-person care becomes exceedingly difficult. Organizations responsible for delivering health and social services need to be able to communicate and share data securely and efficiently in order to drive better health outcomes. Without a holistic view of a patient’s health journey, it is impossible to make fully informed decisions about their care. 
3. Making workflows efficient – Manual processes and inefficient workflows are both time-consuming and error-prone, posing significant risks when it comes to effectively addressing social care needs. If patient information is misrecorded or miscommunicated, it can directly impact the safety and efficacy of patient care plans. Social care technology that fosters interoperability and workflow automation plays a pivotal role in driving successful and scalable social care outcomes. 
4. Resourcing teams – There’s projected to be a shortage of 3.2 million healthcare workers by 2026. With a growing shortage of healthcare workers and increasing levels of provider burnout, addressing social needs will become more challenging without technology that seamlessly automates and accelerates the SDOH screening and referral process. Plus, social care technology vendors that offer professional care coordination services can alleviate the administrative burden to facilitate more connections to care.
5. Shared accountability – Social care referrals result in connections to care only if they’re sent to organizations with the resources, capacity, and bandwidth to solve those needs. When social care networks require accountability from their partners, there is a much greater chance of successfully connecting patients to resources. Without such accountability, listings may be out of date, and it can be difficult for providers and patients alike to gauge resource availability and a patient’s eligibility for those resources. 

How Can Providers Address SDoH?

So, what can healthcare providers do once a social care need is identified? 

Given that needs and circumstances can vary widely, it can be difficult to find the right resources or services to help the patient. 

Unite Us is the nation’s leading software company bringing sectors together to improve the health and well-being of communities. We drive the cross-functional collaboration needed to identify, deliver, and pay for services that impact whole-person health. This enables network partners to work together and meet complex individual, family, and community social health needs.  

Just as importantly, the Unite Us Platform allows for closed-loop referrals, enabling partners to securely track a patient’s progress to confirm they’re receiving the right care and measure the resulting health outcomes. 

The Value of Closed-Loop Referrals For Addressing SDoH 

Closed-loop referrals ensure that rendered social services actually meet patient needs and move the needle on health outcomes. This will become increasingly paramount for providers to track as CMS continues to make it mandatory for providers to assess and address SDoH needs. Plus, as commercial health plans engage more in value-based care, they will also require healthcare providers to have the capabilities and resources to handle this complex set of challenges. 

Now is the time for providers to prepare for that future. With the right technology and network, providers can position themselves for efficiency and success when addressing SDoH and looking to improve whole-person health outcomes.

Learn more about how Unite Us helps healthcare providers successfully address social determinants of health

Solutions for Providers

The post The Healthcare Provider’s Guide for Addressing Social Determinants of Health (SDoH) appeared first on uniteus.com.

In communities across the US, the state of child welfare is both a call to action and a beacon of hope. Despite the complexities, there are a number of approaches to prevention, intervention, and systemic reform that are reshaping the child welfare landscape.
Join us for a discussion grounded in best practices and practical insights, as we double down on the crucial role of public-private partnerships in supporting families. We’ll dive into innovative strategies for increasing interagency collaboration, leveraging technology to enhance connections to care, and improving outcomes for vulnerable children and families.

In this webinar, we’ll discuss the relationship between economic factors and child welfare involvement, community activation as a cornerstone of prevention and promoting resilience, and the importance of technology tools that foster collaboration and grow alongside the continuum.

The post Mobilizing Communities: Essential Strategies for Enhancing Child Wellbeing appeared first on uniteus.com.

Introduction

It is well documented that social drivers of health (SDOH) contribute to a person’s health, well-being, and quality of life and that unmet social needs contribute to health disparities, especially among vulnerable populations. The healthcare industry and regulatory environment continue to advance value-based payment models, with increasing emphasis on primary and longitudinal services to address chronic and communicable diseases and their associated healthcare costs, in an effort to improve health equity. 

Given the substantial evidence base tying unmet social needs (e.g., food, housing, transportation, social connection) to poorer health outcomes and higher healthcare costs, it is no surprise that the shift to quality care has ushered forth renewed energy across sectors to resolve those unmet needs that may be impacting health. Addressing social needs may require providers and systems to change their documentation practices and lean into community services and partnerships. Providing this type of “person-centered” quality care will require building bridges and closed-loop infrastructure between the health and social sectors to allow for seamless patient referrals, social care navigation, documentation of outcomes, and reimbursement. 

In this article, we review the current literature pertaining to social care and quality outcomes, provide a case example, and follow up with recommendations for assessing and addressing the diverse spectrum of social care needs. We believe that by adopting this approach to inclusive health care and de-siloing health and social services, we move toward true quality care. When we do this at scale, quality care will become equitable care and equitable care, quality care.

Healthcare Stakeholders Recognize the Role of Social Drivers of Health (SDOH)

Before social needs can be addressed, they must first be assessed. National organizations such as the National Committee for Quality Assurance (NCQA), Joint Commission, National Quality Forum (NQF), American Hospital Association and at least 28 states recommend or require social need screening, with 17 states requiring uniform SDOH questions within screening tools. Social need measures are currently included or proposed to be included in at least 18 CMS programs, initiatives, or federal guidance. Beginning in 2024, the Centers for Medicare and Medicaid Services (CMS) will require hospitals reporting to the Inpatient Quality Reporting program to submit two brand new measures: SDOH-1 (Of all the patients admitted to the hospital, how many were screened for SDOH?) and SDOH-2 (How many were identified as having one or more social risk factor?).

In advance of specific recommendations and regulations, healthcare stakeholders have already recognized that implementation of interventions to identify and address SDOH is one mechanism to improve the quality of care and deliver better outcomes. From 2017 to 2019, fifty-seven health systems in the U.S. publicly announced investments of approximately $2.5 billion toward addressing SDOH including housing, food security, and job training. Additionally, analysis of a 2021 national hospital survey demonstrated that more than 75% of acute care hospitals already screen for health-related social needs. 

 Health plans too are recognizing the importance of addressing SDOH by working to expand information exchange and establishing partnerships with community-based organizations (CBOs), especially in light of recent Medicare Advantage policy changes (i.e., supplemental benefits that are not primarily health-related). For example, from 2023-2023, Horizon Blue Cross Blue Shield of New Jersey operated one of the largest programs, Horizon Neighbors in Health, to address SDOH in the state of New Jersey. The Neighbors in Health program utilized community health workers and personal health assistants to improve the health and well-being of individuals across 21 counties. By the summer of 2023, the program had enrolled over 13,000 members and had met the social needs of 8,000 individuals. The success of the program led Horizon to integrate the approach into its larger care management program and increase screening of and engagement with members who have SDOH needs.

The Impact of Social Care on Quality Outcomes 

Healthcare systems, payers, and others are understandably eager for additional rigorous evidence showing that addressing social care needs can measurably improve health outcomes and reduce unnecessary spending. While longer-term outcomes are important, quality measures such as preventive screenings, engagement with primary care, medication adherence, and satisfaction with care can serve as more proximal measures for the impact of addressing social needs. Improvements in these process measures may be a signal that social needs are being addressed. 

Results from a retrospective, cross-sectional analysis of 7,995 individuals found that those with transportation vulnerability were significantly less likely to be vaccinated against influenza. A study examining the relationship between cancer screening completion and receipt of government housing assistance among low-income adults found that housing assistance facilitated increased breast cancer screening among certain subgroups (with odds of mammography completion increasing more than two-fold for Hispanic and younger women). Another cohort study of 6,692 antihypertensive medication users found that receipt of Supplemental Nutrition Assistance Program benefits was associated with a nearly 14-percentage point reduction in medication nonadherence among food-insecure patients. Importantly, interventions that help individuals address social needs (e.g., via connection to community-based resources) have been linked to improved patient satisfaction. In one national study of nonelderly Medicaid managed care enrollees, those who received social needs assistance (e.g., transportation, food, housing) rated perceived quality of care as “the best” compared to those who did not receive social needs assistance. Two other nationally representative patient satisfaction surveys indicated that patients perceived they were “better cared for” and had more trust in their provider or health system when screened for social risks. 

Finally, results from the Accountable Health Communities model, which systematically tested the impact of screening and navigation interventions to resolve health-related social needs of publicly-insured individuals, show reduced emergency department visits among Medicaid and fee-for-service Medicare beneficiaries compared to matched controls. The reduction, especially for Medicare beneficiaries, was driven largely by avoidable healthcare use, suggesting social care navigation may impact beneficiary behavior that fundamentally alters the type of healthcare used. Additional insights shared directly from one model participant highlight the value of screening and referral work for both providers and patients alike, and the importance of “closing the loop” and reimbursing community partners for their important role. 

Case Study: Insights from Scaling Social Needs Screening Workflows Across New Mexico

One highly successful example of a universal social needs screening program is Presbyterian Healthcare Services. In the fall of 2021, Presbyterian Healthcare Services implemented universal social needs screening to ensure all patients with a clinical encounter within the delivery system were screened at least every six months to identify social needs in the areas of food, housing, transportation, utilities, substance/alcohol/tobacco use, possible depression, and interpersonal safety. Presbyterian’s IT and Clinical Informatics teams were engaged to identify optimal workflows and leverage SDOH functionalities within its Electronic Medical Records (EMR) system. In ambulatory and inpatient settings, screening was integrated into the rooming process, while in emergency department settings it was added to the secondary triage workflow. 

The project team focused on automating the screening process by configuring pop-up messages to alert rooming and triage teams when screening questions were due to be asked, and adding the questions to the eCheck-in process to give patients the option to self-screen through their patient portal. If a social need is identified during screening, an automated process initiates within the EMR and an integrated cross-sector collaboration software (Unite Us) generates a personalized list of community services delivered directly to the patient’s after-visit summary. Since the launch of universal screening, Presbyterian Healthcare Services has conducted more than 2.8 million screenings, identifying and providing community resources for more than 250,000 social needs.

While identification of social needs is a critical step, improving clinical outcomes will require acting on those social needs through SDOH interventions, including follow-up to determine if the need was resolved. As Leigh Caswell, Vice President of Community and Health Equity at Presbyterian Healthcare Services states, 

“Scaling and sustaining the social care navigation infrastructure has been a challenge because we’ve learned a referral to a social service isn’t enough; there needs to be navigation through community health workers, social workers, and/or peer support specialists to community resources and follow-up to support patients through the barriers faced while navigating these systems. With innovative value-based payment models and Medicaid 1115 waivers, these types of social care navigators and social service resources are becoming more accessible and sustainable, incorporating funding for these services including direct payment for food prescription programs and reimbursement for community health workers.” 

In 2024, Presbyterian will utilize a closed-loop referral system through Unite Us that will facilitate referrals directly to CBOs on behalf of Presbyterian patients, and provide visibility into the community care delivered, until an outcome or resolution is documented for the patient’s social need. Using metrics that track not only if screening occurred and if a referral was made, but also how long it takes the referral to be accepted by a partner—and ultimately the specific outcome of the referral—will enable better understanding of where additional investment is needed in the community to ensure appropriate capacity of social services to address needs. 

Standardization in Social Needs Measurement: A Key to Meaningful Data 

The standardization of measures involves a nuanced approach that extends from aligning data elements within specific measures, with a focus on screening and intervention terminology, to establishing a coherent standardization across the broader SDOH ecosystem. This comprehensive effort not only harmonizes the granularity of data elements needed to screen for social needs, but also addresses the need for uniform metrics across the healthcare system. To access valuable data, standardization ensures meaningful comparisons of population health outcomes, contributing significantly to the goal of reducing health disparities, especially for underserved communities. Nationally, work is being done to ensure alignment among social needs measures, with a commitment to create a unified and interoperable framework for robust analysis and informed decision-making for all stakeholders. Five fundamental domains, encompassing aspects of food insecurity, housing instability, transportation needs, utility insecurity, and interpersonal safety, have been recognized across national and state-level programs and initiatives. As the industry begins to incorporate social care data into standard practice, care should be taken to utilize standard and validated tools to evaluate impact on quality of care.

In February 2023, NCQA, the Joint Commission and NQF released a joint statement recognizing the importance of using a Fast Healthcare Interoperability Resources (FHIR)-based approach to meet the social needs of individuals in the healthcare system. The FHIR Questionnaire and Questionnaire Response profile enables the exchange of findings on standardized instruments, which can be measured and trended at the individual level. This person-reported information will be valuable for improving quality and equity at the population health level. By incorporating standardized data elements, we can more accurately compare outcomes across organizations and industries. 

In Measurement Year (MY) 2023, NCQA published their Social Needs Screening and Intervention measure in the Healthcare Effectiveness Data and Information Set (HEDIS®) to assess, quantify, and evaluate the performance of social needs screening at interventions at the health plan level. NCQA’s primary emphasis has centered on tackling unmet social needs in the domains of food, housing, and transportation through the ongoing implementation of Social Needs Screening and Intervention measure, which was released in HEDIS Measurement Year (MY) 2023. First year analysis, scheduled for the summer of 2024, promises valuable insights into the effectiveness of utilizing current Logical Observation Identifiers Names and Codes (LOINC®)-based terminology for capturing social need screenings. Furthermore, this evaluation will play a pivotal role in determining the seamless integration of CMS’s recent recommendations, as outlined in the Physician Fee Schedule for 2024. This includes exploring the incorporation of additional SDOH data, such as ICD-10 Z codes, into the existing landscape of social needs measurement. 

Another critical component to addressing social needs is data stratification that captures and respects the diversity of the U.S. population including race, ethnicity, language, or disability (REALD) as well as sexual orientation or gender identity (SOGI). For example, CMS recommends states implement stratification in the Medicaid Home and Community Based Services Quality Measure Set and the Hospital Readmissions Reduction Program, and NCQA required race and ethnicity stratification for 5 HEDIS measures in measurement starting in 2022. These data categories can be used to create more detailed and meaningful stratification for quality performance measurement, which must not be overlooked as we continue to understand differences in SDOH outcomes among subpopulations. 

Looking Forward

We are at a pivotal moment where multiple sectors are more motivated than ever to address SDOH, eliminate healthcare disparities, and measurably improve the lives of the individuals they serve. In communities across the U.S., health systems, payers, government agencies, CBOs, and others are working more closely together to assess social needs, address identified concerns, document the outcome of assistance received, and, increasingly, provide financial reimbursement for services rendered. This cross-sector collaboration is driven, in part, by the fundamental belief that addressing health-related social needs is core to providing high-quality, equitable, and whole-person-centered care. As screening for social needs becomes even more commonplace, it is imperative that organizations proactively consider the “so what” should a need be identified. To do this effectively, we are calling for a paradigm shift that recognizes community-based services like food assistance, housing support, and transportation, as equal partners in the care continuum. We encourage early and sustained engagement of CBOs, as well as patients, in the design, implementation, and evaluation of interventions to assess and address social needs. 

 ¹HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

The post The Foundational First Step in Achieving Quality Care: Assessing and Addressing the Diverse Spectrum of Social Care Needs appeared first on uniteus.com.

Our goal? To provide a space where you can cultivate more meaningful connections with the people who care about your cause, gather new ideas and insights for scaling your impact, and help you build a stronger foundation no matter what’s next for you and your organization.

Still not convinced? Here are just some (of the many) reasons why it’s worth your time to join us at One Continuum Community.

1. There’s something for everyone.

With four different panels and 14 different speakers, you’re guaranteed to find a wide range of thought-provoking discussions, actionable best practices, and practical takeaways from your industry peers. Scope out your favorite sessions and build a customized learning track ahead of time to make sure you don’t miss a thing! Interested in what you missed at previous summits? Read about what we learned from the 2022 One Continuum Community Summit.

2. Celebrate your impact.

Each community knows their needs best, and you are the expert of your community’s strengths and capacities. While building relationships and strategies to improve health takes time and intention, sharing those experiences with others can inspire change and spark new ideas. Join the conversation and let us know what’s working for your organization, community, and network.

3. Make surprise connections.

What better way to expand your network (and your skill set) than to attend an event with other organizations who are champions in community outreach and committed to making an impact together?

4. Tap into fresh ideas and new perspectives.

We have some really incredible partners, and we’re excited to hand the virtual microphone over for some of them to celebrate their successes, share their insights, and lead important conversations. Whether it’s learning more about the power of collaboration or how your organization can better prepare for future funding opportunities, our hope is that you’ll leave with plenty of practical takeaways that you can bring back to the office.

5. It’s free!

The One Continuum Community experience is free and open to anyone looking to have a positive impact in their own community. You don’t have to leave your house, wait in line, get on a plane, or do anything at all other than open up your laptop in the comfort of your own home or office.

And make sure you don’t summit alone! Share this opportunity with your network or with anyone interested in learning how organizations are uniting to celebrate and inspire change.

What are you waiting for? Join us at the next One Continuum Community.

To watch replays of the discussions on-demand and learn more, visit our One Continuum page.

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