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).

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With our proven track record of successfully facilitating secure closed-loop referrals and social care payments in New York and other Medicaid waiver states, Unite Us stands ready to support this important initiative.

Key Insights on Social Care Components

Social Care Networks (SCNs): 

SCNs, or contracted entities in each of the State’s nine regions, will be charged with establishing a network of social services and community providers to deliver eligible Medicaid beneficiaries with HRSN screenings and referral services. The State will reimburse selected HRSN services related to housing, food, and transportation.

Managed Care Plans: 

Managed care plans will contract with SCNs to deliver the selected HRSN services through two tiers of benefits. Level 1 services will be available to all Medicaid beneficiaries and will include referrals to existing public programs that are separate from the newly authorized HRSN services; Level 2 services will be provided to targeted beneficiaries who meet certain criteria. Subsequently, MCOs will be required to report data in order to evaluate the utilization and effectiveness of the HRSN services on health outcomes and equity of care.

Hospitals:  

Safety net hospitals located in Brooklyn, Bronx, Queens, and Westchester Counties can apply to participate in a Medicaid Hospital Global Budget Initiative that aims to help safety net hospitals transition to a global budget system. This initiative is designed to empower selected hospitals to prioritize population health and enhance quality of care in order to stabilize their financial situations and advance accountability and health equity.

Together, Driving Impact in New York

Building upon our ongoing collaborations with valued partners and community networks in New York, we are ready to deliver the solutions needed to successfully achieve the goals of the waiver while establishing a sustainable infrastructure for the continuous delivery of social care.

Leveraging Our Experience with State Medicaid Programs

We are proud to have established a reputation as the leading software solution for Medicaid programs addressing HRSNs across the country. Our cross-sector collaboration tools support a no-wrong-door system of social care, produce comprehensive insights to measure social need and community capacity at scale, and enable government leaders to strategically shift investments upstream to community-based partners, maximizing health benefits and better managing government spending. Like many Medicaid leaders, we know that social care coordination will improve outcomes, so we built our tools to collect structured social care data using a longitudinal care record. This allows states to measure real-time network performance and conduct integrated or longitudinal program evaluations over time, which will be critical in New York.

With networks in 44 states and partners leading the way in Medicaid transformation across the country, we’ve learned a lot about how we can support this critical work. Here are just a few examples:

We’re proud to support partners across the country in leveraging our solutions to support Medicaid waiver initiatives and advancing whole-person care. Interested in learning more about Unite Us solutions?

Get in Touch

The post Unite Us Celebrates the Approval of the New York State 1115 Medicaid Waiver: Improving Access to Care and Advancing Health Equity Together 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.

Watch Now

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

Tell us more about your organization.

San Joaquin County Public Health Services (PHS) is the local health jurisdiction for San Joaquin County. Through various health programs, our goal is to protect, promote, and improve health and the conditions that impact well-being for San Joaquin County residents.

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

Since we started using Unite Us, we have served over 300 constituents and have made over 620 referrals through our program. The greatest needs of the people we serve include benefits navigation, food assistance, housing and shelter, and individual and family support. Through our partnership with Unite Us, we are able to easily find these critical resources for clients and ensure their needs are met. 

What are the main programs or offerings that your organization provides?

In addition to our ongoing health offerings that primarily focus on encouraging healthy lifestyles and disease prevention, one of our newer initiatives is a Community Health Worker (CHW) program designed to address high risk residents’ vaccine and testing hesitancy, improve access to preventive health care services, increase management of underlying health conditions, and improve social determinants that serve as life barriers to care. To kick off this effort, PHS received a large grant from the CDC in 2021 to fund CHWs throughout the county. So far, 35 CHWs across 13 health and community-based organizations have been trained on the core competencies of this work. Another 35 will be trained in the third year of our program, as we continue to build our CHW network.

We have also worked closely with the Unite Us technical assistance team to train program staff. Many of the organizations in this program already utilize and are familiar with Unite Us. In addition, we have onboarded and trained six community and faith-based organizations to the network and continue to use the Unite Us dashboard daily to securely send and receive referrals. 

How has working with Unite Us impacted the work that you do?

Unite Us has become a one-stop shop for PHS and our sub-contracting organizations, as well as many other organizations in San Joaquin County. PHS is one of the first local health jurisdictions in California to become part of the Unite Us network. Because the platform is so user-friendly, our CHWs are able to send and receive referrals connecting clients to services in a timely manner. Thanks to Unite Us’ closed loop referral capability, we are able to track client progress and, ultimately, drive toward better population outcomes. 

“Unite Us provides client-centered care coordination and a quicker and more efficient connection to the services clients need. Their client-centered approach gives a sense of importance to the clients because organizations/agencies are reaching out to them, instead of them reaching or calling the organizations for their needs.” – Maria Argayosa, Community Health Worker at San Joaquin County Public Health Services

The Unite Us staff who we have worked with have been amazing. They are very attentive, responsive, and easy to work with. 

Our program CHWs continue to go above and beyond for their clients, ensuring their needs are being met. The best thing about Unite Us is that it makes it so much easier for our community health workers to do what they do best. 

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

Community and faith-based organizations play a huge role in the work PHS does. Over 80 organizations are using Unite Us in San Joaquin County. Each of our partners plays an essential role in connecting our most vulnerable community members to free services and resources via the platform. They are continually helping us reduce social and health disparities and address social determinants of health to improve our community members’ overall well-being. 

What’s next for PHS and Unite Us?

We are excited to continue onboarding the many different PHS programs and services onto Unite Us. As of right now, we have worked to onboard five different departments within PHS but will continue to add more in the near future. This will ultimately help raise awareness of PHS resources and connect residents to services.

Interested in learning more about how to bring Unite Us to your organization?

Get in Touch

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In our communities, we each play a role in creating spaces where all feel welcome and safe, including LGBTQ+ individuals. With safe access to health and social care, LGBTQ+ individuals can live happier, healthier lives.

What Health Disparities Do LGBTQ+ Individuals Face?

LGBTQ+ individuals experience specific health disparities that affect their physical and mental well-being. In spite of the advancements made, individuals who identify as LGBTQ+ still face more unfavorable health consequences compared to their heterosexual peers. Factors such as limited access to health insurance, increased stress caused by systematic harassment and discrimination, and a lack of understanding and sensitivity within the healthcare system contribute to higher risks of cancer, mental disorders, and other illnesses. Research shows:

• LGBTQ+ populations have the highest rates of tobacco, alcohol, and other drug use.
• LGBTQ+ youth are more likely to experience homelessness.
• LGBTQ+ youth are two to three times more likely to attempt suicide.

Why Is LGBTQ+ Health Important?

By working together to eliminate LGBTQ+ health disparities, we can reduce disease transmission and progression, improve physical and mental well-being, and increase longevity in our communities. A history of exclusion from traditional health and social services systems exacerbates the health challenges LGBTQ+ individuals face, particularly for teens and young adults.

Creating Safe Spaces for All

Creating safe spaces is a building block for healthy, thriving communities. Rainbow Labs, a Los Angeles-based CBO in the Unite Us network, is ensuring the next generation of LGBTQ+ youth finds their community, peers, and safe spaces earlier on while gaining a sense of empowerment to propel them into bright futures.

“A lot of our youth we interact with are foster youth, and they don’t know where they’re going to eat at night. There are a lot of resources, but a lot of the kids don’t feel safe. How do we create safe spaces for our young people at Rainbow Labs? We build relationships and train everybody else around our youth to say we can be a resource. We can be a referral place. We don’t have all the answers, but we can start,” says Luis Vasquez, Founder and Executive Director of Rainbow Labs.

The key to connecting the Rainbow Labs youth to services in the Los Angeles area is partnering through Unite Us to create critical linkages, like with area schools and their associated programs.

“Our mentors know the systemic challenges that our kids are facing before they even show up to Rainbow Labs, like childhood trauma and basic human needs; and when it comes up, how can we refer them out to the right services?” says Jacob Toups, Founder of Rainbow Labs. “The benefit is in our collaborative partnerships because we’ve partnered with after-school agencies that also have connections or provide food directly to kids. We already have a built-in support network because they’re being referred out.”

Through Unite Us, Rainbow Labs securely receives referrals from county agencies (like the LA County Department of Children and Family Services) and works with a network of trusted organizations to connect LGBTQ+ youth with community resources that address basic needs: “The reality is we can’t really serve kids who don’t have their basic human needs met. That’s why we partner with organizations that already have that built in. We come in and say, ‘Let us take the next step and have a conversation around identity.’”

Expand Your Reach Through a Network of Coordinated Care

Community-based organizations have the opportunity to support LGBTQ+ individuals through Unite Us’ nationwide coordinated care network. In Unite Us’ ever-growing, national network, there’s a vast array of network partners offering programs that specialize in helping the LGBTQ+ population, and more partners join the network every day.

Like Rainbow Labs shows, joining a network of coordinated care provides more opportunities for your LGBTQ+ clients or patients to access care that meets their needs. Through the Unite Us network, you can:

• Refer individuals to shelters where they will be safely housed according to their gender identity.
• Facilitate connections to peer support groups for parents, families, and friends.
• Help individuals find organizations that provide LGBTQ+-affirming behavioral health services.
• Help individuals get a state ID and other legal documents to match their true gender identity.
• Guide families to healthcare providers with experience serving the LGBTQ+ community.
• Connect individuals with employment or legal services at inclusive and LGBTQ+-affirming organizations.

Learn how Unite Us can help your organization to expand its impact for the LGBTQ+ community and beyond.

Get in Touch

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Andy Slavitt was President Biden’s White House Senior Advisor for the COVID-19 response. He is currently a member of a President’s Council of Advisors on Science and Technology (PCAST) working group on public health. He’s led many of the nation’s most important healthcare initiatives, serving as President Obama’s head of Medicare and Medicaid and overseeing the turnaround, implementation, and defense of the Affordable Care Act. Slavitt is the “outsider’s insider,” serving in leading private and nonprofit roles in addition to his government services. He is founder and Board Chair Emeritus of United States of Care, a national, nonprofit health advocacy organization, and he’s a founding partner of Town Hall Ventures, a healthcare firm that invests in underrepresented communities. 

In 2019, Andy became an investor to Unite Us through Town Hall Ventures. As Town Hall Ventures explained, “Unite Us represents a rare opportunity to invest in a high-quality network asset that is well-positioned to address the unmet social determinants of health at scale through vertical integration of healthcare, government, and social service organizations.”

For this series, we asked Andy about our work together and his vision of how cross-sector collaboration creates lasting change for our country.

As we reflect on a decade bringing sectors together through technology to ensure people’s needs are met, what do you think has changed the most for public health in that time?

Ten years ago, there was no public health technology to speak of. Electronic medical records (EMRs) were just getting rolled out, and there were certainly no standards to communicate. Fax machines and paper checks and what information people had sat on hard drives. Today we have a playing field. We have the Cloud, we have fintech and smartphones, we have virtual visits and remote patient monitoring, and we have companies like Unite Us stitching things together so that we can finally add value to people’s lives.

What do you think about collaboration with other sectors to impact health outcomes?

Most companies want to come into healthcare and “disrupt” when really what they need to come in and do is radically collaborate. Too many companies draw a picture of the healthcare system with themselves at the center and everybody else revolving around them. If you did it the right way and if the person actually was in the center of their healthcare needs, we would build a support structure, common goals, and resources around them. People should be the reason we use to get out of our silos.

What impact are you most hopeful for as a result of our partnership?

Everywhere I look, people would benefit from Unite Us. They don’t always know it. But they know the problem they have. Coordinating services, building networks, and tapping into how people live instead of just their healthcare needs is the solution. I have seen states, service organizations, health systems, and entire communities transformed when Unite Us becomes part of their world.

What programs or initiatives related to drivers of health and community health are you most excited about? What’s on the cutting edge that you think will have the greatest impact in the next decade?

It’s clear that we need to house people in a stable way so that they have a chance at building meaningful pathways to a happy life, and that includes their health. Allowing people to accumulate savings and get a little breathing room is the number one thing we can do for people—particularly those who come from generations of poverty and whose families never had the chance to own a home and escape poverty. Put some money in the pockets of people who don’t have much, and it will do wonders for their health.

What is your biggest hope for cross-sector collaboration to improve community health?

We have an excellent evidence base for even the most complex illnesses. Medication-assisted treatment, long lasting injectables, continuous glucose monitors, mammograms. The hard part has always been engaging people up front to understand their needs and make services and resources available to them in a manner that shows them we understand how they live and the issues present in their daily life. It takes the proverbial village—connecting to people where they work, where they live, and where they play. The good news is there are resources and answers out there. The challenge is to have them reach people whenever and wherever that need identifies itself.

What thoughts would you share with Unite Us leadership as they look out on the next 10 years?

You’ve accomplished so much. You’ve taught the world what’s possible and yet we know you’re only scratching the surface. In many ways, that’s an ideal place to sit. Knowing you’re on the right track and seeing all the potential for more. It won’t be easy. Transforming things never is. But the payoff is huge. Think of one person who didn’t have to suffer, and then you can get a good night’s sleep knowing the world worked just a little bit better for them on that day thanks to Unite Us. Now imagine that happening every minute of every day. All over the country. 

The more essential Unite Us becomes, the better off we are as a country.

For more information about Town Hall Ventures and Andy, visit https://www.townhallventures.com/andy-slavitt.

Interested in learning more about how to bring Unite Us to your organization?

Get in Touch 

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The Role of Drivers of Health

Life sciences organizations are increasingly aware of the powerful role drivers of health (DOH) play in whole-person care. DOH are non-clinical contributors to whole-person health. Such behavioral, personal, lifestyle, socio-economic, and environmental factors are responsible for around 80 percent of an individual’s overall health status. However, it’s often a challenge for life sciences organizations to identify DOH needs for the communities they serve and to successfully factor them into research and development efforts. Clinical trial diversity, in particular, has remained both a pressing challenge and a key priority.

Interview with Dr. Rodrigo Burgos on Clinical Trial Diversity

We interviewed industry expert Dr. Rodrigo Burgos, Clinical Assistant Professor and HIV PGY-2 Residency Co-Director at the University of Illinois Chicago, to share his thoughts on the evolving matter of clinical trial diversity. As an HIV pharmacotherapy specialist and pharmacy residency director, Dr. Burgos is committed to expanding opportunities to support pharmacists who serve minority communities.

What are some ways that pharma organizations can expand clinical trials to be more diverse?

When thinking about ways for pharma to expand diversity in clinical trials, the first thing to note is that understanding diversity, equity, and inclusion (DEI) in clinical trials is complex. There is no single root-cause, nor a single solution. Expanding clinical trial diversity is a long-term commitment and ongoing effort that must come from all of us.

That said, there are some guidelines that many experts in this space recommend:

Four Ways to Increase Clinical Trial Diversity

1. Understand regulatory evolution: Since around 2006, U.S. legislation such as the Prescription Drug User Fee Act (PDUFA), CURES Act, DEPICT Act (Diverse and Equitable Participation in Clinical Trials) and other laws have come into effect that incorporate aspects of diversity and inclusion in therapy development. (See Figure 1 below.) For instance, the FDA Guidance on Collection of Race and Ethnicity Data in Clinical Trials; Evaluation and Reporting of Age, Race, Ethnicity Data provides helpful guidance on this topic.

2. Incorporate a DEI team and sponsors: Consider implementing a DEI team that keeps track of the regulatory landscape and assists with DEI implementation in clinical trials. Sponsors (a person, company, institution, group, or organization that oversees or pays for a clinical trial and collects and analyzes the data) can also work with sites on how to best approach their diverse patient populations. Having a dedicated support team for this work can go a long way in furthering clinical trial diversity.

3. Engage in collaborative data-sharing relationships: The FDA requests sponsors define their enrollment goals for diverse populations as early as possible. Goals are established based on gold-standards or benchmarks, which are defined based on epidemiological data. Many disease states have little to no epidemiological data to inform their gold standards, which can hinder research efforts in the long term.

4. Take a human-centered design approach: Putting real people at the center of the trial development process is critical. We must engage with communities and their leaders to understand the best ways to reach, educate, and communicate with prospective patients and study participants. Consider key areas such as:

• Communication methods: What is the best way to reach this audience (social media, advertising, community events, etc.)?
• Messaging: Is the messaging about the trial culturally sensitive? Does the community we’re trying to reach understand the key message?
• Reading comprehension: Is the reading level appropriate for this audience?
• Language: Are we using the same language as the community we’re trying to reach?
• Imagery: Are the images in our outreach culturally sensitive and relevant?

Advancing Whole-Person Care, Health Equity, and Organizational Performance

Every healthcare organization is more aware today of how disparities in health equity and DOH influence health outcomes, whole-person health, and overall healthcare costs.

Life sciences organizations can take a leading role in addressing these disparities and improving whole-person health by incorporating DOH insights into their business processes and by coordinating services with providers, payers, community partners, advocacy and support organizations, government agencies, and patients. Specifically, they can leverage data-driven insights to support strategic initiatives that advance adherence and improve outcomes.

By addressing the drivers of health, life sciences organizations can help build the future infrastructure of care and meet the challenge of health equity through targeted and effective investments.

Read the full Q&A report to learn more about how life sciences organizations can improve clinical trial diversity.

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To that end, CMS is seeking to focus providers on connecting health outcomes to broader community care needs through a variety of programs. These range from the recently announced “Birthing-Friendly” hospital designation aimed at improving maternal health to data collection rules that will require providers to assess health-related social needs and deliver more equitable care that improves health outcomes.  

While these requirements are not yet mandatory, what can providers do now to build an effective social health strategy and prepare for that future reality? 

Health for all is healthcare’s next great challenge. An effective social health strategy is critical for providers to meet the non-clinical health needs of their patients and local communities. 

Grasping the Tip of the Iceberg

Eighty to 90 percent of health outcomes are due to behavioral, social, or environmental factors that go beyond clinical care, including socio-economic 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 in their adherence and recovery. 

Physicians everywhere have encountered this challenge across broad populations of patients throughout the COVID-19 pandemic. Across the nation, physicians observed the communities hit hardest by the pandemic firsthand: rural communities, Black and Brown communities, and marginalized groups with historically limited access to care. These populations faced extensive social care needs that rendered medical treatment a temporary bandage for other challenges.

Consider this example: A patient who is unable to manage his diabetes becomes a frequent visitor of the emergency department. Concerned, the physician takes matters into his own hands and applies 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.

Connecting Health to Social Care

To tackle this challenge strategically, a provider needs an innovative analytics approach that defines and measures social and economic risk and a tight network of community-based organizations that can help meet social care needs. Few provider organizations can meet this challenge on their own. 

CMS’ health equity data requirements will motivate provider organizations to collect social risk measures the way they have long collected clinical risk measures, like elevated blood pressure readings. CMS-approved drivers of health (DOH) screening measures will help, but it can be very difficult to get a comprehensive understanding of a patient’s whole-person needs. At the same time, neighborhood- or community-level risk scores don’t always tell the whole story. For example, research published in JAMA Network Open found that 42 percent of patients with at least one social risk lived in neighborhoods not defined as underserved. 

Unite Us has developed a comprehensive Social Needs System to enable organizations to evaluate individuals, communities, and regions across six key categories of need, creating a more personalized and precise approach.

What can the provider organization 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 collaboration 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 needs.  

Just as importantly, the Unite Us Platform allows partners to securely track a patient’s progress through a referral to confirm they’re receiving the right care down the line and measure the resulting health outcomes. 

Closing the Loop

This closed-loop referral capability ensures that services meet patients’ needs and actually move the needle on health outcomes. This will be a critical skill when CMS makes it mandatory for providers to assess and address whole-person needs while also improving physical health. As commercial health plans engage more in value-based care, they will also require that provider organizations have the capabilities and resources to handle this complex set of challenges. 

It’s time for provider organizations to prepare for that future. With the right technology and network, they have the opportunity to position themselves for success in a world where health for all is fundamental. Physicians, nurses, and public health workers will have the resources to ensure that their patients are connected to the right organizations that can meet their deeper needs.

Clinicians and public health practitioners want to improve their patients’ whole-person care. Government, local communities, and healthcare providers want to address all care needs at scale. By working together through collaborative technology, we can achieve these goals and unlock potential in every community. Everyone wins when we have a healthier population and access to health for all.

Learn more about how Unite Us can help healthcare providers improve health outcomes with whole-person care.

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The post The Healthcare Provider’s Guide to Building an Effective Social Health Strategy appeared first on uniteus.com.