How to Target Social Determinants of Health in Managed Care - NowPow

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July 6th, 2020 | PatientEngagementHIT

For behavioral health network Illinois Health Practice Alliance, managed care boils down to screen, intervene, and social determinants of health.

By Sara Heath

 – At Illinois Health Practice Alliance (IHPA), an integrated behavioral health network with over 90 clinicians across the state, practicing managed care and addressing the social determinants of health requires a sustainable, three-pronged support system.

It begins with a screening process, working to uncover patient social determinants of health, or the social needs that affect a patient’s wellness and whether she can adhere to a managed care plan.

“If someone can’t eat, if someone doesn’t have a home, if someone doesn’t have a job, oftentimes the issues that they’re dealing with related to those social needs are primary to whether they’re taking their medication properly,” David Berkey, the CEO of IHPA, told PatientEngagementHIT.

“It sways whether they’re following their clinical care plan and being compliant with their doctor’s orders. If you don’t have a place to live, you’re not really worried about whether or not you should take your medicine the right way. That need is higher on the hierarchy than your medical needs might be.”

The data corroborate those experiences. A 2019 JAMA Network Open study revealed that race, socioeconomic status, and age can all influence whether a patient adheres to or even begins a fitness and wellness program. In 2020, researchers from the Harvard Kennedy School found that social determinants of health affected whether patients had adequate health literacy levels and could access public health education.

Like other behavioral health providers and networks in Illinois, IHPA has to complete an extensive screening process to fully understand the social needs of its patient populations.

On the managed care side of things, IHPA providers are required to complete the Health Risk Screening and Health Risk Assessment, which identify both the clinical needs of an individual as well as the social needs.

On the behavioral health side, clinicians in Illinois must complete the Illinois Medicaid Comprehensive Assessment of Needs and Strengths (IM+CANS), which Berkey said is a much broader screening tool that focuses on the behavioral and social determinants of health needs for the patient, framing those needs as they would help encourage behavioral stabilization.

“In the IHPA universe we’re required to complete all three of those tools, which frankly is a lot of duplicative administrative work but also helps bring more clinical need to light in the exercise,” Berkey said.

Integral to that process is getting the patient to engage throughout the entirety of the screening. This can sometimes be an hours-long process, one that is not always feasible for every patient, especially in a behavioral health setting.

Berkey said many providers at IHPA will split the screening up into multiple different sittings, helping to accommodate the emotional and social needs of their patients.

But still, behavioral health providers will need to earn the trust of their patients in order to truly glean insights about a patient’s deepest social needs.

“Oftentimes people who are homeless, people who are suffering serious mental illness, are very difficult to develop a trusting relationship with, and subsequently that lack of trust precludes the effects of a clinical intervention,” Berkey explained.

At IHPA, Berkey leans on community health workers and patient navigators who have lived experiences. This includes individuals who have successfully completed substance use disorder treatments, those who have stabilized serious mental illness, or who have been hospitalized during their lives.

“When you hire those folks, they come from a level of understanding that some couldn’t possibly hold, having never walked in those shoes,” Berkey asserted. “And subsequently they know by nuance of having the lived experience, they know the right level of engagement or pressure on an individual to develop an engaged relationship.”

These employees are essential for both reaching out to patients and also for training clinician staff who do not have the same lived experiences as their patient populations.

The second leg of IHPA’s care management plan is ensuring clinicians are plugged into a patient’s physical health. The organization’s managed care platform has a plug-in that notifies IHPA providers whenever a patient has visited the emergency department, been admitted into the hospital, or been discharged from the hospital.

“If we’re working with a client that we’re contracted to manage care for and they’re at an ED, we want to know why they’re there, what they’re there for, whether they’re in crisis or not in crisis, and if we can intervene in that crisis and ensure that they get restabilized in the community,” Berkey said.

Enter the third leg of their approach: social determinants of health referral.

When IHPA providers see one of their patients have been admitted into the ED, that could mean a more intensive behavioral health intervention is necessary.

But it might also mean that a social need hasn’t been met.

Both of those are IHPA’s concerns.

A patient might be in the hospital because she has both behavioral health needs and diabetes. Food insecurity may have kept her from adhering to her nutritious diet plan, and landed in her in the hospital with an acute diabetes need. IHPA wants to know about that, and knows part of meeting that patient’s health need is in fact connecting her with a food bank.

For a while, this third leg of IHPA’s approach was fragmented and hard to accomplish. While there are a number of community health partners, it is difficult for medical providers to know which is available at that time. The referral process can be cumbersome.

What’s more, providers want to make sure they’re not sending their patients to just any open community service; they want the service to be convenient for the patient, make the patient feel safe, and meet patient social needs in a culturally competent way.

IHPA has closed that loop by recently partnering with NowPow, a technology that plugs into managed care platforms and helps refer patients to different community health partners based on their specific social determinants of health.

“If part of the reason a patient is in crisis is that they don’t have a home and it’s January and 20 degrees below freezing in Chicago, if our crisis staff can intervene in the ED setting before the admission and use NowPow to secure adequate temporary housing for that client, that A, puts the client in a more effective clinical setting for them, and B, can save a substantial expense of an unnecessary admission to a hospital,” Berkey said.

Referral technology has been especially useful during the COVID-19 pandemic. The virus outbreak shone an unflattering light on the social determinants of health, underscoring just how weak the social safety net truly has been. At the same time, the social services providers that do exist have been crippled either by social distancing protocol or inadequate funding.

“The capacity of the communities our clients live in and our providers deliver care in are radically different, depending on their location throughout the state of Illinois,” Berkey pointed out.

“Here in the Chicagoland area, the level of resources for the food banks and those sorts of things can be substantially higher, and the ease of access to this type of social fulfillment organization is much greater. When you go downstate, depending on a geographic location, there can be huge challenges there.”

“A part of the tool is to help identify all the resources that are available within the community and to make that knowledge accessible in one site for our clinicians,” Berkey added. “The other part of it is to identify the need for capacity building and help us document that, so that we can then work with both local and state organizations, as well as local and state political advocates, to help create services where there may be a lack of services or a greater need for them.”

Ultimately, this approach closes the loop on IHPA’s care management strategy – screen, intervene, and address the social determinants of health.

And for the healthcare organization writ large, referral management ensures coordination across different community health partners, something that has always been integral but that has been exacerbated during the COVID-19 crisis.

“A lot of those things exist in individual Rolodexes and individual organization relationships, but they’re not necessarily integrated within a system such as this,” Berkey concluded. “By doing so, we not only give the IHPA provider community participants the opportunity for improved efficiency and better care for our clients, but we can then introduce that to other providers across the state.”

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