Social Determinants of Health

Medicaid ACOS provide an exciting opportunity to address the social determinants of health (SDOH) among the Medicaid population. The SDOH are the conditions - such as food, housing, and safety - in the places that people live, learn, work, and play. Addressing these factors improves health, reduces disparities in health care and access to care, and reduces long term health care costs.

Does your state Medicaid ACO program do the following?

Encounter level:

  • Regularly assess individual patients’ social and economic needs. Provide appropriate referrals to social service organizations, navigation assistance for accessing social services, and follow-up to see if patients received the needed services.

    • North Carolina’s Prepaid Health Plans (PHPs) are be required to conduct social needs screenings using ten standardized questions that cover four domains: food security, housing and utilities, transportation and interpersonal safety.

Organizational level:

  • Utilize payment models that incentivize ACOs to provide and coordinate social services,  

    • Hennepin Health in Minnesota can include non-medical services in the total cost of care, which allows them to better address patients’ social and economic needs. For example, they provide housing to homeless patients with complex care needs.

    • Oregon’s CCOs can use Medicaid dollars for non-medical services including housing supports.  A  survey of 15 of Oregon’s 16 CCOs found that they all provide some form of housing supports, such as assistance with housing applications, move-in costs, eviction prevention or utilities assistance.

  • Include requirements that ACOs implement a range of specific programs that directly address social determinants of health, such as  supportive housing or food and nutrition interventions.

    • Massachusetts developed a guidebook to help ACOs determine how to address housing, income insecurity, nutrition, domestic violence, education, physical activity and transportation.

    • New York requires any provider in a value-based purchasing arrangement, including ACOs, to implement at least one SDOH intervention. The state provides a menu of options, including Housing-first programs to address homelessness, child-care support, or prescriptions for healthy food.

  • Include quality measures related to addressing the SDOH.

  • Improve information exchange between health systems and social service organizations to provide better care to consumers.

Community level:

  • Regularly assess the social service needs of the community, including using a community health needs assessment (CHNA) and community health improvement plan.

    • The Trenton Health Team in New Jersey used quantitative data and community forums during their last community health needs assessment, to find out what health issues were most important to their community. Their Community Advisory Board (CAB), whose members include 50 community-based organizations, oversees each CHNA process. The CAB also directs grants to improve the community’s health, based on the needs identified in the CHNA.

    • Oregon requires all Coordinated Care Organizations (CCOs) to conduct community health needs assessments. The state provides trainings to teach CCO administrators how to develop CHNAs and community health improvement plans.

  • Require your Medicaid ACO to form community partnerships. Advocates should ensure that the partnering organization meets the needs of the community that the ACO serves. 

    • Oregon’s CCOs must have agreements with particular community emergency and mental health programs. These are often local government offices, such as an Area on Aging office. The CCOs are also encouraged to form partnerships with community-based organizations that provide services like crisis management or community prevention.

    • To provide mental health and substance abuse services to MassHealth members. The Massachusetts Behavioral Health Partnership works with a network of community-based clinics, primary care physicians, and other organizations.

    • Colorado’s ACO requires contractors to establish relationships with community-based organizations and includes medical and non-medical services within care coordination. Organizations such as Centura Health partner with faith-based organizations to provide mental health and spiritual care services. Colorado’s ACO also has an employee who assesses the demographics of high-risk members and refers them to social services.

  • Assess the effectiveness of the ACO’s community partnerships.

    • Massachusetts measures ACOs on social service screenings and use of state certified community partners.


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