By Melinda Young
Researchers are finding that Accountable Health Communities (AHCs) need greater flexibility in activities geared toward improving patients’ health-related social risks.1
The Centers for Medicare & Medicaid Services (CMS) adopted quality metrics for health systems, requiring them to screen for health-related social risks. The authors of a new study found that the model does not allow for the flexibility needed to ensure hospitals sustain the adoption of AHC activities.1
“We deliberately reached out to AHCs because they were tasked with doing this work and had applied for the program and followed strict guidelines and implementation rules about what they had to do and how they were to do it,” explains Laura B. Beidler, MPH, lead study author and research project manager at Dartmouth Institute for Health Policy and Clinical Practice in Hanover, NH. “We talked with organizations about what they were doing in the structure of the AHC program, what learnings we could take from their experience in the demonstration project, and how to apply it more broadly.”
The qualitative interviews lasted for an hour and involved people in 22 of 31 AHC central management offices. Beidler and colleagues also connected with their frontline staff to include experiences with those on the ground, implementing the work.
“We really focused on their structure and how they organized themselves,” Beidler explains. “There were guidelines from CMS, but in practice, all were a little different.”
Screen for Social Determinants
The core elements involved screening patients for social needs. The details involved who was conducting the screening, what they were screening, and how they were screening for social needs.
Beidler and colleagues also wanted to know how AHC staff were using information from screenings to help patients with their social needs. For example, some AHCs assisted patients with finding resources to meet their needs, so how were they approaching that? How were they working with community-based organizations (CBOs), and did they keep a list of CBOs that could be used for referring patients in need of those services?
Organizations making referrals to CBOs need to consider some of the challenges and resources required, such as workflow, staffing, tailoring referrals to patients’ specific needs, variation between locations and patients, developing and maintaining referral lists, involving clinicians and obtaining their buy-in, follow-up processes, and common challenges, as well as questions about closed-loop referrals.
“What is it like to work with CBOs? What do partnerships look like? How formal are they?” Beidler asks.
Some study participants said they wanted to tailor the referrals they provided to patients. For example, instead of just handing patients a list of all places where they could get help with finding affordable or free food, they could hand them a list of places within a mile or two of where they lived.
Creating a tailored list takes more work. But those who tailored their lists of resources to patients’ specific needs reported more success in connecting patients to organizations that would help them.
“They may have a list in every clinic, preprinted by ZIP code or county, of all the needs. But they could go a step further to have a preprinted list that a staff member goes through and hand-highlights a few that they think would be really good,” Beidler explains. Or they could use a software platform and print off a tailored list, she adds.
“One thing that surprised me was how screening is a core activity for all of these organizations,” Beidler says. “They use a specific tool and screen in specific clinical areas.”
Organizations varied in how they carried out screening. Some used volunteer college students, such as pre-med or nursing students who wanted healthcare experience, to perform the screenings. Other organizations hired people to screen patients in the ED. “They were working within a constrained budget, but you saw real variation across tasks within the organization,” Beidler adds.
CMS Guide
CMS offers a guide to using the AHC Health-Related Social Needs Screening Tool, which includes specific questions related to housing and living situations, food access, transportation, affording utilities, experiences of violence, financial problems, work problems, activities of daily living, childcare, loneliness, education and English proficiency, physical activity, substance use, mental health, and disabilities.2
These are a few examples of the screening tool’s questions:
- “How often does anyone, including family and friends, scream or curse at you?”
- “Do you want help finding or keeping work or a job?”
- “Stress means a situation in which a person feels tense, restless, nervous, or anxious or is unable to sleep at night because his or her mind is troubled all the time. Do you feel this kind of stress these days?”
- “Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?”
- “Think about the place you live. Do you have problems with any of the following?” The list includes pests, mold, lead paint or pipes, lack of heat, oven or stove not working, missing smoke detectors, and water leaks.
“Some of our interviewees said that prior to this program, they were screening patients using different questions,” Beidler says. “For some people, the descriptive nature of the screening program worked really well; for others, they had legacy questions they would have preferred to ask.”
Some organizations employed validating social needs screeners for patients. When required to use the AHC screening tool for their Medicaid and Medicare patients, they had to decide whether to stop using their existing tool and use the AHC tool for all patients or to use both tools, which could be confusing to case managers and others performing the screening.
“Any change you do causes hiccups,” Beidler says.
The challenge was that the AHC initiative was a five-year pilot program with limited CMS funding. If organizations fully embraced the program and adopted the CMS screening for all patients, they would be committing to using a longer list of questions that could be hard to support with staff time once the CMS funding ended.
“We heard a lot that they wanted to do this with minimal disruption and interference with their tasks,” Beidler says. “Many didn’t feel they could ask all front desk secretaries to do the screening.”
Beidler and colleagues found interviewees had hopes and goals that the program to help patients with their social needs would continue after the pilot program and become a part of their normal clinical practice. “But they faced challenges on how to sustainably build out these activities,” Beidler says. “Another thing they talked about that was a challenge and benefit was how the AHC program itself has robust accountability milestones built in. That was very motivating, and they really wanted to meet those milestones.” Interviewees cautioned that it was important to carefully consider setting those benchmarks correctly, she adds.
Some organizations wanted the AHC initiative to be made permanent. “They also were thinking about how to use those milestones across the organization and within a specific clinic and how to reward them and not just make it a daunting task, but something people feel some accomplishment around,” Beidler explains.
REFERENCES
- Beidler LB, Colvin JD, Winterer CM, Fraze TK. Addressing social needs in clinical settings: Early lessons from Accountable Health Communities. Popul Health Manag 2023;26: 283-293.
- Centers for Medicare & Medicaid Services. A Guide to Using the Accountable Health Communities Health-Related Social Needs Screening Tool: Promising Practices and Key Insights. August 2022.
Researchers are finding that Accountable Health Communities need greater flexibility in activities geared toward improving patients’ health-related social risks. The Centers for Medicare & Medicaid Services adopted quality metrics for health systems, requiring them to screen for health-related social risks. The authors of a new study found that the model does not allow for the flexibility needed to ensure hospitals sustain the adoption of AHC activities.
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