Accountable Health Communities--Addressing Social Needs through Medicare and Medicaid.

F decades, experts have described a profound imbalance between public funding of acute medical care and investments in upstream social and environmental determinants of health.1 By some estimates, more than 95% of the trillion dollars spent on health care in the United States each year funds direct medical services, even though 60% of preventable deaths are rooted in modifiable behaviors and exposures that occur in the community.1 Most clinicians are familiar with the stories behind these statistics: the child with asthma whose substandard housing triggers repeated emergency department visits; the patient with repeated visits for severe abdominal pain caused by her violent home life; the older adult with diabetes forced to choose between paying for heat and buying groceries. But in our current system, patients’ health-related social needs frequently remain undetected and unaddressed. Despite calls for obtaining an expanded social history at the point of care,2 most health care systems lack the infrastructure and incentives to develop comprehensive, systematic screening-and-referral protocols and relationships with the array of community service providers that would be required to address their patients’ health-related social needs. If the rate of preventable hospitalizations among residents of low-income neighborhoods could be reduced to the level among residents of high-income neighborhoods, there would be 500,000 fewer hospitalizations per year.3 As health systems are increasingly being held accountable for health outcomes and reducing the cost of care, they need tools and interventions that address patient and community factors contributing to excess utilization. Effective partnerships among medical care, social services, public health, and community-based organizations could improve population health outcomes, but developing sustainable payment models to support such partnerships has proved challenging.4 Some encouraging innovations have emerged. Catalyzed in part by statewide all-payer deliverysystem reform and the growth of value-based or shared-risk payment models, some purchasers and providers of medical care have found innovative ways to support high-value communityfocused interventions. For example, Hennepin Health, a countybased Medicaid managed-care organization in Minnesota, has reduced emergency department visits by 9% by using housing and community service specialists who are part of a tightly integrated medical and social service system. Tracking patients’ service utilization across clinical and human-service systems allows Hennepin to target upstream interventions so that its patient care can be more effective (as documented in composite quality metrics of asthma, diabetes, and vascular care); the organization has improved patients’ access to social services and reinvested savings in a broad range of programs.5 Other examples come from the Health Care Innovation Awards granted by the Centers for Medicare and Medicaid Services (CMS); these awards have supported organizations such Chicago-based CommunityRx, which generates prescriptions for community services through an interface linking the patient’s electronic health record with a community-resource database, and the Michigan Public Health Institute Pathways to Better Health Community Hub model, in which community health workers perform a structured assessment of clients’ health and social service needs and use standardized “pathways” to link beneficiaries to community resources and track outcomes. These projects have generated valuable insights regarding addressing the social determinants of health, including the importance of establishing cross-sector partnerships, building data systems that bridge health and community services, and developing a workforce to deliver interventions to vulnerable populations. We still lack expertise, however, in the best ways of scaling these approaches across myriad settings; we remain unsure whether broad-based investments improve health care utilization and costs; and we need to develop and test a template that allows a wide variety of communities to undertake transformation efforts.