Networks Of Support Help Patients Navigate Complex Systems

Jackie Kloos went to an Allina Health primary care clinic in downtown Minneapolis, Minnesota, for a preoperative visit in July 2022. Similar to all of Allina’s Medicare patients, she received a one-page screening questionnaire asking her whether she needed help with any of eight health-related social needs, including housing, food, transportation, or money to pay for medical care or drugs. She checked the boxes indicating that she could use help with several items.

In late September the sixty-one-year-old Minneapolis woman got a follow-up phone call from Allina Health “navigator” John Sathrum, an experienced but unlicensed community health worker.

Kloos, who three years ago left her career as a home health aide and went on Social Security disability because of medical and mental health issues, provided Sathrum with information about her medical, financial, and insurance situation; he promised to call her back shortly with resources.

When he did call back, Sathrum eagerly informed Kloos that she was likely eligible for Medicaid, which, he told her, means that “you’ll have no Medicare premium and no medical bills.” Sathrum explained that “if you qualify, you’ll be assigned a case manager, and you’ll possibly have an independent living skills specialist.”

“I can? Oh my gosh,” she gushed. “I had no idea. This is wonderful. It’s almost too good to be true.”

Kloos is one of thousands of Allina patients who since 2017 have received screening and referrals to community resources to address their health-related social needs. The program started under the auspices of the Accountable Health Communities Model, a demonstration sponsored by the Centers for Medicare and Medicaid Services (CMS).1 Allina has continued the effort since the five-year demonstration ended earlier this year. It plans to expand the program to all patients at its ten hospitals and eighty-plus primary care and urgent care clinics in Minnesota and Wisconsin by sometime next year.

“Social workers at hospitals have been doing this for a long time, so it’s nothing new,” said Dan Behrens, Allina’s manager of population health operations, whose first job in health care was serving as an Allina patient navigator. “But having it more structured and standardized across our entire system was new to us and to many other organizations. It’s a huge culture change, and patients and staff are happier that we are doing this.”

“We say this is just another vital sign for our patients. That hits home for our providers,” said Ellie Hallen, Allina’s director of population health and of the Health-Related Social Needs Program.

‘Upstream Factors’

The Accountable Health Communities demonstration was the first project by the CMS’s Center for Medicare and Medicaid Innovation (CMMI) to test a model for bringing health care providers, payers, and community-based organizations together to address patients’ social determinants of health.2 Allina was one of twenty-eight “bridge” organizations located in both big cities and rural areas in twenty-one states that received CMMI funding to act as service hubs. Those organizations included health systems, insurers, health information exchanges, a public health department, academic institutions, and community organizations. Each bridge organization received up to $1.17 million over the course of five years to coordinate the program with a variety of partners, with the goal of determining whether addressing patients’ social needs reduced total health costs and care use and improved beneficiary and provider experience.3

Such efforts have been part of an emerging national effort to establish community collaborations to improve the social, economic, and environmental conditions that are largely responsible for people’s health status.46 Despite the long-standing recognition of the importance of social drivers of health, the health care system has been slow to refocus on them.3,7 That’s due to a variety of factors, including the daunting complexity of addressing social needs, the lingering belief that the health care industry isn’t responsible for tackling those issues, the disorganization and underfunding of social services, and the predominant fee-for-service model of paying for discrete medical services rather than for overall health outcomes.6

“We know that poor health outcomes, especially in communities of color, are exacerbated…by living without a safe place to call home, a job that supports a family, good schools, and enough food on the table,” said Sen. Tina Smith (D-MN), who has introduced a bill8 to address social determinants of health. “Allina’s Accountable Health Communities program confirms that we can improve health outcomes if we address these upstream factors.”

Although each of the twenty-eight Accountable Health Communities bridge organizations structured their programs somewhat differently, they all targeted noninstitutionalized Medicare and Medicaid beneficiaries with one or more of five health-related social needs: housing instability, food insecurity, transportation problems, utility difficulties, and interpersonal violence (Allina has since added trouble paying for medications and medical bills and social isolation to the list). Participants also had to have two or more emergency department (ED) visits in the twelve months before screening.

In the assistance track of the demonstration, navigation-eligible beneficiaries were randomly assigned to either the intervention group, which was offered both community services referrals and navigation, or the control group, which received only referrals. In the alignment track, all eligible beneficiaries were offered navigation.9

All bridge organizations and clinical partners used a standard questionnaire to screen beneficiaries for the five health-related social needs. Screenings took place in EDs, physicians’ offices, and behavioral health clinics, with data entered on paper forms, tablet computers, or patient portals. When the COVID-19 pandemic hit in 2020, screenings largely were performed by telephone or digitally. Most sites used a combination of existing staff and newly hired, dedicated staff to conduct the screenings and initiate follow-up. As of June 2022 more than 1.1 million patients had been screened as part of the Accountable Health Communities demonstration, according to CMS.2

Patients who reported at least one health-related social need were eligible for referral and navigation to community services, which the bridge organizations compiled in resource directories. More than 137,000 patients had accepted navigation help in connecting to resources as of June 2022—about 80 percent of those eligible.2 But only 14 percent of patients who had completed a full year of navigation in December 2019 had any health-related social needs documented as resolved.9

Overall, the Accountable Health Communities demonstration showed promising early results in improving patient outcomes and reducing costs, according to RTI International’s evaluation published in December 2020, the first of four planned reports. Medicare beneficiaries in the assistance track of the demonstration had significantly fewer ED visits than the control group in the first three quarters after screening.9 A similar analysis for Medicaid beneficiaries has not yet been published because of delayed availability of Medicaid data.

What is more, CMMI officials acknowledged in August 2022 that “it was difficult to track navigation and resolution outcomes. Patient needs are sometimes left unresolved due to insufficient community resources.”2

Individual demonstration sponsors including Allina and the Parkland Center for Clinical Innovation, in Dallas, Texas, separately reported encouraging results on outcomes and cost reduction. In Allina’s demonstration, patients screened as experiencing housing instability who had their need resolved had fewer inpatient admissions and ED visits at six, nine, and twelve months after screening.10 The Dallas Accountable Health Communities demonstration site reported that patients receiving referrals and navigation experienced a greater decrease in ED visits than the control group both during the period when they were receiving navigation services and in the twelve subsequent months. That demonstration’s bridge organization, the Parkland Center, cited a positive return on investment of 1.3 to 1, with gross one-year savings from reduced ED visits exceeding $1.25 million.11

‘Navigating To Nowhere’

Looking ahead, CMS officials say that the agency is drawing on lessons from the Accountable Health Communities Model to build social needs assessment and navigation into other programs, including Medicare accountable care organizations, Medicare Advantage plans, and quality measurement of hospitals and physician practices.2

One of the big challenges is how best to develop more community resources for patients with social needs so that health care providers aren’t “navigating to nowhere, for social services that don’t exist,” said Kate Abowd Johnson, an acting deputy division director at CMMI, who previously led the Accountable Health Communities demonstration. She noted that this requires collaboration and diplomacy: “Community organizations have a lot of expertise, and they don’t necessarily want payers or providers to overreach.”

Although experts say it’s long overdue for health care providers to partner with community organizations to address their patients’ social needs, Allina leaders say that it was a tough decision to launch the program. Since then, they admit, it’s been extremely demanding, although rewarding, to implement.

The impetus for the program came from Allina’s 2015 community health needs assessment. Allina’s leaders were hearing that they needed to address food insecurity and housing instability. “But we wondered, what was our role?” recalled Ellie Zuehlke, who led the Accountable Health Communities launch at Allina and now serves as Allina’s director of philanthropic advisory boards.

Around this time, Allina’s primary care providers were increasingly calling for social workers to be placed in their clinics—a reaction to being held ever more financially accountable for patient health outcomes. It’s hard, they argued, to improve outcomes for patients with diabetes if those patients can’t access or afford healthy food.

This was when Allina leaders saw CMMI’s call for applicants to seek Accountable Health Communities grants. They hesitated, worrying that the funding wouldn’t cover the full costs and that the program went beyond the traditional role of a medical provider. But then-CEO Penny Wheeler decided that participating in the Accountable Health Communities demonstration would advance Allina’s “whole-person care” philosophy.

So Allina launched a small pilot test of the screening and navigation model at one of its suburban clinics in late 2016. According to Zuehlke, Allina found that 39 percent of 249 patients screened had health-related social needs and that staff were able to help them with those needs in many cases.

One family in particular helped convince Allina providers and other staff that the Accountable Health Communities demonstration would be worthwhile. In a 2017 video that Allina produced for its staff, a young mother with two little boys, including one with cystic fibrosis and seizures, described going to the clinic and filling out the screening questionnaire indicating social needs. “I said yes, we have issues with putting food on the table, our washer broke, our car broke, I’m working three jobs, and we miss a lot of our son’s appointments,” she said.

The woman went on to say that an Allina staffer helped her and her husband get their car and washing machine fixed, put them in touch with a food pantry, and got them help with their electricity bill. “We were down, and she helped us address everything,” she said. “There’s no way I could have done any of that. She made our family whole.”

Zuehlke said that this woman’s story was a turning point. “That really changed the tune, where people could see it made such a difference for those patients and for the relationship between the provider team and the patient,” she said.

‘A Wild Ride’

Allina staff members were won over by the rewarding experiences they had in connecting patients with community resources.

There were more staff challenges along the way. For one, Allina leaders had to help staff become comfortable asking patients questions about social needs. Also, this new work brought to the surface some biased perspectives on lower-income people. For example, many staff members, especially those serving predominantly White, middle-class communities, felt that their own patients didn’t need any help. Zuehlke and her colleagues used Allina’s screening data to show staff that their own patients—of all races and ethnic backgrounds, in both rural and urban areas—had lots of needs.

In addition, the staff needed cultural competency training in screening and referring diverse populations, including Latino, Somali, and Hmong patients, for social needs. That training was offered by HealthFinders Collaborative, a community health center in Faribault, Minnesota, located fifty miles south of Minneapolis in Rice County. The collaborative serves as a key navigation provider for Allina’s Health-Related Social Needs Program.

Allina leaders had to help staff become comfortable asking patients questions about social needs.

Eventually, Allina staff members were won over by the rewarding experiences they had in connecting patients with community resources. “The data and the stories about how staff made a difference in the life of a person finally created the flip,” Zuehlke said. “But it took a long time to get there.”

Along the way, the COVID-19 pandemic almost ended Allina’s Accountable Health Communities experiment. In the first weeks of the pandemic, Allina closed clinics and furloughed staff, nearly halting the screening and referral of patients for social needs. At the same time, CMS told Allina that it wasn’t hitting its volume targets and threatened to pull demonstration funding. Then CMS officials became more flexible and allowed screening and navigation to be done temporarily through Allina’s patient portal. That saved the program.

“I had a panic attack. I thought, ‘Oh my gosh, this is how this story is going to end,’” Zuehlke said with a laugh. “It was a wild ride.”

Unlike some other Accountable Health Communities bridge organizations that hired new staff to conduct screening, Allina assigned front-desk staff in its clinics, urgent care centers, and hospitals to hand out the survey. That’s because its leaders wanted to engage the entire workforce in its work on the social determinants of health.

At Allina’s United Family Physicians Clinic, in St. Paul, Minnesota, the front-desk staff members give patients the one-page screening questionnaire, shortened from the six-page survey used during the Accountable Health Communities demonstration. Medical assistants enter the responses through an online tool called NowPow that is embedded in the health system’s Epic electronic health records system. That soon will be replaced by a tool called Unite Us, whose owner acquired NowPow in 2021.

When patients indicate that they have social needs, other clinic staff members follow up during the visit and ask whether the patients would like referrals and navigation help. Patients receive a printed after-visit summary with a list of nearby community resources, and the case is sent to Allina’s team of nine full-time navigators for a follow-up call. For patients who report food insecurity, the clinic offers a package of nonperishable food items on the spot before they leave.

Physicians admit that before the screening program started at their St. Paul clinic early last year, they often didn’t know about the precarious social and economic situations of some of their long-time patients. They say that the systemic collection of social needs information has been valuable in caring for their patients, as well as in training their family practice residents to address social determinants of health.

Although they’ve always tried to understand patients’ social circumstances, the physicians say that they may miss important factors while trying to cover multiple medical issues in relatively short visits. Plus, patients often don’t disclose this type of information without being asked, as it hasn’t traditionally been discussed during medical visits.

‘It Isn’t Magic’

Stephanie Rosener, the clinic’s residency program director, said that the social needs screening for one of her long-time patients was particularly eye opening. It revealed that the patient and her husband had lost their home of many years, put their belongings into storage, and were living in a motel. The motel and storage costs made it difficult for her to afford insulin for her diabetes, and she had ended up in the ED.

As soon as Rosener found out about this, Allina staff connected the patient with a medication assistance program. With help from a social worker, the patient and her husband found an affordable home. These social interventions made it possible for Rosener to work with the patient on getting her diabetes under control and avoiding other infections.

“It didn’t occur to her that we could help her, and it wouldn’t have occurred to me that she didn’t have a home,” Rosener said. “We need a systematic team-based approach like this where we each have our role and we have data on what we should be addressing. It isn’t magic.”

It’s not easy, however, to make sure that patients get connected with the housing assistance, food resources, transportation, insurance benefits, or other help they need. Patients might not follow up, sometimes because of a language barrier. Community organizations, which are already short on funding and staff, may get overwhelmed with referrals. Navigators may be backed up with too many patients to serve. Above all, there often are shortages of community resources, particularly affordable housing.

Many patients are skeptical when they get a call from a navigator because they may worry about their immigration status, they’re suspicious of phone fraudsters, or they’re ashamed of receiving help, said Jonathan Hernandez, an Allina navigator, between phone calls to patients in late September. On one such call he spoke through a sign-language interpreter with a Hmong woman with impaired hearing. On her screening form, she had indicated a need for help with food, transportation, utilities, and medications. But on the call she only requested help with utilities. That’s common, he said.

“I had a seventy-year-old Hispanic guy who was apprehensive about working with me, and I told him to check with the clinic and find out that I’m an Allina employee,” recalled Hernandez, who’s bilingual and recently earned his master’s degree in social work. “I told him I have a passion for helping people because I was on social services as a kid growing up in poverty. I feel I’m giving back to the community for that help. I say, ‘Don’t feel bad about getting food stamps or help paying bills. It’s temporary. You’ll get back on your feet and pay money back into the system.’”

‘Closing The Loop’

Similar to Hernandez, Allina leaders express concern about whether the Health-Related Social Needs Program is “closing the loop” and actually resolving patients’ social needs discovered during the screening process. That’s essential in making the business case for insurers to reimburse Allina and its community organization partners for this work, especially now that the CMMI demonstration and its funding have ended and Allina is moving to expand its program to all of its patients and care sites.

To optimize the resolution of needs, Allina is enhancing its electronic health record system to make sure that navigators and patients have rapid access to accurate information about effective community resources. Wherever possible, navigators are referring patients to community organizations that are able to serve as a one-stop shop for patients with social needs.

Those organizations work closely with Allina patients over extended periods of time and can more reliably document whether they have resolved patients’ needs. Allina sends patient information directly to them through its NowPow data tool, and those organizations, in turn, can update Allina on navigation outcomes.

“Unless we have data from community organizations, we can’t tell the story about what happened between the latest screening and the previous screening that [led to] the resolution of the social need.” Behrens said.

HealthFinders Collaborative, the community health center that provided cultural competency training to Allina’s staff, has also been a valuable partner in driving outreach and ensuring successful follow-up. During Allina’s Accountable Health Communities demonstration, Rice County, where HealthFinders is based, had the highest resolution rate of all participating counties for patients’ social needs, Behrens said.

HealthFinders provides health care training to leaders in the local Latino, Somali, and other diverse communities and deploys them as community health workers, said Charlie Mandile, the organization’s executive director. “We get a warm handoff from Allina, and we reach out and connect with folks in their homes, [in] community spaces, or on the phone,” he said. “When our folks do a home visit for a diabetes follow-up, food or housing may be a higher priority. We work with them until their needs are met.”

Another of Allina’s key community partners is Hunger Solutions, in St. Paul, which connects people with food resources. Jill Westfall, the organization’s director of programs, said that she appreciates Allina’s NowPow data sharing system, which makes it easy to report back on the outcomes of patient referrals.

A major challenge for Allina, and particularly for community-based organizations such as HealthFinders, is getting paid for these services. Minnesota insurers have expressed interest in funding screening and navigation services if providers and community organizations can demonstrate improved health outcomes and reduced hospital and ED use resulting from the program, said Molly Clark, Allina’s chief population health officer.

Blue Cross and Blue Shield of Minnesota has established a value-based payment model with Allina to reward work that resolves its enrollees’ social needs, such as food security, although it’s not paying Allina for these services on an individual claims basis, said Mark Steffen, the insurer’s senior vice president of medical management and chief medical officer.

And Allina isn’t the only entity in the region with which Blue Cross and Blue Shield of Minnesota is building partnerships. The insurer recently teamed up with the Winona Community HUB, a service-coordinating nonprofit organization not affiliated with Allina. They signed the first agreement in the state to reimburse on a claims-based system for services to its enrollees that resolve a social need.12

“We’re looking to create sustainable models to drive this work of closing social needs barriers,” Steffen said. “The difficulty is that solutions for social needs don’t have a set structure like hospitals and clinics. Figuring out how to ensure you are paying for the right services in the right patients at the right time is the challenge here.”

Meanwhile, Minnesota’s public and private insurers, including Blue Cross and Blue Shield, have been talking with health care providers and community organizations in the state for the past eighteen months about how to better address social determinants of health and pay for those efforts.

Sue Severson, vice president of health information technology at StratisHealth, the organization convening those talks, said that the group is studying financial models for similar efforts in other states but that those efforts around the country are in their early stages. One particular concern for health plans is ensuring that any payments they contribute are counted as medical expenses rather than administrative costs in their medical loss ratio filings. Tallying them as administrative costs would increase the plans’ risk for triggering federal rebate requirements, thus eroding the plans’ return on investment for resolving social needs.

One possible approach to payment, Severson said, is for providers to submit “Z codes” as part of their International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis codes, listing patients’ social needs. CMS has published a number of these Z codes, such as Z59 for problems relating to housing and economic circumstances.13 But so far, few providers have submitted Z codes, and there is variability in how these codes are defined. CMS itself is not currently reimbursing for these Z codes.

“Philosophically, we have strong agreement among the stakeholders about coordinating for social needs,” Severson said. “But the devil is in the details about the mechanism to make this happen.”

Behrens said that Allina’s preliminary financial analysis shows that reduced hospital inpatient and ED use by patients who receive screening and navigation help saves nearly $6,000 per patient per year. “With the volume of patients we’re screening, we can argue this would save payers millions if we resolve patients’ needs successfully,” he said. Nevertheless, Allina hasn’t yet presented this financial case to payers to seek reimbursement.

Even without having cracked the reimbursement riddle, Allina’s Health-Related Social Needs Program already has made an important difference.

Even without having cracked the reimbursement riddle, Allina’s Health-Related Social Needs Program already has made an important difference, Behrens said, by spotlighting social services gaps in various communities. For example, many patients at Allina’s primary care clinic in Forest Lake, Minnesota, reported a need for help with transportation. Allina navigators steered them to one particular transportation provider, but more than half of the patients referred had complaints about that provider. Sharing those data with the community, Behrens said, helped a community coalition working with Washington County officials to launch a free county-funded bus service, with stops at the clinic, the courthouse, and other vital facilities.

Behrens and his team similarly are sharing data on other service gaps with local, state, and federal officials to support funding and legislation such as Senator Smith’s Improving the Social Determinants of Health Act.8

Although the concept of health care providers helping people with their social needs sounds simple, implementation is complicated, and there is a great deal of work to do before the practice becomes seamless and widespread.

Still, there already are lots of heartening experiences. Kloos, the patient helped by navigator Sathrum, said that she has struggled on her Social Security disability checks to afford food, medical bills, and transportation. She tried by herself to apply for Medicaid and the Supplemental Nutrition Assistance Program but was turned down several times. Having someone patiently guide her through the step-by-step process has been huge.

“I’ve never had a case manager. I did it all myself, and it was really hard,” she said. “I’ve been with other types of clinics, and I’ve never been offered this help. When John called, it was a godsend.”


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