1 year later: How CommonSpirit is organizing outcome-based healthcare in underserved communities nationwide

What if competing health systems, payers, and community health organizations could join together to provide care for the most high-risk populations? Thanks to CommonSpirit Health, it's already happening in several states. 

The Chicago-based health system partnered with the Pathways Community HUB Institute in 2022 to launch a community-centric care navigation model in multiple communities across the country. Ji Im is senior director of community and population health at CommonSpirit and sat down with Becker's to discuss what the program has achieved in its first year. 

"The big difference here is that we're not hiring our own community health workers, and payers aren't either," she said. "We're all saying, community health workers are best in their community. We're going to contract with those organizations so that they help not in a clinical setting, but a community setting."

The PCHI model has three components: an outcome-based payment model, cross-sector collaboration and cultural diversity in the approach. The cross-sector collaboration component is designed to allow health systems, payers, public entities and community organizations to identify and reach out to those "greatest at risk" and connect them to social, medical and behavioral interventions and services within their community. Once connected with services, the model can track health outcomes and contract with payers to directly tie payment to those outcomes.

A total of 21 pathways represent the steps needed to remove risk, which could be a lack of housing, employment or subpar access to health services. A pathway is completed once the risk factor is removed. 

"We all talk about social determinants of health and the importance of screening, but that's just the beginning," Ms. Im said. "Truly understanding an individual's social needs is knowing what's happening with their circle and their ecosystem. This model serves not only the individual, but their family members, recognizing that social needs are way just beyond one person." 

CommonSpirit has invested $1.1 million into the new program and raised $3.4 million from other healthcare organizations, including 11 payers. The populations served are predominantly Medicaid recipients, with Ms. Im noting that participating organizations have specifically selected populations that are high-risk and have been most difficult to reach. 

To date, the new model has contracted with stakeholders in Nevada, California, Texas and Nebraska. Nevada started receiving patient referrals in March, and the others will start this summer. The Nevada model has enrolled more than 770 individuals, with the average length of enrollment being 72 days. Community health workers have conducted 380 home visits and closed 337 pathways.

"The feedback that we're getting is just how critical it is to get buy-in from healthcare entities, very early on," Ms. Im said. "Health plans are actually investing in this program before they even contract with it — they want to build this infrastructure so they can use it."

Moving forward, CommonSpirit is looking to expand the model to rural communities and Medicare recipients. The health system is also looking to better measure the program's outcomes, and is looking to partner with other national community care hubs that aim to align with federal and state agencies. 

Pathways Community Health Institute has published a playbook featuring CommonSpirit that demonstrates how hospitals and health systems can participate in the model and establish their own community-centric care.


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