How one health system addressed 2,000 patients' social needs in 2 years

After accepting her position as CEO of Martinez, Calif.-based Contra Costa Regional Medical Center in 2009, Anna Roth, RN, had enough on her plate. But she wanted to do more.

"When I walked into the system [as a staff nurse] in 1993, I was struck by the complexities the population was facing," she says. "There was a lack of ability to meet the basic needs people were facing."

Approximately seven years after taking the helm, Ms. Roth has led the medical center through many changes, including EHR implementation and transformations related to the Affordable Care Act. Still, it wasn't enough. "If I'm being very honest, we really have not progressed at all in meeting the social needs of the health system," she says. "As I moved into a leadership position, this was at the forefront for me."

Located in the east San Francisco Bay area, Contra Costa County has a population of approximately 1 million, according to state data from 2014. But the same data shows that while the median household income is $78,187, the per capita income is $38,106. "There's a high percentage of people experiencing everything from poverty all the way to affluence," Ms. Roth says. "It's a geographically and demographically diverse county." As such, the No. 1 need of Contra Costa County residents is food, followed by housing and employment.

Contra Costa Regional Medical Center started talking to Boston-based Health Leads, a social enterprise that works to address patients' basic resource needs as standard parts of care. Together in the summer 2013, Contra Costa and Health Leads co-visioned a partnership built on four pillars: clinical integration, evaluation, innovation and sector leadership.

"We walked into the county system completely committed to addressing social needs and knowing we'd be able to support them," says Alexandra Quinn, Health Leads' principal of strategy and leadership, who heads up the partnership.

By June 2014, the partnership between Contra Costa and Health Leads was off the ground with the opening of a desk at San Pablo, Calif.-based West County Health Center. Undergraduate students from local universities, called advocates, staffed the desk. Approximately 50 advocates continue to do so today. Patients, while waiting, complete a systematic screening process to uncover their basic needs, whether they be hunger or loss of employment. Using the Health Leads Reach™ resource and case management system, advocates act as part of the care team and assist patients in accessing the right resources to meet these needs. After their visit, the Health Leads advocate follows up to ensure the patient's needs are met.

Since launching the partnership, Health Leads has worked with Contra Costa providers to connect almost 2,000 patients to local resources. Including patients' families, this impacts approximately 5,000 lives. The difference is nearly palpable — at Contra Costa, approximately 70 percent of patients served reported being satisfied with the care they received as the care teams now connect patients with resources for food stamps, subsidized child care or housing or payment plans and discounts for their electricity bills.

The first phase of this partnership focused on using advocates from the local university. But starting in June of this year, CCRMC will begin training additional staff — such as community health workers — to use Health Leads technology to address patients' basic resource needs.

Health Leads has partnered with numerous hospitals and health systems across the nation — including Boston Medical Center, University Hospitals of Cleveland's Rainbow Babies & Children's Hospital, Baltimore-based Johns Hopkins Medicine and Oakland, Calif.-based Kaiser Permanente — to achieve similar results. Health Leads' approach involves a co-designed partnership surrounding six levers of success, all of which a system should consider in its strategy to address patients' unmet social needs.

1. Patient identification and screening. This aspect involves screenings tailored to each health system's patient population, program scope and overall goals. Using clinically validated and patient-centric questions, the screening process identifies where the partnership will go moving forward. "You need to first identify the target patient population and then design a screen to identify and better understand their resource needs," says Ms. Quinn.

2. Workforce. Because clinicians often don't have the time or capacity to address patients' social needs, Health Leads' approach utilizes community health workers to assist with this work. Using a specific workforce for social needs give physicians and nurses more time to focus on clinical care. As Ms. Quinn notes, "You need to identify a workforce that can be focused on addressing social needs as a distinct part of their job."

3. Workflow. For a system's social needs strategy program to succeed, it should be completely integrated into the clinical workflow process. Health Leads works with each health system to help it understand the potential workflow challenges and how to solve them. For example, Health Leads ensures the system comprehends the significance of following up with patients after their visit. In addition, Health Leads works specifically with care teams to make sure they understand the processes involved in integrating a social needs strategy.

4. Resource directory. Health Leads created its own directory called Health Leads Reach. Through the cloud-based resource directory and case management system, any workforce focused on addressing social needs can find and search thousands of nearby community resources and create a tailored list that will help meet each patient's needs.

"We spend 400 man hours a week updating Reach," says Ms. Quinn. "Because information like phone numbers, addresses and eligibility requirements change for 40 percent of resources each year, keeping the resource directory up-to-date is critical to making successful resource connections and building trust with a patient."

5. Analysis and ROI. Tracking success in every aspect of the program is vital to Health Leads' approach. Through Health Leads Reach, the organization is able co-design reports with partners like Contra Costa to look at a variety of factors, from patient demographics to patient outcomes to the number of patients who accessed certain resources. "This allows us to support our partners to better understanding the effectiveness of their social needs intervention. In addition, we can use the aggregate data for advocacy work, such as identifying the most used resources and major resource gaps in the local landscape," Ms. Quinn says.

6. Leadership and change. Leaders' commitment to addressing patients' social needs is key for these interventions to work. According to Ms. Quinn, before Health Leads partnered with Contra Costa, Ms. Roth and her team focused on addressing social needs nationwide. Since the partnership began, Contra Costa's leadership team has worked side-by-side with Health Leads to design the intervention that best fits the needs of Contra Costa patients and providers. This type of leadership and commitment that has led to Contra Costa's success.

Contra Costa Regional Medical Center's recent triumphs aren't going to stop it from working even more intensely to reach its overall goal: "to make addressing social needs a standard part of healthcare in Contra Costa County," in the words of Ms. Roth. "With Health Leads' support, we're pioneers," she adds. "I have a lot of passion, a lot of hope, but we can't do it alone."

Meeting patients' social needs is becoming a greater priority with CMS' recent Accountable Health Communities model that launched in January. Through the model, CMS awarded 44 agreements worth between $1 million and $4.5 million to organizations — be they hospitals, health systems, government entities or higher education institutes. Agreement recipients "will partner with state Medicaid agencies, clinical delivery sites and community service providers and are responsible for coordinating community efforts to improve linkage between clinical care and community services," according to CMS.

The effort continues as both the government and organizations like Health Leads work to address the disparity between healthcare and meeting patients' social needs. "The reality is people are suffering all around us," Ms. Roth says. "I don't see it as a challenge, but as a mandate for us to develop these new skills. It's time and it's overdue."

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