posted by AHIP
on March 26, 2020
For Tufts Health Plan, addressing the social barriers to health involves many initiatives to make care more accessible and connect members with community services.
Our corporate mission is to improve the health and wellness of the diverse communities we serve. Addressing members’ social needs is a critical part of this philosophy, particularly because we offer coverage to all people, regardless of their age, income or circumstances. While we incorporate thinking about social determinants of health into all product lines, it is particularly relevant for our Medicaid and Medicare populations, where there is a high demand for services among older people and people with disabilities. Understanding these members’ social needs and offering appropriate care management interventions is critical to improving overall health and well-being.
To achieve these goals, we leverage the infrastructure in place within the communities that we serve, particularly resources provided by community-based organizations. Our workforce includes community health workers who know where these resources and social services are available and how to connect members to them.
Here’s a couple of recent examples that demonstrate our approach.
One of our senior members was recently hospitalized with shortness of breath. She was eventually discharged home with the need for an oxygen tank, but she lived on the second floor of senior housing building that did not have an elevator, and it was difficult for her to use the stairs all the time. The family was having trouble relocating the member until one of our care managers worked with the local housing authority to fill out the paper work and find the member a building with a working elevator. It’s only because the care manager had frequent touch points with the member to discuss her medical condition that the underlying housing issue became apparent.
Another member recently moved to a new home from a shelter with her two sons. The member has physical disabilities and no car available, which made it difficult for her to get to needed medical appointments. Our care manager joined a Long Term Service Coordinator (LTSC) from a local community organization to develop a care plan for the family. The member was provided with in-home services that addressed her disability and provided other daily living supports like a laundry service. Local community organizations donated school supplies for her son. We connected her with transportation and local providers, as well, which helped her get to the appointments she needed.
We are in the third year of a 5-year waiver with the ACO model with MassHealth, the state’s Medicaid program. There are two primary ways that the program design addresses SDOH. The first is through the establishment of community partners for members with significant behavioral health needs or those that require long term services and support. Community partners are community-based organizations that coordinate with the health plan and traditional providers, like primary care doctors, to provide local resources to members with intensive needs. A significant portion of the federal investment in the ACO program is dedicated to these community partners.
The state also has a smaller pool of money that it has made available to ACOs to pay for non-traditional services called flexible services. The state sees these flex services as another avenue to address social barriers to good health. This part of the ACO program has just started, and to date we have collaborated with our ACO partners to focus on providing medically tailored meals for people with chronic diseases, like cardiovascular disease, end-stage renal disease, and diabetes.
We have created a longitudinal data repository of claims, clinical, and non-clinical data on all 1.2M members at Tufts Health Plan with three years of historic data, updated every month at a minimum, with some utilization data updated daily. Tufts Health Plan’s data-driven approach segments its membership using the Bridges to Health macro-segmentation and then micro segments according to specific conditions, social determinants, frailty status, etc. We further predict risk of these segments to prioritize members to reach out to with intervention solutions, that often include referrals into programs to address social, mental and or physical health needs.
This data strategy ingests information from multiple sources – including claims data, information from our pharmacy benefit manager (PBM), laboratory data, hospital records, health risk assessments, and consumer data – to create a picture of both the needs of individuals and the needs of the community. It is important to target the right members up front and connect them to the right programs.
Data measures the success of existing programs. Once a member uses services, we evaluate if they are receiving the appropriate care. We look at the impact on emergency department visits, medication adherence, and hospitalizations, all of which would improve if a high-need member is receiving appropriate supports.
Although we track return on investment (ROI), connecting members with needed assistance is not strictly a decision based on financial return – serving the needs of a broad population irrespective of age or socioeconomic status is simply core to our mission.
Our foundation promotes healthy living with a focus on older adults. As part of that commitment, we provide grant funding to organizations working to advance healthy aging policies and practices that are relevant, focus on the most vulnerable, and include older people in the process. We address various aspects of living include housing, transportation, social isolation and other issues important to community. Our grants promote innovation in systems, policies, and community activities that can benefit our members and their communities.
These organizations and others provide valuable community supports. We’re working to make sure they can deliver innovative resources for the diverse communities we serve.