ADDRESSING PATIENTS’ SOCIAL NEEDS An Emerging Business Case for Provider Investment Deborah Bachrach, Helen Pfister, Kier Wallis, and Mindy Lipson Manatt Health Solutions MAY 2014 The COMMONWEALTH FUND The COMMONWEALTH FUND The Commonwealth Fund, among the first private foundations started by a woman philanthropist—Anna M. Harkness—was established in 1918 with the broad charge to enhance the common good. The mission of The Commonwealth Fund is to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. An international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries. Jeff Skoll created The Skoll Foundation in 1999 to pursue his vision of a sustainable world of peace and prosperity. Led by CEO Sally Osberg since 2001, our mission is to drive large scale change by investing in, connecting and celebrating social entrepreneurs and the innovators who help them solve the world’s most pressing problems. Social entrepreneurs are society’s change agents, creators of innovations that disrupt the status quo and transform our world for the better. By identifying the people and programs already bringing positive change around the world, we empower them to extend their reach, deepen their impact and fundamentally improve society. The Pershing Square Foundation is a private family foundation based in New York. The Foundation was founded in December 2006 by Karen and Bill Ackman. Bill is the CEO and Portfolio Manager of Pershing Square Capital Management, L.P. The Pershing Square Foundation awards grants and social investments to support exceptional leaders and innovative organizations that tackle important social issues and deliver scalable and sustainable impact. Cover photo: Will Figg The COMMONWEALTH FUND ADDRESSING PATIENTS’ SOCIAL NEEDS An Emerging Business Case for Provider Investment Deborah Bachrach, Helen Pfister, Kier Wallis, and Mindy Lipson Manatt Health Solutions MAY 2014 ABSTRACT Despite growing evidence documenting the impact of social factors on health, providers have rarely addressed patients’ social needs in clinical settings. But today, changes in the health care landscape are catapulting social determinants of health from an academic topic to an on-the-ground reality for providers, with public and private payers holding providers accountable for patients’ health and health care costs and linking payments to outcomes. These new models are creating economic incen- tives for providers to incorporate social interventions into their approach to care. Investing in these interventions can enhance patient satisfaction and loyalty, as well as satisfaction and productivity among providers. A variety of tools for addressing patients’ social needs are available to providers looking to leverage these opportunities. With the confluence of sound eco- nomics and good policy, investing in interventions that address patients’ social as well as clinical needs is starting to make good business sense. Support for this research was provided by The Commonwealth Fund, The Skoll Foundation, and the Pershing Square Foundation. The views presented here are those of the authors and not necessarily those of the funders or their directors, officers, or staff. To learn more about new publications when they become available, visit the Fund’s website and register to receive email alerts. Commonwealth Fund pub. 1749. CONTENTS About the Authors 6 Executive Summary 7 Introduction9 Impact of the Changing Health Care Landscape 9 Impact of Social Needs on Patient Health and Costs 10 Economic Incentives for Addressing Patients’ Unmet Social Needs 11 Indirect Economic Benefits 14 Strategies to Address Patients’ Unmet Social Needs 15 Paying for Social Interventions 16 Conclusion17 Notes18 Appendices23 ABOUT THE AUTHORS Deborah Bachrach, J.D., a partner with Manatt, Phelps & Phillips, has more than 25 years of experience in health policy and financing in both the public and private sectors and an extensive background in Medicaid policy and health care reform. She works with states, providers, plans, and foundations in implementing federal health reform and Medicaid payment and delivery system reforms. Most recently, Ms. Bachrach was Medicaid director and deputy commissioner of health for the New York State Department of Health, Office of Health Insurance Programs. She has previously served as vice presi- dent for external affairs at St. Luke’s-Roosevelt Hospital Center and as chief assistant attorney general and chief of the Civil Rights Bureau in the Office of the New York State Attorney General. Ms. Bachrach received her J.D. from New York University School of Law and a B.S. from the University of Pennsylvania, Wharton School. Helen Pfister, J.D., a partner with Manatt, Phelps & Phillips, focuses on advising health care providers and nonprofit organi- zations on legislative, regulatory, and transactional matters. Ms. Pfister’s clients include hospitals, community health cen- ters, mental health facilities, substance abuse providers, nursing homes, home care agencies, health information exchange organizations, and social service agencies. She has extensive experience representing clients before state and federal regu- latory agencies, including the New York State Department of Health and the Centers for Medicare and Medicaid Services, and in helping clients navigate the legal and political challenges of Medicare, Medicaid, and other public health insurance programs. Ms. Pfister received her J.D. from Boston University School of Law and a B.A. from Cornell University. Kier Wallis, a manager with Manatt Health Solutions, assists public and private organizations in preparing for and respond- ing to federal and state policy changes related to health care policy and reform. Ms. Wallis works closely with founda- tions, health care providers, health plans, and pharmaceutical manufacturers to understand, implement, and participate in health care reform initiatives. Prior to joining Manatt, she served as a project coordinator for the California Regional Health Information Organization, where she managed their participation in the Health Information Security and Privacy Collaboration (HISPC) project. Ms. Wallis received her B.A. from University of California, Santa Barbara. Mindy Lipson, M.P.H., a senior analyst with Manatt Health Solutions, provides research, analysis, project support and stra- tegic business services to health care providers and other health care organizations on a broad range of issues, including health care reform, public health insurance programs, health care delivery transformation, payment and reimbursement reform, and health information technology and exchange. Prior to joining Manatt, Ms. Lipson was a health research analyst at Mathematica Policy Research, where she was responsible for quantitative and qualitative data collection and analysis on a wide array of issues, including public health programs, state health policy, Medicare, and Medicaid. Ms. Lipson received an M.P.H. from the Mailman School of Public Health of Columbia University and a B.A. from Brandeis University. Editorial support was provided by Sandra Hackman. 6 ADDRESSING PATIENTS’ SOCIAL NEEDS: An Emerging Business Case for Provider Investment EXECUTIVE SUMMARY hospitals for excess readmissions of patients with heart Extensive research documents the impact of social fac- attack, heart failure, or pneumonia. Meanwhile a review tors such as income, educational attainment, access to of 70 studies found that unemployment and low income food and housing, and employment status on the health were tied to a higher risk of hospital readmission among and longevity of Americans, particularly lower-income patients with heart failure and pneumonia. populations. These findings attribute as much as 40 per- To be certified as a patient-centered medical cent of health outcomes to social and economic factors. home (PCMH) or Medicaid health home, providers Asthma is linked to living conditions, diabetes-related must integrate social supports into their care models. hospital admissions to food insecurity, and greater use And these certifications almost always trigger higher of the emergency room to homelessness. levels of reimbursement. More than 40 states have These findings are not lost on health care adopted PCMH programs, providing important fund- providers: 80 percent of physicians conclude that ing opportunities for qualified providers. Even if new addressing patients’ social needs is as critical as address- payment models do not require social interventions, ing their medical needs. Yet until recently, providers many providers have concluded that they are essen- rarely addressed patients’ unmet social needs in clinical tial to achieving quality metrics and earning available settings. revenue. However, changes in the health care landscape Beyond these direct economic benefits, provid- are catapulting social determinants of health into an on- ers that incorporate social supports into their clinical the-ground reality for providers. The Affordable Care models can also reap indirect economic benefits. Patient Act is expanding insurance coverage to millions more satisfaction rises when providers address patients’ social low- and modest-income individuals, and, for many, needs, engendering loyalty. Patient satisfaction can also social and economic circumstances will define their affect the amount of shared savings a provider receives health. Six years after analysts introduced the concept of from payers. Providers that include social supports in the “Triple Aim,” its goals of improved health, improved their clinical models also report improved employee sat- care, and lower per capita cost of care have become the isfaction. And interventions that address social factors organizing framework for the health care system. As allow clinicians to devote more time to their patients, a result, growing numbers of providers are concluding allowing them to see more patients and improving sat- that investing in interventions addressing their patients’ isfaction among both patients and clinicians. social as well as clinical needs makes good business sense. Strategies to Meet Patients’ Social Needs A range of tools, both broad and targeted, are available The Economic Rationale for Investing in to providers to address patients’ unmet social needs. Social Interventions Broad interventions—usually provided at primary care Informed by the Triple Aim, public and private pay- clinics—link clinic patients to local resources that can ers are introducing payment models that hold provid- address their unmet social needs. For example: ers financially accountable for patient health and the • Health Leads, which operates in hospital clinics costs of treatment. These models—including capitated, and community health centers in six cities, enables global, and bundled payments, shared savings arrange- health care providers to write prescriptions for ments, and penalties for hospital readmissions—give their patients’ basic needs, such as food and heat. providers economic incentives to incorporate social Trained volunteers who staff desks at the hospitals interventions into their approach to care. For exam- and clinics connect patients to local resources to ple, in October 2012, the Centers for Medicare and address those needs. Across all sites, Health Leads Medicaid Services penalized 77 percent of safety-net www.commonwealthfund.org7 volunteers addressed at least one need of 90 percent children with uncontrolled asthma. Urgent care costs of patients referred to them. for participants in a high-intensity intervention were • Medical-Legal Partnerships (MLPs) place lawyers projected to be up to $334 per child lower than among and paralegals at health care institutions to help those receiving a less intensive intervention. The share patients address legal issues linked to health of individuals using urgent care services also fell by status. This program has had marked success: an almost two-thirds during the intervention. MLP in New York City targeting patients with moderate to severe asthma found a 91 percent Looking Forward decline in emergency department visits and hospital As more low-income people gain health care coverage, admissions among those receiving housing services. evidence on which interventions are most cost-effective in addressing their social needs and improving their Targeted interventions, in contrast, link indi- health will grow, and value-based reimbursement will viduals with chronic or debilitating medical conditions become standard across payers. With these changes in to social supports as part of larger care management the health care landscape, the economic case for pro- efforts. For example, in the Seattle-King County vider investment in social interventions will become Healthy Homes Project, community health work- ever more compelling. ers conduct home visits to low-income families with 8 ADDRESSING PATIENTS’ SOCIAL NEEDS: An Emerging Business Case for Provider Investment care environment. Informed by published research and ADDRESSING PATIENTS’ SOCIAL interviews with more than 25 experts, we point out the NEEDS: AN EMERGING BUSINESS direct and indirect economic benefits that may inure to CASE FOR PROVIDER INVESTMENT providers who address patients’ unmet social needs. We also identify specific strategies and inter- INTRODUCTION ventions that providers can use to target patients’ social Social and economic factors such as income, educational needs, and provide evidence for their success in amelio- attainment, access to food and housing, and employ- rating social need, improving patient health, and reduc- ment status have a profound impact on health. In fact, ing patient costs. For providers unable or unwilling to these nonmedical factors account for as much as 40 invest in social interventions, the report suggests several percent of health outcomes.1 Nonetheless, until quite alternative opportunities for funding them. Overall, this recently, clinicians rarely addressed patients’ unmet exploration shows how social and economic impera- social needs. Payments to health care providers were tives are converging to create an economic rationale for tied to procedures, visits, and discharges, so providers providers to integrate interventions that target social had limited accountability for clinical outcomes, and determinants of health into clinical care. little financial incentive to integrate interventions tar- geting social needs into clinical care. Health policy, too, focused on providing and More than one-quarter of recipients of the Center for paying for interventions that address medical needs, not Medicare and Medicaid Innovation’s 2012 Health Care Innovation Awards included social supports as a key social needs. And payers had little incentive to cover component of their projects. social interventions that promised long-term clinical and financial rewards when their low-income enrollees regularly churned on and off coverage. Finally, evidence that interventions that target social needs actually IMPACT OF THE CHANGING HEALTH improve health and reduce health care costs was limited. CARE LANDSCAPE However, changes in the health care landscape Several factors have coalesced to make 2014 an inflec- are catapulting social determinants of health from a tion point for the nation’s health care system, potentially topic for academics into an on-the-ground reality for triggering the fundamental shift from an illness-focused providers. With more low- and modest-income indi- system to the health-focused system called for by viduals gaining access to stable coverage through the policymakers.3 First, the major coverage provisions of Affordable Care Act (ACA), a growing focus on the the ACA went into effect January 1, 2014: expanding “Triple Aim” of better care, better health, and reduced Medicaid to adults with incomes below 133 percent of costs, and the advent of value-based purchasing and the federal poverty level (FPL), and providing subsi- other outcomes-based payment models, providers have dies to individuals and families with incomes up to 400 a strong business case to invest in interventions that percent of the FPL. More than 32 million individuals address patients’ social needs.2 What was once a path could gain access to coverage under the ACA—the vast pursued by a handful of mission-driven providers and majority of whom will have low and modest incomes. grant-funded social services organizations may soon For many of these individuals, their social and economic become the standard of care, demanded by payers, poli- circumstances will be a defining feature of their health. cymakers, and consumers alike. Second, in light of the ACA’s continuum of This report explores the impact of social fac- coverage options and streamlined eligibility and enroll- tors on patient health and health care costs, and the ment processes, health care coverage for low- and growing relevance of such factors in today’s health modest-income populations should become more stable, www.commonwealthfund.org9 giving providers more opportunity to address patient • More illness. Poor health is closely tied to inadequate health, including the social needs that affect it. housing, food insecurity, and unemployment or This new coverage paradigm is occurring in a underemployment.10,11 Individuals with inadequate health care system poised to change. Six years ago, the housing are more likely to experience lead Institute for Healthcare Improvement (IHI) articulated poisoning, asthma, and other respiratory conditions.12 a vision for a new health care system organized around Food insecurity is linked to a higher risk of chronic the Triple Aim of improving population health, improv- conditions and overall poor mental and physical ing the patient experience of care, and reducing the health status.13 Food-insecure individuals are per capita cost of care.4 Since then, the Triple Aim has 20 percent more likely to report that they have become an organizing framework for growing numbers hypertension, and 30 percent more likely to report of public and private systems of care. they have hyperlipidemia, than their food-secure While the powerful role social and economic counterparts.14 Individuals who lose their jobs factors play in health outcomes and population health because their place of employment closes are 54 had been well documented, the Triple Aim injected percent more likely to report that they are in fair or patients’ social needs into the health care continuum.5 poor health and 83 percent more likely to develop a The ACA took that development one step further by stress-related health condition such as heart disease establishing the Center for Medicare and Medicaid or stroke.15 Innovation (CMMI), and appropriating $10 billion • Shorter life expectancy. Better-educated adults from 2011 to 2019 to test “innovative payment and ser- have longer life expectancies. As of 2006, 25-year- vice delivery models to reduce program expenditures… olds with a bachelor’s degree or higher were while preserving or enhancing the quality of care” expected to live eight to nine years longer than for individuals who receive benefits under Medicare, their peers without a high-school diploma.16 Medicaid, or the Children’s Health Insurance Program.6 Babies born to mothers who have not finished CMMI has targeted much of its grant funding to test- high school are almost twice as likely to die before ing payment and service delivery models that advance their first birthdays as babies born to women who the Triple Aim.7 have graduated from college.17 Social factors are Finally, new public and private payment models the direct cause of death for a large number of are holding providers accountable for health care qual- Americans. One study attributed some 133,000 ity and costs, offering both an imperative and a finan- deaths to individual poverty, 245,000 deaths to low cial opportunity for providers to look beyond patients’ educational attainment, and 162,000 to weak social medical needs. Notably, almost two-thirds of provid- support (a lack of social ties and relationships) in ers report that they are signing value-based contracts 2000.18 Those figures are comparable to deaths with commercial payers, and provider participation in that occurred from acute myocardial infarction contracts in which they share financial risk for health (192,898) and cerebrovascular disease (167,661)— outcomes more than doubled between 2011 and 2013.8 two of the leading reported causes of death in the That trend is likely to continue.9 United States.19 • Increased health care spending. Unmet social IMPACT OF SOCIAL NEEDS ON PATIENT needs are associated with higher rates of emergency HEALTH AND COSTS room use, hospital admissions, and readmissions.20 Compelling evidence has revealed the impact of unmet A recent study in California found that in the social needs on people’s health and longevity, and on fourth week of the month, low-income individuals health care spending: had a 27 percent greater risk of hospital admission for hypoglycemia than in the first week of the 10 ADDRESSING PATIENTS’ SOCIAL NEEDS: An Emerging Business Case for Provider Investment month, suggesting that their monthly food budget was insufficient.21 Several of the 10 health “Because Kaiser does not operate within the conditions in 2011 that accounted for the highest traditional fee-for-service reimbursement health care expenditures are linked to unmet model, we can look for the best package social needs, including heart disease, mental of services to meet members’ needs. This disorders, asthma, diabetes, hypertension, and package may venture outside of traditional hyperlipidemia.22 medical services.” —Ray Baxter, Senior Vice President, Community Benefit, Research and Health Policy ECONOMIC INCENTIVES FOR the CCOs to manage patient costs within a capitated ADDRESSING PATIENTS’ UNMET payment.25 SOCIAL NEEDS In Minnesota, Hennepin Health—a partner- The impact of social factors on patient health is play- ship of two providers, a health plan, and the county ing out in new payment models that hold providers health and human services agency—receives a global accountable for patient health and health care costs. payment to provide physical health, behavioral health, These models give providers substantial economic and social services, including vocational training, incentives to incorporate interventions that target housing, and transportation, to low-income childless patients’ social needs into their approach to care. adults.26 Providers and organizations are eligible for shared savings based on performance.27 In its first year, Capitated, Global, and Bundled Payments Hennepin Health reduced hospital admissions and Several payment approaches give providers a budget for emergency room use for target patient populations by managing covered services. Some arrangements, gener- more than 20 percent. The partnership used the savings ally referred to as bundled payments, cover a limited to finance a vocational services program.28 number of services for a limited time period, or for an Both Medicaid and Medicare are beginning episode of care. Other arrangements, such as capitation to rely on bundled payment models.29 For example, in or global payments, cover a comprehensive range of January 2013 the Centers for Medicare and Medicaid services for a fixed time period. Some payment models Services (CMS) announced the first 100 participants in require providers to include social supports, while other its Bundled Payments for Care Improvement Initiative, models allow providers to choose to include these sup- under which Medicare providers take performance ports to manage patient care effectively within a fixed and financial accountability for episodes of care.30 budget. Participating acute care hospitals receive a fixed fee for In Oregon, coordinated care organizations an episode of care, defined as an inpatient stay and all (CCOs) receive global capitation payments for 90 per- related services during a certain period after discharge. cent of the state’s Medicaid population.23 CCOs must The hospital does not receive any additional payment if help members gain access to social support services, a patient is readmitted during that period. and many are taking innovative approaches to address- ing social barriers to health in their communities.24 Penalties for Readmissions Emergency department visits declined by 9 percent Medicare’s Hospital Readmission and Reduction among people served by CCOs, and hospital admissions Program, created under the ACA, also gives hospitals for individuals with certain chronic conditions dropped financial incentives to avoid readmissions. Under the by up to 29 percent, according to the state. These program, which took effect in October 2012, CMS outcomes have obvious implications for the ability of reduces payments to hospitals with excess readmissions www.commonwealthfund.org11 within 30 days of discharge for patients with at least one of three conditions: heart attack, heart failure, and “We partner to align stable housing, job pneumonia.31 CMS has already penalized some 2,225 and educational opportunities, and access hospitals for excess readmissions. Those hospitals saw to healthy foods and exercise with our their reimbursements drop by an average of 0.38 per- comprehensive, coordinated health care to cent, translating into $227 million in fines.32 Safety-net advance the health of our community.” hospitals, which treat patients with the greatest social —Dr. Steven Safyer, president and CEO, needs, were hit hard: 77 percent were penalized.33 Montefiore Health System, New York City However, Medicare hospital readmission rates have dropped by 10 percent since 2011.34 million during this period, with nine of the 23 ACOs To reduce readmissions, hospitals—especially exceeding both savings and quality benchmarks.39 those serving large numbers of low-income patients— While the MSSP and Pioneer programs do not have a strong incentive to address their patients’ social require ACOs to address patients’ social needs, anecdotal needs. A review of more than 70 studies that examined evidence suggests that many of the most successful ones social factors in hospital readmissions among patients do. Montefiore Medical Center, in New York City, is with heart failure and pneumonia found a link between an early and leading Pioneer ACO. Montefiore relies those factors and readmission risk. For example, pneu- on several strategies to improve quality and outcomes monia patients who had low education levels and and reduce spending. These include using a central- income, or who were unemployed, had a higher risk of ized system for collecting and analyzing data, actively readmission.35 Similarly, a North Carolina transitional following up with at-risk patients, and partnering with program for Medicaid enrollees that coordinated care community organizations to provide “wraparound” ser- management across physician, social services, and com- vices, such as housing, legal, financial, employment, and munity organizations found that 20 percent of partici- transportation assistance.40 In its first year as an ACO, pants were readmission-free after one year, compared Montefiore reduced the cost of care for its 23,000 with 12 percent of a control group.36 Medicare patients by 7 percent, and earned some $14 million in shared savings payments from CMS.41 Shared Savings Programs Montefiore is not alone in successfully manag- Shared savings programs incentivize providers to reduce ing the care of its ACO beneficiaries by targeting both spending on a defined patient population by offer- clinical and social needs.42 For example, the Franciscan ing them a share of savings realized as a result of their efforts—if they meet quality metrics. In Medicare alone, One-Stop Shop in Michigan Focuses on more than 360 accountable care organizations (ACOs) Social and Medical Needs of Patients Dr. David Share—founding medical director of the were participating in two shared savings initiatives as of Corner Health Center, which participates in the January 2014. These are the Medicare Shared Savings medical home initiative of Blue Cross Blue Shield of Program (MSSP) and the Pioneer ACO Program, Michigan—considers the Center a one-stop shop for addressing patients’ medical and social needs. The which together affect 5.3 million Medicare beneficia- Center offers an onsite team of social workers, peer ries.37 Almost an equal number of ACOs have shared educators, psychiatrists, and nutritionists as well as savings agreements with commercial payers. family doctors, nurse practitioners, certified nurse midwives, and pediatricians. Preliminary results are promising: 54 of 114 MSSP ACOs that began operating in 2012 had lower “There is no question in my mind that if we didn’t address psychosocial needs, we would put on a lot of expenditures than projected for the first 12 months, bandages and give immunizations, but we wouldn’t while 29 of the 54 produced more than $126 million change the trajectory of our patients’ lives from a in savings.38 Pioneer ACOs generated savings of $147 health and well-being perspective,” says Share. “We wouldn’t be very effective.” 12 ADDRESSING PATIENTS’ SOCIAL NEEDS: An Emerging Business Case for Provider Investment Alliance ACO in Indiana earned $6.6 million in shared 2013, New York State Medicaid paid PCMH- savings for managing 20,000 high-need Medicare recognized providers more than $148 million in patients. And Phoenix-based Banner Health Network incentive payments.48 received $13 million in shared savings for managing the • Providers in New York’s Adirondacks region are care of 50,500 Medicare beneficiaries.43 Both include participating in a multipayer medical home pilot social supports in their care models.44 that includes Medicare, Medicaid, and seven commercial health plans, each of which has agreed Enhanced-Reimbursement Models to pay PCMH-certified providers $84 per member The new payment models noted above do not require per year over their regular reimbursement rates. providers to address their patients’ social needs, One payer noted that that these upfront payments although many do, finding that such interventions can were a “leap of faith,” but that it expected to break improve patient outcomes, reduce patient costs, and even by year three, and achieve a positive return on trigger more revenue. Models such as the patient-cen- investment in years four and five.49 Participating tered medical home (PCMH), in contrast, do require providers received about $2.3 million in such providers to address patient social needs as a prerequi- payments from 2010 to 2012.50 site to payment. To achieve PCMH recognition, a pro- vider must meet standards focused on organizing care Blue Cross in Michigan Requires Medical around patients, by enhancing care coordination and Homes to Refer Patients to Social Supports supporting self-care by linking patients to local social Primary care providers and specialists participating in service agencies. Blue Cross Blue Shield of Michigan’s patient-centered As of April 2013, 43 states had adopted poli- medical home program must show that they: cies and programs to advance PCMHs, and 19 of those • Maintain a database of community resources. included multipayer initiatives.45 Public and private • Have received training in those resources, so they payers are offering a range of additional payments to can identify and refer patients to them. PCMH-recognized providers.46 For example: • Have created a systematic approach to assessing patients’ needs and making referrals to • In 2009, New York State began offering PCMH- community resources. recognized providers incentive payments for • Track referrals of high-risk patients to community Medicaid fee-for-service and managed-care resources, and work to ensure that the patients follow up on their referrals. patients, ranging from $7 a visit for a provider with Level I recognition to $21.25 for a provider with Level III recognition.47 From January 2010 to April • Blue Cross Blue Shield of Michigan pays PCMH- recognized providers enhanced fees through a Patient-Centered Medical Home in New York fee-for-value reimbursement system made possible State Reduces Medicaid Costs by savings achieved through the PCMH program. In the patient-centered medical home at the Hudson More than 3,600 primary care physicians in 1,243 Headwaters Health Network in New York’s Adirondack region, case managers screen and refer patients with practices participate, and the program achieved social needs to the network’s community resource savings of $155 million from 2009 to 2011—its first advocate, who assists patients with housing, heat, three years—and $155 million in 2012 alone. food, and transportation needs, finds financial support for medical care and prescriptions, and helps Under the ACA’s health home provisions, CMS them enroll in insurance and disability programs. The medical home initiative has produced a 7 percent pays a 90 percent federal match for Medicaid health drop in emergency department visits and a 15 percent home programs that include community and social sup- to 20 percent drop in Medicaid costs. ports.51 And in July 2013, CMS proposed regulations www.commonwealthfund.org13 that would establish two new Medicare payment codes for complex care management that includes social sup- “For many of us (particularly primary care ports.52 That Medicare is proposing to reimburse health physicians), more than any…. financial care providers for nonclinical services delivered outside incentives, our most fulfilling rewards and clinical visits demonstrates both growing recognition of professional satisfactions come from having the importance of interventions that address social fac- meaningful relationships with our patients, tors and the willingness of payers to support programs as well as our ability to broadly ameliorate that include them. their problems and suffering.” —Dr. Gordon Schiff, Brigham and Women’s Hospital, Boston INDIRECT ECONOMIC BENEFITS In considering whether and how to invest in social Interventions that address social needs can interventions, providers will want to take into account improve the satisfaction of providers and other employ- indirect as well as direct economic returns that may ees. For example, providers and staff at Washington’s inure to their benefit. Group Health medical home reported less staff burnout and emotional exhaustion than employees at control clinics.59 Employee Productivity Some 40 percent of primary care physicians report that they are unable to spend enough time with their Patient Satisfaction patients.53 Yet many physicians spend a substantial share Many new health care delivery and payment models of a patient visit addressing social needs.54 Interventions hold providers accountable for patient satisfaction.60 For that address patients’ social needs allow providers to example, to be eligible for the maximum shared savings reallocate their time to patients’ physical needs, and can payment under the MSSP, ACOs must score well on increase the capacity of clinicians to practice at the “top eight measures of patient satisfaction, including patients’ of their license.”55 ratings of their providers. Addressing patients’ social needs also can boost Interventions that address patients’ social needs office productivity by increasing employees’ billable have been shown to improve patient satisfaction. For time. For example, after a health and human services example, in one intervention targeting low-income agency in Boston instituted Health Leads, an interven- minority women with abnormal mammograms, patient tion that connects individuals to resources that address navigators guided the women through their care and their social needs, weekly billable minutes by the connected them to social supports. Women who par- agency’s pediatric social worker rose an average of 57 ticipated in the intervention reported significantly percent.56 (See Appendix B and Appendix C for more higher satisfaction than women in a control group on this example.) who received usual care—4.3 versus 2.9 on a five-point scale.61 Provider Satisfaction “If the medical home program were to go Eighty percent of physicians do not feel adequately away, there would be an uproar among equipped to address their patients’ social needs, and as patients and providers, who have come to a result do not believe they are providing high-quality expect social services as the status quo.” care.57 Physicians who believe that they are providing —Dr. John Rugge, CEO, high-quality care are more than twice as likely to report Hudson Headquarters Health Network that they are satisfied.58 14 ADDRESSING PATIENTS’ SOCIAL NEEDS: An Emerging Business Case for Provider Investment EXHIBIT 1. TECHNIQUES FOR ADDRESSING PATIENTS’ SOCIAL NEEDS Social need Technique to address it • Assess home safety • Connect individuals to housekeeping services Housing • Connect individuals to pest extermination services • Connect individuals to appliance repair services • Assist individuals with legal needs related to housing, such as housing code violations and utility shutoffs • Connect individuals to food supports, such as the Supplemental Nutrition Assistance Program, a food bank, the Women, Infants and Children Program, and Meals on Wheels Food • Connect individuals to a home care agency that can prepare meals • Provide prescriptions for healthy foods • Help individuals apply for Medicaid and overturn wrongful denials • Help individuals apply for Social Security Disability Insurance and Supplemental Security Income, and Public benefits overturn wrongful denials • Provide counseling on available public benefits Employment • Offer workshops to improve professional qualifications STRATEGIES TO ADDRESS PATIENTS’ a printout of local social services that could help them address their unmet needs.64 More than half UNMET SOCIAL NEEDS of families that contacted the organization to which Providers looking to address the social needs of their they were directed resolved their primary problem, patients can tap a growing number of tools and tech- according to HelpSteps.65 Healthify developed a niques (Exhibit 1). These interventions fall into two screening tool that patients can use on a tablet or in buckets: those that focus broadly on connecting low- a kiosk in a waiting room. The tool transmits a list and modest-income patients with social supports, and of each patient’s social needs to the clinician. The those that target more medically complicated, high-cost tool also provides patients with a list of local, state, patients through both clinical and social components. and federal resources that could help address their The broad interventions typically depend on needs, and follows up with a text message.66 referrals from clinicians, who use a screening tool to identify patients’ social needs and connect them to sup- • Medical-Legal Partnerships (MLPs) place lawyers port services, usually within the clinical setting. For and paralegals at health care institutions to help example: patients address legal issues that affect health • Health Leads, which operates in six cities, status. The program has had marked success: a encourages health care providers to write health system funding an MLP in rural Illinois prescriptions for patients’ basic needs, such as food obtained a 319 percent return on investment over and heat. The prescriptions are filled by trained a three-year period by helping individuals appeal volunteers, who staff desks at hospitals and clinics Medicaid coverage denials.67 An MLP in New and connect patients to community resources.62 York targeting individuals with moderate to severe Across all sites, Health Leads volunteers addressed asthma produced a 91 percent decline in emergency at least one need of 90 percent of patients referred department visits and hospital admissions among to them.63 those receiving services to improve their housing conditions.68 • HelpSteps and Healthify offer electronic platforms that screen patients for unmet social needs in Targeted interventions, in contrast, integrate clinical settings, such as clinic waiting rooms. social supports into larger care management initiatives Patients in the Boston area use HelpSteps on a for individuals with chronic or debilitating medical con- laptop while waiting to see a doctor, and receive ditions. For example: www.commonwealthfund.org15 • The Frequent Users of Health Services Initiative— Nurse case managers use records of recent six case management programs in California— emergency department and hospital admissions refers frequent users of emergency departments to identify potential participants, and inform during a specified time frame to medical and eligible families about the intervention by phone or social services. During the two years after patients during a hospital admission. At two-year follow- enrolled, their inpatient charges fell by 69 percent, up, the intervention had saved $3,827 per child and inpatient days by 62 percent, on average.69 in decreased emergency department visits and Homeless individuals connected to permanent hospitalizations.74 housing showed a 32 percent drop in emergency (See Appendix B and Appendix C for more infor- department charges, compared with a 2 percent mation on these examples.) drop among those who were not connected to permanent housing.70 Both broad and targeted interventions aim to • The Seattle-King County Healthy Homes Project meet patients’ medical and social needs holistically, as in Washington State relies on community health envisioned by the Triple Aim. Considerable evidence workers to conduct home visits to low-income shows that broad interventions connecting individuals families with children with uncontrolled asthma, to social supports do ameliorate their social needs— and to provide self-management and social support although evidence on improvements in health outcomes services. The project recruited families into a and reductions in health care spending stemming from randomized, controlled trial through health clinics, each intervention is more limited. hospitals, emergency departments, and referrals There is more evidence showing that targeted from community agencies. Urgent care costs among interventions reduce costs and improve health out- families receiving a high-intensity intervention comes. However, because these interventions target were estimated to be up to $334 per child lower both the clinical and social needs of select patients, than among families receiving a less intensive isolating the impact of the social component can be intervention. The percentage of individuals using difficult.75 urgent care services also declined by almost two- Collecting better data on the impact of these thirds during the intervention.71 programs is crucial, but providers report that obtain- ing funding to gather such information and pursue • The Camden Coalition for Healthcare Providers in research can be difficult.76 Nonetheless, given compel- New Jersey operates a care management program ling evidence of links between social factors and patient for intensive users of health care services, providing health—and growing evidence of the success of inter- connections to both medical and social services. The ventions that address patients’ unmet social needs— program relies on a citywide health information many providers have concluded that investing in such exchange to identify people who would benefit from interventions will in fact improve health outcomes and the program.72 Monthly hospital charges among lower costs. In short, they are not waiting for the final 36 participants who completed the intervention piece of evidence. fell by 56 percent, and their monthly emergency department and hospital visits declined by about 40 percent.73 PAYING FOR SOCIAL INTERVENTIONS • The Community Asthma Initiative, run by Some providers are prepared to commit operating dol- Boston Children’s Hospital, coordinates cares lars to fund interventions connecting individuals to for low-income children with asthma, including social supports, having determined that the direct and by referring them to community-based services. indirect economic benefits can support that investment. 16 ADDRESSING PATIENTS’ SOCIAL NEEDS: An Emerging Business Case for Provider Investment Other providers remain unwilling or unable to commit state transformation plans. For example, New York’s operating funds. For those providers, “community ben- recently approved DSRIP program makes more than efit” spending by hospitals could be a source of funding. $6 billion available for revamping the state’s delivery To justify their tax-exempt status, nonprofit system, supporting, among other efforts, programs that hospitals must provide a community benefit usually bring together medical, mental health, and social service equal to the value of their tax exemption—estimated organizations as well as payers to move care from hospi- to total $13 billion annually.77 While the majority tals to the community. of community benefit dollars have historically gone Social impact bonds are another source of funds toward care for underinsured and uninsured patients, for serving patients’ social needs. Such funds use pri- expanded coverage under the ACA should enable pro- vate capital to support efforts to address complex social viders to shift some funds to programs that target social problems. If the efforts work, investors receive a portion needs.78,79 For example, Kaiser Permanente, recognizing of the cost savings or returns.84 that the process of ameliorating patients’ social needs The Massachusetts Prevention and Wellness may take place over time, has instituted a community Trust Fund, created in 2012, offers yet another approach benefit strategy that budgets these dollars across mul- to funding interventions aimed at nonclinical determi- tiple years.80 nants of health and wellness-focused activities. With a The Affordable Care Act requires tax-exempt four-year, $60 million commitment of state funds, the hospitals to conduct a community health needs assess- fund will invest in a small number of community– ment and develop an implementation strategy for clinical partnerships that, among other things, will link addressing identified needs every three years,81 and the local residents to health-related resources and track U.S. Centers for Disease Control and Prevention rec- referrals, to address nonclinical barriers to optimal ommends that the assessments include information on health.85 the social determinants of health.82 Tax-exempt hospi- tals must report their spending on activities benefiting the community to the Internal Revenue Service. Such CONCLUSION activities may include alleviating water or air pollution Few working in health care would doubt the role that to protect the community from environmental hazards, social factors play in patients’ health. Until recently, providing child care and mentoring programs, provid- however, that understanding did not translate into ing or rehabilitating housing for vulnerable populations, action by providers—no matter how many policy briefs and advocating for policies and programs that improve called on them to expand their mind-set and mission housing and transportation.83 from treating illness to advancing health. Today the The ACA is also triggering significant trans- health care system is poised for change, girded by the formations in state-based systems for delivering and Triple Aim, supported by expanded insurance coverage, paying for health care, with social interventions often and financed by value-based approaches to reimburse- a key element of the emerging models. With funding ment. With this confluence of sound economics and from CMMI programs such as the State Innovation good policy, investments in interventions that address Model (SIM) Program and the Health Care Innovation patients’ social as well as clinical needs are starting to Awards, states are designing, implementing, and evalu- make good business sense. ating a broad range of projects aimed at improving patient and community health, and advancing the Triple Aim. Medicaid waivers are likewise providing new funding opportunities through delivery system reform incentive payment (DSRIP) programs, which support www.commonwealthfund.org17 10 NOTES C. Mansfield and L. F. Novick, “Poverty and Health: Focus on North Carolina,” North Carolina Medical Journal, Sept.-Oct. 1 B. C. Booske, J. K. Athens, D. A. Kindig et al., Different 2012 73(5):366–73. Perspectives for Assigning Weights to Determinants of Health 11 (Madison, Wis.: University of Wisconsin Population Health S. H. Woolf and P. Braveman, “Where Health Disparities Institute, Feb. 2010). Begin: The Role of Social and Economic Determinants—And Why Current Policies May Make Matters Worse,” Health 2 Institute for Healthcare Improvement, “The IHI Triple Aim,” Affairs, Oct. 2011 30(10):1852–59. http://www.ihi.org/engage/initiatives/tripleaim/pages/ 12 default.aspx. J. Krieger, and D. L. Higgins, “Housing and Health: Time Again for Public Health Action,” American Journal Public Health, May 3 R. Wilkinson and M. Marmot (eds.), Social Determinants of 2002 92(5):758–68. Health: The Solid Facts, 2nd ed. (Geneva: World Health 13 Organization, 2003); U.S. Department of Health and Human H. K. Seligman, B. A. Laraia, and M. B. Kushel, “Food Insecurity Services, “Social Determinants of Health,” http://www. Is Associated with Chronic Disease Among Low-Income healthypeople.gov/2020/topicsobjectives2020/overview. NHANES Participants,” Journal of Nutrition, Feb. 2010 aspx?topicId=39; Centers for Medicare and Medicaid Services, 140(2):304–10; and J. E. Stuff, P. H. Casey, K. L. Szeto et al., “Health Care Innovation Awards Round Two,” http://innova- “Household Food Insecurity Is Associated with Adult Health tion.cms.gov/initiatives/Health-Care-Innovation-Awards/ Status,” Journal of Nutrition, Sept. 2004 134(9):2330–35. Round-2.html; and RWJF Commission to Build a Healthier 14 Seligman, Laraia, and Kushel, “Food Insecurity Is Associated America, Time to Act: Investing in the Health of Our Children with Chronic Disease,” 2010. and Communities (Princeton, N.J.: Robert Wood Johnson Foundation, 2014). 15 K. W. Strully, “Job Loss and Health in the U.S. Labor Market,” 4 Demography, May 2009 46(2):221–46. D. M. Berwick, T. W. Nolan, and J. Whittington, “The Triple Aim: Care, Health, and Cost,” Health Affairs, May/June 2008 16 National Center for Health Statistics, Health, United States, 27(3):759–69. See also: Institute for Healthcare Improvement, 2011: With Special Feature on Socioeconomic Status and “The IHI Triple Aim,” http://www.ihi.org/Engage/Initiatives/ Health (Hyattsville, Md.: NCHS, 2012). TripleAim/Pages/default.aspx. 17 5 T. J. Matthews and M. F. MacDorman, “Infant Mortality Wilkinson and Marmot, Social Determinants of Health, 2003. Statistics from the 2008 Period Linked Birth/Infant Death 6 Data Set,” National Vital Statistics Reports, May 2012 60(5). Section 1115A [42 U.S.C. 1315a] of the Social Security Act, Center for Medicare and Medicaid Innovation. 18 S. Galea, M. Tracy, K. J. Hoggatt et al., “Estimated Deaths 7 Attributable to Social Factors in the United States,” American CMS Innovation Center, Early Implementation Efforts Suggest Journal of Public Health, Aug. 2011 101(8):1456–65. Need for Additional Actions to Help Ensure Coordination with Other CMS Offices (Washington, D.C.: U.S. Government 19 Ibid. Accountability Office, Nov. 2012), www.gao.gov/ 20 assets/660/650119.pdf. L. A. Lebrun-Harris, T. P. Baggett, D. M. Jenkins et al., “Health 8 Status and Health Care Experiences Among Homeless J. Stone, “Survey Results: Percentage of Providers Taking on Patients in Federally Supported Health Centers: Findings from Risk Doubled Since 2011” (New York: The Advisory Board the 2009 Patient Survey,” Health Services Research, June 2013 Company, June 5, 2013), http://www.advisory.com/ 48(3):992–1017; H. K. Seligman, A. F. Bolger, D. Guzman et al., Research/Health-Care-Advisory-Board/Blogs/Toward- “Exhaustion of Food Budgets at Month’s End and Hospital Accountable-Payment/2013/05/Accountable-payment- Admissions for Hypoglycemia,” Health Affairs, Jan. 2014 survey. 33(1):116–23; and L. Calvillo-King, D. Arnold, K. J. Eubank et al., 9 “Impact of Social Factors on Risk of Readmission or Mortality In 2013, UnitedHealthCare tied $20 billion of its reimburse- in Pneumonia and Heart Failure: Systematic Review,” Journal ments to providers to quality and cost efficiency. The insurer of General Internal Medicine, Feb. 2013 28(2):269–82. hopes to raise that amount to $50 billion by 2017. See UnitedHealth Group, “UnitedHealthCare Expects to More 21 Seligman, Bolger, Guzman et al., “Exhaustion of Food Than Double Industry-Leading Accountable Care Contracts to Budgets at Month’s End,” 2014. $50 Billion by 2017,” News release, http://www.unitedhealth- 22 group.com/Newsroom/Articles/Feed/UnitedHealthcare/201 Agency for Healthcare Research and Quality, Medical 3/0710AccountableCareAnswers.aspx. Expenditure Panel Survey (Rockville, Md.: U.S. Department of Health and Human Services, 2011). 18 ADDRESSING PATIENTS’ SOCIAL NEEDS: An Emerging Business Case for Provider Investment 23 30 Oregon Health Authority, “Director’s Message: We’re Heading Centers for Medicare and Medicaid Services, “BPCI Model 1: in the Right Direction,” (Salem, Ore., Dec. 6, 2013), http:// Retrospective Acute Care Hospital Stay Only,” http://innova- www.dhs.state.or.us/oha/dir-msg/2013/2013-1206.html. tion.cms.gov/initiatives/BPCI-Model-1/; Centers for Medicare and Medicaid Services, “BPCI Model 2: Retrospective Acute 24 Chapter 414 of the 2011 Laws of Oregon, Section 414.625(1)(e); and Post Acute Care Episode,” http://innovation.cms.gov/ini- Jackson Care Connect, “Jackson Care Connect Wants to Ease tiatives/BPCI-Model-2/index.html; Centers for Medicare and Barriers to Health for Its Members,” http://jacksoncarecon- Medicaid Services, “BPCI Model 3: Retrospective Post Acute nect.org/sub-group/news/2013/09/16/jackson-care-con- Care Only,” http://innovation.cms.gov/initiatives/BPCI- nect-wants-to-ease-barriers-to-health-for-its-members; and Model-3/index.html; and Centers for Medicare and Medicaid K. Foden-Vencil, “How Oregon Is Getting ‘Frequent Flyers’ Services, “BPCI Model 4: Prospective Acute Care Hospital Out of Hospital ERs,” Kaiser Health News, July 10, 2013, Stay Only,” http://innovation.cms.gov/initiatives/BPCI- http://www.kaiserhealthnews.org/Stories/2013/July/10/ Model-4/index.html. emergency-room-frequent-flyers.aspx. 31 Centers for Medicare and Medicaid Services, “Readmissions 25 Oregon Health Authority, “Oregon’s Health System Reduction Program,” http://www.cms.gov/Medicare/ Transformation, Quarterly Progress Report,” http://www.ore- Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/ gon.gov/oha/Metrics/Documents/report-november-2013. Readmissions-Reduction-Program.html. pdf. 32 Foden-Vencil, “How Oregon Is Getting ‘Frequent Flyers’ Out 26 J. DeCubellis, “Hennepin Health,” presentation to the National of Hospital ERs,” http://www.kaiserhealthnews.org/Stories/ Center for Quality Assurance, Nov. 2013; and S. Somers and 2013/July/10/emergency-room-frequent-flyers.aspx. T. McGinnis, “Broadening the ACA Story: A Totally 33 Accountable Care Organization,” Health Affairs Blog, Jan. 23, Ibid. 2014, http://healthaffairs.org/blog/2014/01/23/broaden- 34 ing-the-aca-story-a-totally-accountable-care-organization/. D. Cutler, “The Health-Care Law’s Success Story: Slowing Down Medical Costs,” Washington Post, Nov. 8, 2013, http:// 27 Agency for Healthcare Research and Quality, “County-Based www.washingtonpost.com/opinions/the-health-care-laws- Accountable Care Organization for Medicaid Enrollees success-story-slowing-down-medical-costs/2013/11/08/ Features Shared Risk, Electronic Data Sharing, and Various e08cc52a-47c1-11e3-b6f8-3782ff6cb769_story.html. Improvement Initiatives, Leading to Lower Utilization Costs,” 35 http://www.innovations.ahrq.gov/content.aspx?id=3835. Calvillo-King, Arnold, Eubank et al., “Impact of Social Factors on Risk of Readmission or Mortality,” 2013. 28 N. Garrett, “How a Social Accountable Care Organization 36 Improves Health and Saves Money and Lives,” Nov. 12, 2013, C. T. Jackson, T. K. Trygstad, D. A. DeWalt et al., “Transitional http://healthyamericans.org/health-issues/prevention_ Care Cut Hospital Readmissions for North Carolina Medicaid story/how-a-social-accountable-care-organization- Patients with Complex Chronic Conditions,” Health Affairs, improves-health-and-saves-money-and-lives; and Hennepin Aug. 2013 32(8):1407–15. Arkansas and Massachusetts are Health, http://healthyamericans.org/health-issues/wp-con- also implementing bundled payment initiatives for their tent/uploads/2013/11/Hennepin-Health-1-page- Medicaid programs; see American Medical Association, “Issue description-v2.docx. Brief: Innovative Medicaid Delivery System and Payment Models” (Chicago: AMA, 2013), http://mmaoffice.org/janda/ 29 Health Care Payment Improvement Initiative (Arkansas), files/home/Medicaid/Issue%20Brief%20Medicaid%20 “How It Works,” http://www.paymentinitiative.org/howIt- Delivery%20and%20Payment%20Models%20FINAL.pdf. Works/Pages/default.aspx; Centers for Medicare and 37 Medicaid Services, “State Innovation Models Initiative: Model Centers for Medicare and Medicaid Services, “More Design Awards,” http://innovation.cms.gov/initiatives/state- Partnerships Between Doctors and Hospitals Strengthen innovations-model-design/; and S. Silow-Carroll, Medicaid Is Coordinated Care for Medicare Beneficiaries,” News release, One of Multiple Payers in Vermont’s Health Care Reforms (New Dec. 23, 2013, http://www.hhs.gov/news/ York: The Commonwealth Fund, March 2013). press/2013pres/12/20131223a.html. 38 Centers for Medicare and Medicaid Services, “Medicare’s Delivery System Reform Initiatives Achieve Significant Savings and Quality Improvements: Off to a Strong Start,” News release, Jan. 30, 2014, https://www.cms.gov/ Newsroom/MediaReleaseDatabase/Press-releases/2014- Press-releases-items/2014-01-30.html. 39 Ibid. www.commonwealthfund.org19 40 49 Advisory Board Company, “Update from the Symposium: G. Burke and S. Cavanaugh, The Adirondack Medical Home Inside Medicare’s ACO Programs,” Sept. 16, 2013, http://www. Demonstration: A Case Study (New York: United Hospital Fund, advisory.com/research/health-care-advisory-board/blogs/ 2011), http://www.uhfnyc.org/publications/880729. toward-accountable-payment/2013/09/update-from-the- 50 national-population-health-symposium. NYS DOH, Patient-Centered Medical Home Initiative, 2013. 51 41 Montefiore Medical Center, “Montefiore Pioneer ACO Model Patient Protection and Affordable Care Act, Pub. L. No. 111- Achieves Success in First Year: Results Show Improved Care 148 § 2703 (2010). Quality and Patient Outcomes with Significant Cost Savings” 52 78 C.F.R. § 43281 (2013). News release, July 7, 2013, http://www.montefiore.org/body. cfm?id=1738&action=detail&ref=1069. 53 B. E. Sirovich, S. Woloshin, and L. M. Schwartz, “Too Little? 42 Too Much? Primary Care Physicians’ Views on U.S. Health M. Evans and J. Zigmond, “Complex Coordination: Successful Care: Brief Report,” Archives of Internal Medicine, Sept. 26, 2011 Pioneers Credit Focus on Improving Care,” Modern Healthcare, 171(17):1582–85. July 20, 2013, http://www.modernhealthcare.com/arti- cle/20130720/MAGAZINE/307209990. 54 D. Goldstein and J. Holmes, “2011 Physicians’ Daily Life 43 Report,” Presentation to the Robert Wood Johnson Franciscan Alliance, “Franciscan Alliance Accountable Care Foundation, Nov. 15, 2011, http://www.rwjf.org/content/ Organization Achieves 2012 Cost Savings,” News release, July dam/web-assets/2011/11/2011-physicians--daily-life-report, 16, 2013, http://www.franciscanalliance.org/hospitals/india- reporting that primary care physicians and pediatricians napolis/news/Pages/PressRelease.aspx?ARTICLE_ID=550; spend an average of seven minutes during a visit attending to and Banner Health Network, Smart and Healthy, Winter 2013, the patient’s social needs. http://issuu.com/rmcp/docs/smart-healthy- winter2013#embed. 55 R. Pettignano, S. B. Caley, and S. McLaren, “The Health Law 44 Partnership: Adding a Lawyer to the Health Care Team J. Brehm and J. Westall, “Lessons Learned from a Pioneer Reduces System Costs and Improves Provider Satisfaction,” ACO,” presentation to Indiana HIMSS, Nov. 13, 2013, http:// Journal of Public Health Management and Practice, July-Aug. www.indianahimss.org/Brehm_and_Westfall_3_Franciscan_ 2012 18(4):E1–E3; “Aligning Federal and State Approaches to Alliance_ACO.pdf; and A. Gonzales, “Cigna, Banner Health Integrating Primary Care and Community Resources,” webinar Team on Preventative Health,” Phoenix Business Journal, Oct. by D. Gifford, Rhode Island Executive Office of Health and 17, 2012, http://www.bizjournals.com/phoenix/ Human Services, http://www.nashp.org/webinars/integrat- news/2012/10/17/cigna-banner-health-deal-on. ing-primary-care-community-resources/lib/playback.html; html?page=all. and R. Onie, interviews with Manatt, June and Dec, 2013. 45 National Academy for State Health Policy, “Medical Home 56 E. Fernandez Maldonado, Health Leads Desk: Does It Affect and Patient Centered Care: Interactive Map,” http://www. Weekly Billable Hours? An Analysis Using Data from Purposively nashp.org/med-home-map. Selected Site (Washington, D.C.: George Washington 46 See, e.g., M. Bailit, K. Phillips, and A. Long, “Paying for the University, 2011), pp. 1–7. Medical Home: Payment Models to Support Patient-Centered 57 Robert Wood Johnson Foundation, Health Care’s Blind Side: Medical Home Transformation in the Safety Net” (Seattle, The Overlooked Connection Between Social Needs and Good Wash.: Bailit Health Purchasing and Qualis Health, Oct. 2010), Health, Dec. 2011, http://www.rwjf.org/en/research-publica- http://www.co.fresno.ca.us/viewdocument.aspx?id=47520; tions/find-rwjf-research/2011/12/health-care-s-blind-side. and M. Bailit, “Payment Rate Brief,” (Patient Centered Primary html. Care Collaborative, March 2011), http://www.pcpcc.org/sites/ default/files/media/payment_brief_2011.pdf. 58 M. W. Friedberg, P. G. Chen, K. R. Van Busum et al., Factors 47 Affecting Physician Professional Satisfaction and Their New York State Department of Health, “New York State Implications for Patient Care, Health Systems, and Health Policy Medicaid Update,” Dec. 2009, 25(16), http://www.health.ny. (Santa Monica, Calif.: RAND Corp., Oct. 2013), http://www. gov/health_care/medicaid/program/update/2009/2009- rand.org/pubs/research_reports/RR439.html. 12spec.htm. 48 New York State Department of Health, The Patient-Centered Medical Home Initiative in New York State Medicaid: Report to the Legislature (Albany, N.Y.: NYS DOH, April 2013), http:// www.health.ny.gov/health_care/medicaid/redesign/docs/ pcmh_initiative.pdf. 20 ADDRESSING PATIENTS’ SOCIAL NEEDS: An Emerging Business Case for Provider Investment 59 69 Patient-Centered Primary Care Collaborative, “Summary of K. W. Linkins, J. J. Brya, and D. W. Chandler, Frequent Users of Patient-Centered Medical Home Cost and Quality Results, Health Services Initiative: Final Evaluation Report (Falls Church, 2010–2013,” July 2013, http://www.pcpcc.org/resource/ Va.: The Lewin Group, Aug. 2008), http://usich.gov/usich_ summary-patient-centered-medical-home-cost-and-qual- resources/research/frequent_users_of_health_services_ini- ity-results-2010-%E2%80%93-2013; and R. J. Reid, K. tiative_final_evaluation_report/. Coleman, E. A. Johnson et al., “The Group Health Medical 70 Home at Year Two: Cost Savings, Higher Patient Satisfaction, Ibid. and Less Burnout for Providers,” Health Affairs, May 2010 71 J. W. Krieger, T.K. Takaro, L. Song et al., “The Seattle-King 29(5):835–43. County Healthy Homes Project: A Randomized, Controlled 60 National Center for Quality Assurance, “2011 Patient- Trial of a Community Health Worker Intervention to Decrease Centered Medical Home Standards and Guidelines,” http:// Exposure to Indoor Asthma Triggers, “American Journal of www.ncqa.org/tabid/629/Default.aspx#Standards; and Public Health, April 2005 95(4):652–59. Centers for Medicare and Medicaid Services, “Accountable 72 J. Brenner, interview with Manatt, Aug. 2013; and Camden Care Organization 2013 Program Analysis: Quality Coalition of Healthcare Providers, “Camden Health Performance Standards, Narrative Measure Specifications,” Information Exchange,” http://www.camdenhealth.org/pro- Dec. 21, 2012, http://www.cms.gov/Medicare/Medicare-Fee- grams/health-information-exchange/. for-Service-Payment/sharedsavingsprogram/Downloads/ ACO-NarrativeMeasures-Specs.pdf. 73 S. R. Green, V. Singh, and W. O’Byrne, “Hope for New Jersey’s 61 City Hospitals: The Camden Initiative,” Perspectives in Health J. M. Ferrante, P. H. Chen, and S. Kim, “The Effect of Patient Information Management, April 1, 2010 7:1d. Navigation on Time to Diagnosis, Anxiety, and Satisfaction in Urban Minority Women with Abnormal Mammograms: A 74 E. R. Woods, U. Bhaumik, S. J. Sommer et al., “Community Randomized Controlled Trial,” Journal of Urban Health, Jan. Asthma Initiative: Evaluation of a Quality Improvement 2008 85(1):114–24. Program for Comprehensive Asthma Care,” Pediatrics, March 62 2012 129(3):465–72. Onie interviews, 2013; Health Leads, “Our Model,” https:// healthleadsusa.org/what-we-do/our-model/. 75 L. Gottlieb, interview with Manatt, Aug. 2013. 63 Health Leads, correspondence, 2014. 76 Brenner interview, 2013; Onie interviews, 2013; B. Zuckerman, 64 interview with Manatt, July 2013; M. Sandel, interview with S. A. Wylie, A. Hassan, E. G. Krull et al., “Assessing and Manatt, Aug. 2013; and L. Gottlieb, M. Sandel, and N. E. Adler, Referring Adolescents’ Health-Related Social Problems: “Collecting and Applying Data on Social Determinants of Qualitative Evaluation of a Novel Web-Based Approach,” Health in Health Care Settings,” JAMA Internal Medicine, June Journal of Telemedicine and Telecare, Oct. 2012 18(7):392–98. 10, 2013 173(11):1017–20. 65 E. Fleegler and E. Manz, “The Online Advocate: Assessing and 77 U.S. Government Accountability Office, Nonprofit Hospitals: Referring Health-Related Social Problems,” presentation at Variation in Standards and Guidance Limits Comparison of How Children’s Hospital Association conference on Creating Hospitals Meet Community Benefit Requirements, GAO-08- Connections, March 13, 2012, http://www.childrenshospitals. 880 (Washington, D.C., Sept. 2008). net/AM/Template.cfm?Section=t&template=/CM/ ContentDisplay.cfm&ContentID=61791. 78 G. J. Young, C. H. Chou, J. Alexander et al., “Provision of 66 Community Benefits by Tax-Exempt U.S. Hospitals,” New M. Bhat and M. Rogers, interview with Manatt, Aug. 2013. England Journal of Medicine, April 18, 2013 368(16):1519–27. 67 J. A. Teufel, D. Werner, D. Goffinet et al, “Rural Medical-Legal 79 Kaiser Permanente, “Community Benefit: Beyond Our Doors, Partnership and Advocacy: A Three-Year Follow-up Study,” Beyond Our Dollars,” http://info.kaiserpermanente.org/san- Journal of Health Care for the Poor and Underserved, May 2012 bernardino/about_us/documents/Community%20 23(2):705–14. Benefit%20Special%20Section%20Feb12.pdf. 68 M. M. O’Sullivan, J. Brandfield, S. S. Hoskote et al., 80 R. Baxter, interview with Manatt, Aug. 2013. “Environmental Improvements Brought by the Legal Interventions in the Homes of Poorly Controlled Inner-City 81 S. Rosenbaum and R. Margulies, “Tax-Exempt Hospitals and Adult Asthmatic Patients: A Proof-of-Concept Study,” The the Patient Protection and Affordable Care Act: Implications Journal of Asthma, Nov. 2012 49(9):911–17. for Public Health Policy and Practice,” Public Health Report, March-April 2011 126(2):283–86. www.commonwealthfund.org21 82 Centers for Disease Control and Prevention, “Desired State: A Unified Community Health Improvement Framework Supporting Multiple Stakeholders,” http://www.cdc.gov/pol- icy/ohsc/desiredstate.html. 83 Internal Revenue Service, “Instructions for Schedule H (Form 990),” http://www.irs.gov/pub/irs-pdf/i990sh.pdf. 84 For example, Collective Health is pursuing a $1.1 million health impact bond to implement home-based interventions target- ing children with asthma in Fresno, Calif. The organization estimates that the initiative will save California’s Medicaid pro- gram, employers, and health care providers $6.3 million. Collective Health, “Example: Asthma Mitigation in Fresno,” http://collectivehealth.net/new/about_files/CH_fresno%20 asthma%20value%20model.pdf. 85 Massachusetts Executive Office of Health and Human Services, “The Prevention and Wellness Trust Fund,” http:// www.mass.gov/eohhs/gov/departments/dph/programs/ community-health/prevention-and-wellness/. 22 ADDRESSING PATIENTS’ SOCIAL NEEDS: An Emerging Business Case for Provider Investment Anne Langley, Director of Health Policy Planning, Johns APPENDIX A. Hopkins’ Office of Health Care Transformation and LIST OF INTERVIEWEES Strategic Planning Dr. Karl Altenburger, Board Member, The Physicians Ellen Lawton, Co-Principal Investigator, National Center for Foundation, and Dr. Walker Ray, Vice President and Medical-Legal Partnership Chair of the Research Committee, The Physicians Foundation Carol Lewis, Associate Director, University of North Carolina Innovation and Health Care System Ray Baxter, Senior Vice President for Community Benefit, Transformation Research and Health Policy, Kaiser Permanente Rebecca Onie, Founder and CEO, Health Leads Manik Bhat, CEO, Healthify, and Mike Rogers, Community Programs Director, Charm City Clinic Daniel Ortega Nieto, Ph.D. Student, Georgetown Department of Government Dr. Jeffrey Brenner, Founder and Executive Director, Camden Coalition of Healthcare Providers Dr. Kavita Patel, Managing Director for Clinical Transformation and Delivery, Engelberg Center for Rick Brush, Founder and CEO, Collective Health Health Care Reform, The Brookings Institution Center for Medicare and Medicaid Innovation (CMMI) Dr. John Rugge, Chief Executive Officer, and Cynthia Official Nassivera Reynolds, Vice President for Transformation Dr. David Cohen, Vice Chair, Medicine and Senior Vice and Clinical Quality, Hudson Headwaters Health President of Clinical Integration and Affiliations, Network; Cathy Homkey, Executive Director, Maimonides Medical Center Adirondack Health Institute Gary Cohen, Founder, President, and Executive Director, Dr. Steven Safyer, President and CEO, Montefiore Health Health Care Without Harm System Dr. Vera Cordeiro, CEO and Founder, Associação Saúde Dr. Megan Sandel, Associate Professor of Pediatrics, Boston Criança, and Cristiana Velloso, COO, Associação Saúde University Schools of Medicine and Public Health; Criança Medical Director, National Center for Medical-Legal Partnership; and Co-Principal Investigator, Children’s Karen Fifer Ferry and Ray Sessler, Founder and Founding Health Watch Partner, Harwich Group Dr. David Share, Preventive Medicine and Public Health, Dr. Eric Fleegler, Instructor in Pediatrics, Harvard Medical The Corner Health Center, and Senior Vice President, School Value Partnerships, Blue Cross Blue Shield of Michigan Art Gianelli, President and CEO, Nassau Health Care Dr. Prabhjot Singh, Lead Strategic Advisor and Founding Corporation Technical Advisor, City Health Works Dr. Laura Gottlieb, Assistant Professor of Family and Dr. Barry Solomon, Associate Professor in the Division of Community Medicine, University of California, San General Pediatrics and Adolescent Medicine at Hopkins Francisco School of Medicine; Medical Director, Harriet Lane Clinic; and Medical Director, Health Leads Baltimore Brian Hermanspan, Vice President of Business Development, Health Leads Alissa Wassung, Executive Policy and Planning Associate, God’s Love We Deliver Dr. James Krieger, Chief, Chronic Disease and Injury Prevention for Public Health, Seattle and King County, Dr. Barry Zuckerman, Professor of Pediatrics, Boston and Clinical Professor of Medicine, University of University School of Medicine Washington www.commonwealthfund.org23 APPENDIX B. “Poverty is very often the real cause of many INITIATIVE PROFILES diseases. Traditional medical care is not enough for those families who live below the ASSOCIAÇÃO SAÚDE CRIANÇA poverty line.” After witnessing the vicious cycle of poverty in Brazil’s —Dr. Vera Cordeiro public hospitals, Dr. Vera Cordeiro founded Associação Saúde Criança in 1991 and developed a social method- Population Served: Saúde Criança works with ology to address the issues children and their families sick children and their families who are living below the were facing trying to stay healthy. Saúde Criança is a poverty level. Candidates for their services are identified Brazilian nonprofit and nongovernmental organiza- upon a child’s admission to or interaction with one of tion (NGO) dedicated to empowering families living Saúde Criança’s partner public hospitals. below the poverty level to take care of themselves and Social Determinants Addressed by Intervention: achieve self-sustainability. As a result, they break the Saúde Criança and its multidisciplinary approach to cycle of hospital readmissions. Saúde Criança’s work is developing a Family Action Plan address health care, grounded in the belief that health status is social as well income, housing, education, and citizenship. as biological, and that social inclusion is important to Financing: Saúde Criança operates on an individuals and families’ well-being. annual budget of $2 million for its services in Rio de Description of Model: Associação Saúde Criança Janeiro and additional funds in its other five states. Its works with health care providers at select public hos- primary source of funding is corporate and international pitals to identify families with unmet social needs. donations. Upon referral, Saúde Criança helps the family develop Saúde Criança spends, on average, $320 per a Family Action Plan addressing five domains: health family per month to cover its services. care, income, housing, education, and citizenship. To assist families in meeting their goals, Saúde Criança Key Outcomes provides a variety of supports, including medical, psy- • An evaluation of the intervention by Georgetown chological, social, and legal services; food and medica- University showed that it was associated with tion; assistance with housing; and job training. Families improved health outcomes, economic circumstances, enrolled with Saúde Criança visit the program monthly and educational attainment. to check-in on their Family Action Plans, document • Children’s hospital stays were an average of 90 progress toward goals, and address barriers. Saúde percent shorter after participating in Saúde Criança. Criança makes extensive use of volunteers and employs In addition, participating children were 11 percent social workers, psychologists, physicians, engineers, and less likely than comparable nonparticipating architects. children to have needed a clinical treatment or Location of Intervention and Spread: Founded surgery. in Rio de Janeiro, the Saúde Criança model has been • Adults participating in Saúde Criança were adopted and replicated by 23 NGOs near public health approximately 12 percent more likely to be institutions throughout Brazil, benefiting more than employed than similar nonparticipating adults in 50,000 people over the life of the organization. Saúde their community. Criança became a social franchise in 2010 and, as of • Families receiving Saúde Criança’s assistance saw a 2012 there were 11 Saúde Criança franchises. The 35 percent average increase in their income. third largest municipality in Brazil has adopted Saúde Criança’s model as public policy. • After participating in Saúde Criança, 50 percent of beneficiaries owned their homes, as compared with 24 ADDRESSING PATIENTS’ SOCIAL NEEDS: An Emerging Business Case for Provider Investment an ownership rate of 25 percent upon entry into that no single provider or organization has the ability to the program. solve a population or citywide problem alone. Today, the Awards and Recognitions: Saúde Criança has Coalition operates a care management program for high received more than 30 national and international utilizers of health care services. awards. Recently, Saúde Criança was named the “best Description of Model: A care management team nongovernmental organization in Latin America” and comprising a social worker, health outreach worker, and 38th best in the world, out of 100 nongovernmental nurse practitioner assists participants with such activi- organizations, by Swiss magazine The Global Journal. Dr. ties as coordinating primary and specialty care, connect- Cordeiro, the organization’s founder, has been named ing to a medical home, obtaining housing and other an Ashoka Fellow, a Skoll Entrepreneur, an Avina public benefits, managing their legal needs, and meeting Foundation leader, a Schwab Social Entrepreneur, a their personal goals. The Coalition makes extensive use member of the Ashoka World Council, and member of of a health information exchange across providers in the Volans Advisory Board. Camden to evaluate health outcomes and health care utilization of participants. Contacts: Dr. Vera Cordeiro, CEO and Founder, Location of Intervention and Spread: The Associação Saúde Criança. Coalition serves the residents of Camden, New Jersey, one of America’s poorest cities. The Coalition model is Sources currently being replicated in 10 communities includ- Associação Saúde Criança, Annual Report, 2012, http:// ing Allentown, Pennsylvania; Aurora, Colorado; www.saudecrianca.org.br/annual-report-2012/. Kansas City, Missouri; and San Diego, California. Six Associação Saúde Criança, “Our Work,” http:// are funded by the Robert Wood Johnson Foundation www.saudecrianca.org.br/en/nosso-trabalho/ and four are funded by the Coalition’s Healthcare metodologia/. Innovation Award from the Center for Medicare and V. Cordeiro, C. Velloso, interview with Manatt, Aug. Medicaid Innovation (CMMI). The CMMI award will 2013. expand the Coalition’s reach to approximately 1,000 Georgetown University, Evaluating Saúde Criança: residents who are frequent users of hospital and emer- Policy Brief (Washington, D.C.: Georgetown gency department (ED) services. University, Oct. 2013). Population Served: The Coalition targets high- J. Habyarimana, D. Ortega Nieto, and J. Tobin, Assessing cost, complex patients who are often frequent utilizers the Impact of Saúde Criança (Washington, D.C.: of the city’s EDs and hospitals. Coalition staff seg- Georgetown University, Oct. 2013). ment patients into two groups: patients with no source D. Ortega Nieto, interview with Manatt, Sept. 2013. of primary care and who have significant social and CAMDEN COALITION OF HEALTHCARE “Work with our care management teams PROVIDERS came out of looking at the data and getting What began in 2002 as a small group of primary care really interested in the outliers—extreme providers meeting to discuss issues facing providers in patients who go to the emergency or Camden, New Jersey, became the Camden Coalition hospital over and over. We decided to go out of Healthcare Providers, a well-respected commu- and meet patients, engage them, and follow nity organizer focused on a collaborative approach to them through the health care system and improving care delivery and patient outcomes. The slowly we learned how to fix health care for Coalition “focuses on creating solutions from the pro- the most extreme patients.” viders and health systems sides of care,” recognizing —Dr. Jeffrey Brenner www.commonwealthfund.org25 mental health issues, and patients with more stable pri- significant contributions in the future. Dr. Brenner has mary care and less severe social issues. Each morning, been recognized for his work to identify “hot spots” of Coalition staff review data on hospitalized patients and health care high utilizers using data and subsequently determine whether they are eligible for assistance. Once reducing patient visits and costs by 40 percent to 50 an individual is enrolled in the program, Coalition staff percent. visit their home within 24 hours of discharge to begin Contacts: Dr. Jeffrey Brenner, Founder and Executive providing services and with the goal of finding a pri- Director, Camden Coalition of Healthcare Providers. mary care medical home. Social Determinants Addressed by Intervention: Sources The Coalition aims to address all social determinants Camden Coalition of Healthcare Providers, Care impeding their clients’ pursuit and completion of iden- Management Program, http://www.camdenhealth. tified goals. This may include, but is not limited to: org/programs/care-management-program/. housing, addiction, psychosocial issues, legal, and access S. R. Green, V. Singh, and W. O’Byrne, “Hope for New to food. Jersey’s City Hospitals: The Camden Initiative,” Financing: The Coalition is primarily grant- Perspect Health Inf Manag, April 2010 7:1d. funded, but it also receives some funding from hospitals J. Brenner, Interview with Manatt, Aug. 2013. whose patients benefit from the Coalition’s services. The MacArthur Foundation, MacArthur Fellows Program, health information exchange utilized by the Coalition is http://www.macfound.org/fellows/886/. supported by funding from local hospitals, health plans, and the federal government. CITY HEALTH WORKS Key Outcomes After leading the One Million Community Health • After intervention, average hospital charges per Workers Campaign, an initiative to accelerate commu- month for 36 high utilizers fell by 56.4 percent nity health worker programs in sub-Saharan Africa, Dr. from $1,218,010 to $531,203. Prabhjot Singh sought to bring the “most scalable and • After intervention, the average number of transferrable model” from Africa to the United States. emergency department and hospital visits across 36 The result was City Health Works, a social enterprise high utilizers decreased approximately 40 percent founded by Manmeet Kaur in 2011 with Dr. Singh as from 61.6 to 37.2 visits per month. a technical advisor, which is currently piloting its com- • By helping high utilizers obtain insurance, provider munity health worker model in East Harlem in New reimbursement increased by 52 percent. York City. Description of Model: In the City Health Works • A study of 36 high utilizers found that after model, individuals deemed eligible for the program intervention, hospital costs and utilization because of their diagnosis of diabetes or hypertension decreased, while hospital reimbursement increased. are “onboarded” in a community clinic and connected • The Coalition is currently conducting a randomized to a community health worker coach. The community controlled trial. health worker meets with the individual at his or her Awards and Recognitions: Dr. Jeffrey Brenner, home to assess goals, and performs three primary func- the Coalition’s Founder and Executive Director, won tions: 1) assists in the early detection of diabetes or the MacArthur Foundation Award in September 2013. hypertension complications; 2) coaches the individual Dr. Brenner will serve as a MacArthur Fellow, an honor on self-management of diabetes or hypertension; and recognizing exceptionally creative individuals with 3) performs care coordination activities. The commu- a track record of achievement and the potential for nity health worker also conducts community and service 26 ADDRESSING PATIENTS’ SOCIAL NEEDS: An Emerging Business Case for Provider Investment outcomes data. In its CMMI Health Care Innovation “Our goal has been to enrich the public Award application, City Health Works projected the imagination for what community health can following expected cost savings resulting from the be in a way that is systematic, financially intervention: oriented, and most relevant now.” • $3,103,223 per year in cost savings across all —Dr. Prabhjot Singh participants, equating to $1,862 per participant per year; mapping to match individuals with needed assistance. • A return on investment of 1.63; and While in the community, the community health work- • An average of a 15 percent reduction in costs per ers communicate with nurses and clinics by phone and participant over three years, as compared with if the a mobile decision-support application. City Health individual had not participated in the intervention. Works aims to engage networks within communities to “target an entire microenvironment,” such that the Awards and Recognitions: For his work with intervention improves both the health of participating community health workers in Africa and in the United individuals and the community as a whole. States, Dr. Singh received a Robert Wood Johnson Location of Intervention and Spread: Currently, Young Leader Award in 2012. City Health Works is piloting its intervention in East Contacts: Manmeet Kaur, Executive Director and Harlem and plans to expand to other cities in the Founder, City Health Works; Dr. Prabhjot Singh, Lead United States in coming years. In 2014, the organiza- Strategic Advisor, City Health Works. tion anticipates implementing its model in Dallas. Population Served: City Health Works targets Sources individuals with diabetes and hypertension who have a City Health Works, About Us, http://cityhealthworks. moderate readmission risk. It is considering widening com/about-us/. its target population to include individuals who are both City Health Works, Center for Medicare and Medicaid higher and lower risk. Innovation Request (New York: City Health Social Determinants Addressed by Intervention: Works, Aug. 2013). As part of their role as coaches, City Health Works’ City Health Works, Project Narrative (New York: City community health workers connect individuals to com- Health Works, Aug. 2013). munity services and organizations, such as those provid- P. Singh, interview with Manatt, Aug. 2013. ing assistance related to food and shelter. Financing: The majority of City Health Works’ financing is currently through foundation support. HEALTH LEADS It also receives payments from a hospital’s operating Founded in 1996, Health Leads envisions a health care budget for being a component of the hospital’s patient- system that addresses all patients’ basic resource needs centered medical home. City Health Works is working as a standard part of patient care. In the clinics where with three insurance providers to determine optimal Health Leads operates, physicians can prescribe food, pricing of services. In August 2013, City Health Works heat, and other basic resources their patients need to be submitted an application for a $5,721,280 Center for healthy, alongside prescriptions for medication. Patients Medicare and Medicaid Innovation (CMMI) Health then take those prescriptions to a Health Leads’ desk Care Innovation Award. The organization aims to in the clinic waiting room, where a corps of highly achieve revenue sustainability within three to four years. trained college student Advocates work side-by-side Key Outcomes: City Health Works began its with patients to access community resources and public pilot program in September 2013, and does not yet have benefits. www.commonwealthfund.org27 Location of Intervention and Spread: Health “Health Leads envisions moving clinics from Leads desks are located in adult and pediatric outpa- the status quo to addressing patients’ social tient clinics, newborn nurseries, ob/gyn clinics, and needs as a routinized, standard part of care— community health centers in six cities across the United enabling providers to ask the previously States. Last year, Health Leads’ 900 Advocates served unaskable questions. Social needs, and the 11,500 patients in 23 clinics in Baltimore, Boston, clinic-based infrastructure to tackle them Chicago, New York City, Providence, and Washington, effectively, become a basic component of D.C. the patient visit.” Population Served: Health Leads targets low- —Rebecca Onie income patients and their families who have unmet social needs. Description of Model: Health Leads’ model has Social Determinants Addressed by Intervention: been implemented in over two dozen clinical locations Health Leads’ scope of services includes multiple and is an integrated aspect of care delivery in each of categories of patient social needs, ranging from food its partner health care institutions. This integration is assistance to adult education. A recent analysis found achieved through five elements: that the most prevalent needs of Health Leads’ client population were: education, housing assistance, utilities 1. Seamless clinical integration: Health Leads utilizes assistance, food assistance, and employment. systematic screening to determine patient social Financing: Health Leads’ primary funding needs, electronic resource “prescriptions’ via the sources are philanthropic dollars and fees from partner electronic medical record, and real-time updates to health care institutions, drawn from operating budget, the clinical team. community benefit, or philanthropic dollars. 2. Trained lay workforce: Health Leads’ corps of Key Outcomes college student Advocates are competitively • A 2010 study of a Health Leads site in Baltimore recruited, trained, and supervised by full- found that 90 percent of families using the Health time, clinic-based staff with social work/case Leads desk were satisfied with the connection made management experience. by Health Leads. Ninety percent of patients with 3. Patient engagement: Advocates follow-up weekly whom Health Leads worked successfully solved at with patients until they secure the needed resources, least one need or reported that they are equipped to providing targeted guidance on how to navigate secure resources with the information provided by financial, linguistic, and bureaucratic obstacles. Health Leads and without further assistance. 4. Technology: Health Leads has developed a • A time series analysis conducted at The Dimock technology platform to drive resource connections Center in Boston demonstrated that the health via a client management database and a linked center’s pediatric social worker’s average weekly resource directory with a search engine, mapping billable minutes increased by 57 percent after the feature, and geography-specific information. implementation of Health Leads. 5. Data and analytics: This technology platform also Awards and Recognitions: Co-Founder and includes back-end analytics capacity, enabling CEO Rebecca Onie is a MacArthur Fellow and a Health Leads to equip clinics with real-time, World Economic Forum Young Global Leader. population-level data about their patients’ social Contacts: Rebecca Onie, Co-Founder and CEO, Health needs. Leads; Brian Hermanspan, Vice President of Business Development, Health Leads. 28 ADDRESSING PATIENTS’ SOCIAL NEEDS: An Emerging Business Case for Provider Investment Sources A. Garg, M. Marino, A. Vikani et al., “Addressing “The process of going through HelpSteps Families’ Unmet Social Needs Within Pediatric helped individuals take the step of Primary Care: The Health Leads Model,” Clinical thinking about how to solve their problems Pediatrics, Dec. 2012 51(12):1191–93. themselves.” A. Garg, S. Sarkar, M. Marino et al., “Linking Urban —Dr. Eric Fleegler Families to Community Resources in the Context of Pediatric Primary Care,” Patient Educ Couns, May area. It is the backbone referral system for the Boston 2010 79(2):251–54. Public Health Commission’s “Mayor’s Health Line.” A B. Hermanspan, interview with Manatt, July 2013. pilot program is also under way at a community-based E. Fernandez Maldonado, Health Leads Desk: Does It clinic in Little Rock, Arkansas. HelpSteps is in discus- Affect Weekly Billable Hours? An Analysis Using Data sion with other providers in Massachusetts and Rhode from Purposively Selected Site (Washington, D.C.: Island about further expansion. The Boston-oriented George Washington University, 2011). version of the platform is publicly available at https:// Health Leads, Our History, https://healthleadsusa.org/ www.helpsteps.com/home.html. about/our-history/. Population Served: HelpSteps targets low- Health Leads, Our Model, https://healthleadsusa.org/ income families. what-we-do/our-model/. Social Determinants Addressed by Intervention: R. Onie, interviews with Manatt, June and Dec. 2013. HelpSteps targets a wide range of social determinants R. D. Onie, “Creating a New Model to Help Health of health. Its platform directs individuals to commu- Care Providers Write Prescriptions for Health,” nity-based resources for issues including housing, food, Health Affairs, Dec. 2012 31(12):2795–96. employment, safety equipment, education, parenting, and transportation. Financing: Thus far, HelpSteps has primarily HELPSTEPS been funded through research and service grants total- Founded in 2004 by Dr. Eric Fleegler, HelpSteps is a ing approximately $500,000. patient-centered online platform that provides indi- viduals with information about targeted local services to Key Outcomes meet their social needs. • Forty percent of young adults receiving a referral Description of Model: HelpSteps exists in two through HelpSteps contacted the referral forms: 1) a “guided search,” where individuals fill out organization selected through HelpSteps. Of a questionnaire that identifies their social needs, such the families that were in touch with the referral as assistance with obtaining food or accessing health organization, more than 52 percent resolved their insurance; and 2) a “direct search” that allows users main problem. to skip the questionnaire and directly find resources • A study of families with young children showed to help them. Services are categorized into 13 social that more than 90 percent of families would be domains, including access to health care, food security, receptive to HelpSteps becoming integrated into income security, housing, domestic violence, and others. their annual physical. In both cases, the platform identifies community-based • A qualitative study of adolescents and young adults organizations that can support the individual. found that more than 95 percent would recommend Location of Intervention and Spread: Currently, HelpSteps to a friend. HelpSteps has been implemented in locations across Boston Children’s Hospital, such as waiting rooms, and in at least two other health care facilities in the Boston www.commonwealthfund.org29 Awards and Recognitions: In 2005, HelpSteps of Public Health and Health Services’ Department of received the American Academy of Pediatrics’ Special Health Policy. NCMLP promotes learning and sharing Achievement Award. of best practices across MLP sites and leads research and policy initiatives focused on sustaining and scaling Contacts: Dr. Eric Fleegler, Founder, HealthSteps. the MLP model. Sources Description of Model: At MLPs, lawyers and E. Fleegler, interview with Manatt, Sept. 2013. paralegals become part of the health care team, working E. Fleegler, “The Online Advocate: Assessing and on-site in clinical settings alongside physicians, nurses, Referring Health-Related Social Problems,” case managers, and other health care professionals to Presentation at Children’s Hospital Association address health-harming legal needs related to income, Creating Connections Conference, Mar. 13, 2012. health insurance, housing and utilities, education and E. W. Fleegler, T. A. Lieu, P. H. Wise et al., “Families’ employment, legal status/immigration, and personal Health-Related Social Problems and Missed safety and stability. Under the MLP model, Referral Opportunities,” Pediatrics, June 2007 • Legal professionals train health care team members 119(6):e1332-e1341. to recognize health-harming legal needs; A. Hassan, E. A. Blood, A. Pikcilingis et al., “Youths’ • Health care team members identify patients’ health- Health-Related Social Problems: Concerns Often harming legal needs by implementing screening Overlooked During the Medical Visit,” J Adolesc procedures; Health, Aug. 2013 53(2):265–71. • Legal professionals treat individual patients’ HelpSteps, Home, https://www.helpsteps.com/home. existing health-harming legal needs with triage, html. consultations, and legal representation; S. A. Wylie, A. Hassan, E.G. Krull et al., “Assessing and referring adolescents’ health-related social prob- • Health care and legal professionals jointly treat lems: qualitative evaluation of a novel web-based multiple patients’ existing health-harming legal needs approach,” Journal of Telemedicine and Telecare, Oct. by changing clinical or institutional policies; and 2012 18(7):392–98. • Health care and legal professionals jointly prevent additional health-harming legal needs broadly by improving policies and regulations that have an MEDICAL-LEGAL PARTNERSHIP impact on population health. Recognizing that “many legal problems are health Location of Intervention and Spread: There are problems,” the Medical-Legal Partnership (MLP) is a MLPs at more than 250 hospitals and health centers health care delivery model that combines the expertise across the United States. of health and legal professionals to address and prevent Population Served: MLPs target low-income health-harming legal needs for patients, clinics, and and other vulnerable populations. Some MLPs focus populations. Under the MLP model, existing health on specific populations including children and families, care and legal institutions come together and lever- age their existing capabilities and resources to build an “We are convinced the MLP model is an integrated, interprofessional health care team. The first effective way to address social determinants MLP program, MLP-Boston, was founded in 1993 at and make the shift from emergency care Boston Medical Center. to more preventive strategies. It’s an The National Center for Medical-Legal intervention that more than 250 hospitals Partnership (NCMLP) was launched in 2005 and is a and health centers have already embraced.” project of the George Washington University School —Ellen Lawton 30 ADDRESSING PATIENTS’ SOCIAL NEEDS: An Emerging Business Case for Provider Investment elderly patients, patients with HIV, chronically ill adults, oncology patients, Medicaid patients, and “Health care alone can’t solve poverty. We veterans. can and should assess and manage poverty Social Determinants Addressed by Intervention: like the chronic disease that it is, tracking The MLP model addresses unmet legal needs and legal and treating the social problems that most barriers that impede health, including income, health impact health.” insurance, housing and utilities, education and employ- —Dr. Megan Sandel ment, legal status/immigration, and personal safety and stability. by the American Bar Association in 2008. In 2007, Financing: MLPs are financed through a vari- the NCMLP and MLP-Boston were awarded the ety of strategies and sources, predominantly at the local American Hospital Association NOVA Award, which level and predicated on leveraging and matching exist- recognizes hospitals and health systems for collaborative ing institutional and community resources, including efforts toward improving community health. The MLP health care institutions’ operating budgets, community model was also cited as a best practice by the Joint benefit dollars, local and regional private philanthropy, Commission in 2009. and, increasingly, state and federal funding streams Contacts: Ellen Lawton, Co-Principal Investigator, targeting the social determinants of health for specific National Center for Medical-Legal Partnership; populations. Dr. Megan Sandel, Medical Director, National Center Key Outcomes for Medical-Legal Partnership. • An MLP between a federally funded legal aid Sources agency and a community health clinic in rural T. Beeson, B. D. McAllister, and M. Regenstein, Making Illinois assisted individuals with appealing the Case for Medical-Legal Partnerships: A Review of Medicaid coverage denials, and it obtained a 319 the Evidence (Washington, D.C.: National Center percent return on investment over a three-year for Medical-Legal Partnership, George Washington period by obtaining reimbursement through health University School of Public Health and Health care recovery dollars.* Services, Feb. 2013). • A small pilot study of adults with moderate to R. Knight, Health Care Recovery Dollars: A Sustainable severe asthma who received services through an Strategy for Medical-Legal Partnerships? (Boston: MLP in New York demonstrated a 91 percent Medical-Legal Partnership for Children, April decline in emergency department visits and 2008). hospital admissions. Approximately 92 percent of E. Lawton, interview with Manatt, July 2013. participants experienced a decrease of at least two National Center for Medical-Legal Partnership, “Core asthma severity classes. Components and Activities,” http://www.medical- • 70 percent of providers felt that their institution’s legalpartnership.org/model/core-components. use of an Atlanta MLP saved them time that they M. M. O’Sullivan, J. Brandfield, S. S. Hoskote et al., could use on other cases. “Environmental Improvements Brought by the Awards and Recognitions: The value of the Legal Interventions in the Homes of Poorly MLP model was recognized by the American Medical Controlled Inner-City Adult Asthmatic Patients: Association’s passage of a supportive resolution in A Proof-of-Concept Study,” J Asthma, Nov. 2012 June 2010, similar to the supportive resolution passed 49(9):911–17. R. Pettignano, S. B. Caley, and S. McLaren, “The * A white paper published by the Medical-Legal Partnership for Children defines health care recovery dollars as “funds reimbursed Health Law Partnership: Adding a Lawyer to the to hospitals as a result of a successful appeal of improperly denied Medicaid or Social Security Disability application.” www.commonwealthfund.org31 Health Care Team Reduces System Costs and Improves Provider Satisfaction,” J Public Health “In the real world, it makes sense to integrate Manag Pract, July-Aug. 2012 18(4):E1–E3. the medical and social components of M. Sandel, interview with Manatt, Aug. 2013. patients’ needs. For the patient, it makes J. A. Teufel, D. Werner, D. Goffinet et al., “Rural sense to deal with everything at once, Medical-Legal Partnership and Advocacy: A holistically.” Three-Year Follow-Up Study,” J Health Care Poor —Dr. James Krieger Underserved, May 2012 23(2):705–14. include: enrollment in Medicaid; primary language is English or Spanish; and the primary caretaker must SEATTLE-KING COUNTY HEALTHY have the mental and physical capacity to participate. HOMES PROJECT Social Determinants Addressed by Intervention: The Seattle-King County Healthy Homes Project The Project is focused on those social determinants that began as a demonstration project to reduce the exposure impact children’s asthma and their families’ ability to of low-income children with asthma to asthma trig- address and control asthma, including housing condi- gers by providing them with home visits by commu- tions, stress, social support, and access to education and nity health workers (CHWs). In its second phase, the employment. Project broadened its focus to include in-home support Financing: The Project is grant-funded and has from CHWs for both trigger reduction and improved received support from the Centers for Disease Control skills for asthma self-management. and Prevention, U.S. Department of Housing and Description of Model: CHWs conduct home Urban Developments, and National Institutes of visits for families of low-income children with uncon- Health. trolled asthma. CHWs conduct a home assessment for environmental triggers, assess knowledge and skills for Key Outcomes asthma self-management, develop an action plan with • In the two months post-intervention, only 8.4 the family, and provide bedding encasements, vacuums, percent of children in the high-intensity group and other asthma control tools. They also may provide used urgent health services, a decline from 23.4 families with social support services, including assis- percent in the pre-intervention period. The low- tance with obtaining extermination services, advocacy intensity group experienced a smaller, statistically for better housing, and other services geared toward insignificant decrease, from 20.2 percent to 16.4 improving asthma control. percent. Location of Intervention and Spread: The • Post-intervention, days of activity limitation for intervention is located in Seattle-King County in children in the high-intensity group declined by 4.1 Washington State. The intervention has been adopted days over a two-week period. The decline for chil- by multiple sites across the nation, including public dren in the low-intensity group was only 2.6 days. health agencies and health delivery systems in Boston, • On a scale of seven, quality-of-life scores for Baltimore, Philadelphia, Fresno, Calif., and many other caregivers in the high-intensity group increased places. from 4.0 to 5.6, while quality-of-life scores for Population Served: The Project targets low- caregivers in the low-intensity group increased from income and minority children affected by asthma 4.4 to 5.4. in Seattle-King County, Washington. Other criteria 32 ADDRESSING PATIENTS’ SOCIAL NEEDS: An Emerging Business Case for Provider Investment Awards and Recognitions: The Environmental Protection Agency named the Project a 2005 Children’s Environmental Health Excellence Award Winner. In addition, it received the Secretary of Health and Human Services’ Innovation in Prevention Award in 2003 and the U.S. Department of Housing and Urban Development’s Healthy Homes Innovator Award in 2011. Contacts: Dr. James Krieger, Chief, Chronic Disease and Injury Prevention for Public Health—Seattle and King County; and Clinical Professor of Medicine, University of Washington. Sources J. W. Krieger, interview with Manatt, Oct. 2013. J. W. Krieger, T.K. Takaro, L. Song et al., “The Seattle-King County Healthy Homes Project: A Randomized, Controlled Trial of a Community Health Worker Intervention to Decrease Exposure to Indoor Asthma Triggers, “American Journal of Public Health, April 2005 95(4):652–59. Public Health—Seattle-King County, Asthma Program, http://www.kingcounty.gov/healthservices/health/ chronic/asthma.aspx. www.commonwealthfund.org33 APPENDIX C. COST SAVINGS AND QUALITY AND CARE UTILIZATION MEASURES ASSOCIATED WITH SELECTIVE INTERVENTIONS Intervention Quality and care name Description Cost savings utilization measures After implementing a transition program for individuals discharged The Adirondack Medical Home Demonstration is a five- from the hospital, the Hudson year pilot across payers and providers in the Adirondack The Hudson Headwaters Health Headwaters Health Network region of New York State in which participating providers Network, a participant in the reduced its readmissions rate for Adirondack become NCQA-certified patient-centered medical homes Adirondack Medical Home targeted conditions from 19% to 7%. Medical Home (PCMHs). The payers distribute $7 per-member per-month Demonstration, has shown 15% Within the Network, patients are Demonstration to providers to support an extensive set of PCMH services, to 20% savings for Medicaid assessed upon intake and referred b including employing care managers and community resource beneficiaries. to Community Resource Advocates a advocates who assist patients with social needs. to provide social supports, including assistance with housing/living c conditions, food, and transportation. The Camden Coalition of Healthcare Providers operates a After participating in the intervention, Camden care management program for high utilizers of health care In the period post-intervention, the average total number of Coalition of services, where an outreach team assists participants with average total hospital charges per emergency department and hospital Healthcare activities such as connecting to a medical home, obtaining month for 36 high utilizers fell by visits across 36 high utilizers fell by e Providers housing and other public benefits, managing their legal 56.4%, from $1,218,010 to $531,203. approximately 40%, decreasing from d f needs, and meeting their personal goals. 61.6 to 37.2 visits per month. At 12 months into the intervention, The Community Asthma Initiative is an intervention At two-year follow-up, the participants experienced a operated out of Children’s Hospital Boston and a community intervention saved $3,827 in 68% decrease in emergency health center, in which nurse case managers provide care decreased emergency department department visits, an 85% decline in Community coordination services for low-income children with asthma. visits and hospitalizations per child hospitalizations, and a 43% reduction Asthma The families receive home visits from nurses or community when measured against a comparison in “days of limitation of physical Initiative health workers supervised by nurses, who assess the families’ group. The intervention cost $2,529 activity.” In addition, children missed homes for asthma triggers, provide asthma remediation per child, resulting in a return on 41% fewer school days and their g h items, and connect families to community-based services. investment of 1.46. parents missed 50% fewer days of i work. The Frequent Users of Health Services Initiative includes six After two years of program Frequent Users hospital and community-based case management programs enrollment, average inpatient charges Two years post-enrollment into the of Health in California providing referrals to medical and social decreased by 69%, falling from initiative, average inpatient days Services l services for individuals who are frequent users of emergency $46,826 at one-year pre-enrollment decreased by 62%. Initiative j k departments. to $14,684 at the two-year point. For individuals with a high-risk Individuals receiving the intervention of hospitalization, a randomized had a significantly lower rate of controlled trial found similar costs emergency department visits over between individuals participating The GRACE intervention begins with a home visit by a nurse a two-year period than individuals in GRACE and a comparison group Geriatric practitioner–led support team to assess low-income seniors’ receiving usual care (1,445 per 1,000 receiving usual care during the two Resources for medical and psychosocial needs. The support team reports v. 1,748 per 1,000). In addition, years of the study. However, in the Assessment and its findings to a larger group of health care professionals, GRACE participants experienced year following the intervention, Care of Elders which develops and implements a care plan to address the statistically significant improvements individuals at high-risk of (GRACE) individual’s needs, including those related to home safety on the SF-36 quality of life m hospitalization participating in GRACE and social support. instrument in the areas of general had significantly lower total mean health, vitality, social functioning, and costs than similar individuals in the mental health as compared with the comparison group; a difference of o n usual care group. $5,088 v. $6,575, respectively. In the clinics where Health Leads operates, physicians and In fiscal year 2013, 90% of patients other members of the clinical team can systematically screen After the Dimock Center, a health and with whom Health Leads worked their patients for unmet social needs and prescribe resources human services agency in Boston, successfully solved at least one to meet those needs. Trained student Advocates connect Health Leads instituted Health Leads, their pediatric need or reported that they are the patients to community resources by leveraging a client social worker’s average weekly billable equipped to secure resources with management database and resource inventory. They then q therapy minutes increased by 57%. the information provided by Health conduct follow-up to ensure the services were received, and p Leads and without further assistance. loop back to the referring provider. 34 ADDRESSING PATIENTS’ SOCIAL NEEDS: An Emerging Business Case for Provider Investment Intervention Quality and care name Description Cost savings utilization measures An MLP between a federally funded In a small pilot study, adults with legal aid agency and a community moderate to severe asthma who health clinic in rural Illinois assisted received services through an MLP In the Medical-Legal Partnership (MLP), lawyers and individuals with appealing Medicaid in New York demonstrated a 91% Medical-Legal paralegals work onsite in clinical settings or at locations coverage denials and obtained a decline in emergency department Partnership affiliated with provider institutions and assist patients in r 319% return on investment over visits and hospital admissions. addressing legal issues associated with health status. a three-year period by obtaining Approximately 92% of participants reimbursement through health care experienced a decrease of at least s t recovery dollars. two asthma severity classes. For participants in the high-intensity version of the intervention, from baseline to the period post- The Seattle-King County Healthy Homes Project is an intervention, the percentage of intervention in which community health workers conduct Urgent care costs for participants participants using urgent health home visits for families of low-income children with in the high-intensity version of the services over the past two months Seattle-King uncontrolled asthma. Intervention participants received self- intervention were estimated to be declined from 23.4% to 8.4%, a County Healthy management support services including a home assessment $201–$334 per child less than those greater decline than observed in the Homes Project for environmental triggers, help with reducing exposure to in the low-intensity version of the low-intensity group. v asthma triggers, and assistance in developing skills to better intervention. In addition, symptom-free days and u control asthma, such as correct use of medications. asthma-related quality of life for the children’s caregivers improved more among families in the high-intensity w group. a G. Burke and S. Cavanaugh, The Adirondack Medical Home Demonstration: A Case Study, 2011 (New York: United Hospital Fund, March 2011); J. Rugge, D. Reynolds, C. Homkey, interview with Manatt, Nov. 2013. b Interview with John Rugge, Nov. 2013. c Ibid. d S. R. Green, V. Singh, and W. O’Byrne, “Hope for New Jersey’s City Hospitals: The Camden Initiative,” Perspect Health Inf Manag, April 2010 7: 1d. e Ibid. f Ibid. g E. R. Woods, U. Bhaumik, S. J. Sommer et al., “Community Asthma Initiative” Evaluation of a Quality Improvement Program for Comprehensive Asthma Care,” Pediatrics, March 2012 129(3):465–72. h Ibid. i Ibid. j K. W. Linkins, J. J. Brya, and D. W. Chandler, Frequent Users of Health Services Initiative: Final Evaluation Report, 2008 (Falls Church, Va.: The Lewin Group, Aug. 2008). k Ibid. l Ibid. m S. R. Counsell, C. M. Callahan, A. B. Buttar et al., “Geriatric Resources for Assessment and Care of Elders (GRACE): A New Model of Primary Care for Low-Income Seniors,” Journal of the American Geriatrics Society, 2006 54(7):1136–41. n S. R. Counsell, C. M. Callahan, W. Tu et al., “Cost Analysis of the Geriatric Resources for Assessment and Care of Elders Care Management Intervention,” Journal of the American Geriatrics Society, 2009 57(8):1420–27. o S. R. Counsell, C. M. Callahan, D. O. Clark et al., “Geriatric Care Management for Low-Income Seniors: A Randomized Controlled Trial,” Journal of the American Medical Association, 2007 298(22):2623–33. p Garg, Marino, Vikani et al., “Addressing Families’ Unmet Social Needs within Pediatric Primary Care: The Health Leads Model,” 2012; Health Leads, Our Model, https://healthlead- susa.org/what-we-do/our-model/. q E. Fernandez Maldonado, “Health Leads Desk: Does It Affect Weekly Billable Hours? An Analysis Using Data from Purposively Selected Site (Washington, D.C.: George Washington University, 2011), 1–7. r National Center for Medical-Legal Partnership, Core Components and Activities, http://www.medical-legalpartnership.org/model/core-components. s J. A. Teufel, D. Werner, D. Goffinet et al., “Rural Medical-Legal Partnership and Advocacy: A Three-Year Follow-up Study,” J Health Care Poor Underserved, May 2012 23(2):705–14. t M. M. O’Sullivan, J. Brandfield, S. S. Hoskote et al., “Environmental Improvements Brought by the Legal Interventions in the Homes of Poorly Controlled Inner-City Adult Asthmatic Patients: A Proof-of-Concept Study,” J Asthma, Nov. 2012 49(9): 911–17. u J. W. Krieger, T. K. Takaro, L. Song et al., “The Seattle-King County Healthy Homes Project: A Randomized, Controlled Trial of a Community Health Worker Intervention to Decrease Exposure to Indoor Asthma Triggers,” American Journal of Public Health, April 2005 95(4):652–59. v Ibid. w Ibid. www.commonwealthfund.org35 The COMMONWEALTH FUND