Strategies for Insurers to Promote Health Among Sexual and Gender Minority People.

This Viewpoint describes strategies for payers to improve health outcomes among sexual and gender minority people.

Health Equity Adjustment and Hospital Performance in the Medicare Value-Based Purchasing Program.

Importance: Medicare's Hospital Value-Based Purchasing (HVBP) program will provide a health equity adjustment (HEA) to hospitals that have greater proportions of patients dually eligible for Medicare and Medicaid and that offer high-quality care beginning in fiscal year 2026. However, which hospitals will benefit most from this policy change and to what extent are unknown. Objective: To estimate potential changes in hospital performance after HEA and examine hospital patient mix, structural, and geographic characteristics associated with receipt of increased payments. Design, Setting, and Participants: This cross-sectional study analyzed all 2676 hospitals participating in the HVBP program in fiscal year 2021. Publicly available data on program performance and hospital characteristics were linked to Medicare claims data on all inpatient stays for dual-eligible beneficiaries at each hospital to calculate HEA points and HVBP payment adjustments. Exposures: Hospital Value-Based Purchasing program HEA. Main Outcomes and Measures: Reclassification of HVBP bonus or penalty status and changes in payment adjustments across hospital characteristics. Results: Of 2676 hospitals participating in the HVBP program in fiscal year 2021, 1470 (54.9%) received bonuses and 1206 (45.1%) received penalties. After HEA, 102 hospitals (6.9%) were reclassified from bonus to penalty status, whereas 119 (9.9%) were reclassified from penalty to bonus status. At the hospital level, mean (SD) HVBP payment adjustments decreased by $4534 ($90 033) after HEA, ranging from a maximum reduction of $1 014 276 to a maximum increase of $1 523 765. At the aggregate level, net-positive changes in payment adjustments were largest among safety net hospitals ($28 971 708) and those caring for a higher proportion of Black patients ($15 468 445). The likelihood of experiencing increases in payment adjustments was significantly higher among safety net compared with non-safety net hospitals (574 of 683 [84.0%] vs 709 of 1993 [35.6%]; adjusted rate ratio [ARR], 2.04 [95% CI, 1.89-2.20]) and high-proportion Black hospitals compared with non-high-proportion Black hospitals (396 of 523 [75.7%] vs 887 of 2153 [41.2%]; ARR, 1.40 [95% CI, 1.29-1.51]). Rural hospitals (374 of 612 [61.1%] vs 909 of 2064 [44.0%]; ARR, 1.44 [95% CI, 1.30-1.58]), as well as those located in the South (598 of 1040 [57.5%] vs 192 of 439 [43.7%]; ARR, 1.25 [95% CI, 1.10-1.42]) and in Medicaid expansion states (801 of 1651 [48.5%] vs 482 of 1025 [47.0%]; ARR, 1.16 [95% CI, 1.06-1.28]), were also more likely to experience increased payment adjustments after HEA compared with their urban, Northeastern, and Medicaid nonexpansion state counterparts, respectively. Conclusions and Relevance: Medicare's implementation of HEA in the HVBP program will significantly reclassify hospital performance and redistribute program payments, with safety net and high-proportion Black hospitals benefiting most from this policy change. These findings suggest that HEA is an important strategy to ensure that value-based payment programs are more equitable.

Mitigating the Burden of Medication Costs.

This essay discusses medication cost−lowering strategies that clinicians can use in routine clinical and inpatient care to assist patients in affording and adhering to expensive therapy regimens.

Hospital Characteristics Associated With Social Needs Activities in the US.

This study assesses what hospital characteristics, including hospital participation in payment and delivery reform, are associated with activities related to health-related social needs.

Awareness, Adjustment, Assistance, Alignment, and Advocacy: Operationalizing Social Determinants of Health Topics in Undergraduate Medical Education Curricula.

Social and economic factors, such as those related to food, housing, and transportation, are major drivers of health and health inequities. Multiple national professional organizations have articulated roles for physicians in identifying and addressing social determinants of health (SDOH) and the need to include SDOH in all stages of physician education. Despite encouragement from these professional organizations, medical schools still do not routinely offer SDOH education alongside basic and clinical sciences curricula. A recent national expert consensus process identified priority SDOH knowledge domains and professional skills for medical students but lacked an organizing schema and specific pedagogical examples to help translate prioritized skills into routine pedagogical practice. One such schema is the 5As framework developed by the National Academies of Sciences, Engineering, and Medicine, which elaborates on 5 strategies to strengthen social care: awareness, adjustment, assistance, alignment, and advocacy. In this article, the authors highlight and provide examples of how mapping SDOH skills to the 5As framework can help educators meaningfully operationalize SDOH topics into specific curricular activities during the preclinical and clinical stages of undergraduate medical education. As a foundational first step in this direction, medical schools should conduct an internal curricular review of social care content (ideally mapped to the 5As framework) and identify opportunities to integrate these topics into existing courses when relevant (e.g., in social medicine, population health, and health systems science courses). Given that health and social care integration is highly context dependent, each medical school will likely need to tailor curricular changes based on their own institutional needs, mission, patient populations, and ties to the community. To increase interinstitutional alignment, medical schools might consider using or adapting peer-reviewed materials and assessments curated and centralized by the National Collaborative for Education to Address the Social Determinants of Health.

A Tailored SMS Text Message-Based Intervention to Facilitate Patient Access to Referred Community-Based Social Needs Resources: Protocol for a Pilot Feasibility and Acceptability Study.

BACKGROUND: Health care providers are increasingly screening patients for unmet social needs (eg, food, housing, transportation, and social isolation) and referring patients to relevant community-based resources and social services. Patients' connection to referred services is often low, however, suggesting the need for additional support to facilitate engagement with resources. SMS text messaging presents an opportunity to address barriers related to contacting resources in an accessible, scalable, and low-cost manner. OBJECTIVE: In this multi-methods pilot study, we aim to develop an automated SMS text message-based intervention to promote patient connection to referred social needs resources within 2 weeks of the initial referral and to evaluate its feasibility and patient acceptability. This protocol describes the intervention, conceptual underpinnings, study design, and evaluation plan to provide a detailed illustration of how SMS technology can complement current social needs screening and referral practice patterns without disrupting care. METHODS: For this pilot prospective cohort study, this SMS text message-based intervention augments an existing social needs screening, referral, and navigation program at a federally qualified health center. Patients who received at least one referral for any identified unmet social need are sent 2 rounds of SMS messages over 2 weeks. The first round consists of 5-10 messages that deliver descriptions of and contact information for the referred resources. The second round consists of 2 messages that offer a brief reminder to contact the resources. Participants will evaluate the intervention via a survey and a semistructured interview, informed by an adapted technology acceptance model. Rapid qualitative and thematic analysis will be used to extract themes from the responses. Primary outcomes are implementation feasibility and patient acceptability. Secondary outcomes relate to intervention effectiveness: self-reported attempt to connect and successful connection to referred resources 2 weeks after the initial referral encounter. RESULTS: The study received regulatory approval in May 2021, and we anticipate enrolling 15-20 participants for this initial pilot. CONCLUSIONS: This protocol presents detailed implementation methods about a novel automated SMS intervention for social care integration within primary care. By sharing the study protocol early, we intend to facilitate the development and adoption of similar tools across different clinical settings, as more health care providers seek to address the unmet social needs of patients. Study findings will provide practical insights into the design and implementation of SMS text message-based interventions to improve social and medical care coordination. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/37316.

Intervention components of link worker social prescribing programmes: A scoping review.

In the United Kingdom (UK), link worker social prescribing has emerged as an option to improve long-term condition management and address primary care patients' non-medical needs by linking patients with community-based activities and support. Social prescribing is a complex, heterogenous intervention, and there is currently no taxonomy of components to guide its implementation and evaluation. This study aimed to identify and categorise the components of link worker social prescribing schemes in the United Kingdom. A scoping review of peer-reviewed literature was conducted. Six databases were used to identify papers that met inclusion criteria. Eligible articles were original research studies in the United Kingdom describing interventions that included (1) initial referral of adults with chronic physical health conditions and/or unmet social needs from primary care to a link worker or equivalent role, (2) consultation with a link worker or equivalent role and (3) referral to a community-based or government service. Of the 1078 articles identified, 32 met study eligibility criteria, representing 22 social prescribing schemes. We drew from the template for intervention description and replication (TIDieR) to identify, organise and report intervention components. We found wide variations in geography, target populations and intervention components such as activities and procedures conducted by primary care staff and link workers, organisational and staffing configurations and use of tools and financing approaches to facilitate adoption. Intervention components are summarised into a taxonomy to guide future research, policy and practice efforts in addition to supporting standardised intervention reporting.

Patient Barriers to Accessing Referred Resources for Unmet Social Needs.

INTRODUCTION: Many primary care clinics screen patients for their unmet social needs, such as food insecurity and housing instability, and refer them to community-based organizations (CBOs). However, the ability for patients to have their needs met is difficult to evaluate and address. This study explores patient-reported barriers to accessing referred resources using a conceptual framework that identifies opportunities for intervening to optimize success. METHODS: Patients who participated in a social needs screening and referral intervention at a Federally Qualified Health Center (FQHC) were called 2 weeks after the clinic encounter. We conducted a directed content analysis across 6 domains of access to examine responses from patients who reported barriers. RESULTS: Of the 462 patients that were reached for follow-up, 366 patients reported 537 total barriers. The most frequent challenges related to resource availability (24.6%, eg, patients waiting for submitted application to process) and approachability (23.8%, eg, patients lacking information needed to contact or access resources). Barriers in the domains of acceptability (21.6%, eg, competing life priorities such as medical issues, major life events, or caretaking responsibilities) and appropriateness (17.9%, eg, resource no longer needed) largely represented patient constraints expressed only after the clinical encounter. It was less common for patients to identify accommodation (eg, physical limitations, language barriers, transportation barriers, administrative complexity) or affordability of community resources as barriers (11.2% and 0.9%, respectively). CONCLUSION: Findings suggest opportunities for improvement across the access continuum, from initial referrals from primary care staff during the clinical encounter to patients' attempts to accessing services in the community. Future efforts should consider increased collaboration between health and social service organizations, and advocacy for structural changes that mitigate system-level barriers related to resource availability and administrative complexity.

Financing Approaches to Social Prescribing Programs in England and the United States.

Policy Points The number of social prescribing practices, which aim to link patients with nonmedical services and supports to address patients' social needs, is increasing in both England and the United States. Traditional health care financing mechanisms were not designed to support social prescribing practices, and flexible payment approaches may not support their widespread adoption. Policymakers in both countries are shifting toward developing explicit financing streams for social prescribing programs. Consequently, we need an evaluation of them to assess their success in supporting both the acceptance of these programs and their impacts. Investment in community-based organizations and wider public services will likely be crucial to both the long-term effectiveness and the sustainability of social prescribing.

Identifying Priorities to Improve the System of Care for Children With Complex Health Needs in North Carolina: Process and Outcomes of Systematic Stakeholder Engagement.

OBJECTIVE: Children with complex health needs (CCHN) have both medical (eg, chronic conditions) and health-related social needs (eg, potentially adverse social determinants of health) that require ongoing health care and support from multiple community service providers. National standards developed for populations defined by health needs (CYSHCN) provide a framework for stakeholders to plan system-level improvements in care delivery for CCHN, but improvement efforts should reflect the priorities of their families and providers. This article describes a process of prioritizing system-level efforts to improve the health and well-being of CCHN and families in North Carolina (NC), using systematic stakeholder engagement and modified Delphi expert ratings. METHODS: We surveyed stakeholders with experience caring for CCHN using an open-ended, 3-item instrument to identify opportunities to improve systems of care. Using directed qualitative content analysis, we synthesized responses into a master list of potential improvement topics. Using a modified Delphi approach, a 16-member advisory committee rated all topics for importance and urgency, on 9-point Likert scales over 2 rounds; then ratings for each topic were ranked (low, medium, high) to establish relative priority. RESULTS: Forty seven individuals from 31 counties around NC provided survey responses, yielding 59 improvement topics in 10 domains. Through the modified Delphi method process, 21 topics (36%) received the highest rankings, largely representing access to community- and home-based services, equity, and enhancement of the pediatric workforce. CONCLUSIONS: Priorities identified by stakeholders will inform advocacy, policy, and improvement efforts. Next steps for the coalition include developing improvement projects to implement stakeholder-recommended actions for the highest-priority topics.

Integrated Health and Social Care in the United States: A Decade of Policy Progress.

INTRODUCTION: Over the last decade in the United States (US), the burden of chronic disease, health care costs, and fragmented care delivery have increased at alarming rates. To address these challenges, policymakers have prioritized new payment and delivery models to incentivize better integrated health and social services. POLICY PRACTICE: This paper outlines three major national and state policy initiatives to improve integrated health and social care over the last ten years in the US, with a focus on the Medicaid public insurance program for Americans with low incomes. Activities supported by these initiatives include screening patients for social risks in primary care clinics; building new cross-sector collaborations; financing social care with healthcare dollars; and sharing data across health, social and community services. Stakeholders from the private sector, including health systems and insurers, have partnered to advance and scale these initiatives. This paper describes the implementation and effectiveness of such efforts, and lessons learned from translating policy to practice. DISCUSSION AND CONCLUSION: National policies have catalyzed initiatives to test new integrated health and social care models, with the ultimate goal of improving population health and decreasing costs. Preliminary findings demonstrated the need for validated measures of social risk, engagement across levels of organizational leadership and frontline staff, and greater flexibility from national policymakers in order to align incentives across sectors.

Factors Associated with Patients' Connection to Referred Social Needs Resources at a Federally Qualified Health Center.

INTRODUCTION: In an effort to improve health outcomes and promote health equity, healthcare systems have increasingly begun to screen patients for unmet social needs and refer them to relevant social services and community-based organizations. This study aimed to identify factors associated with the successful connection (ie, services started) to social needs resources, as well as factors associated with an attempt to connect as a secondary, intermediate outcome. METHODS: This retrospective cohort study included patients who had been screened, referred, and subsequently reached for follow-up navigation from March 2019 to December 2020, as part of a social needs intervention at a federally qualified health center (FQHC). Measures included demographic and social needs covariates collected during screening, as well as resource-related covariates that characterized the referred resources, including service domain (area of need addressed), service site (integration relative to the FQHC), and access modality (means of accessing services). RESULTS: Of the 501 patients in the analytic sample, 32.7% had started services with 1 or more of their referred resources within 4 weeks of the initial referral, and 63.3% had at least attempted to contact 1 referred resource, whether or not they were able to start services. Receiving a referral to resources that patients could access via phone call or drop-in visit, as opposed to resources that required additional appointments or applications prior to accessing services, was associated with increased odds (aOR 1.95, 95% CI 1.05, 3.61) of connection success, after adjusting for age, sex, race, ethnicity, education, number of social needs, and resource-related characteristics. This study did not find statistically significant associations between connection attempt and any variable included in adjusted analyses. CONCLUSION: These findings suggest that referral pathways may influence the success of patients' connection to social needs resources, highlighting opportunities for more accessible solutions to addressing patients' unmet social needs.

Workforce Models to Screen for and Address Patients' Unmet Social Needs in the Clinic Setting: A Scoping Review.

OBJECTIVES: While healthcare organizations increasingly aim to address the social determinants of health (SDOH) in the clinic setting, there is little guidance on which staff are best equipped to assume this role. The present study is a scoping review of the peer-reviewed literature to characterize workforce models used to screen for and respond to patients' unmet social needs in ambulatory settings. METHODS: Four online databases were used to identify papers published until February 2021. Eligible articles were original research studies or systematic reviews that described the implementation of a standardized assessment for multiple SDOH domains and resulting activities to respond to individual patient needs (eg, referral to community resources) in ambulatory care settings. RESULTS: Of the 1569 articles identified, 65 met study eligibility criteria. Majority of studies had observational study designs (11% were randomized control trials). For screening-related activities, more articles reported using traditional healthcare staff (51%), such as medical providers, medical assistants, and front-desk staff, than social care staff (32%), such as social workers and student volunteers. In contrast, for response-related activities, more articles reported using social care staff (88%) than traditional healthcare staff (60%). While we found wide variations in specific team configurations and training for the roles, social care staff generally provided more intensive forms of assistance than traditional healthcare staff. CONCLUSION: While this review demonstrates the breadth of models for building or deploying a workforce to integrate health and social care, it also identifies the need for rigorous research on workforce development, implementation, and effectiveness.

A Community Resource Navigator Model: Utilizing Student Volunteers to Integrate Health and Social Care in a Community Health Center Setting.

INTRODUCTION: While unmet social needs are major drivers of health outcomes, most health systems are not fully integrated with the social care sector to address them. In this case study, we describe the development and implementation of a model utilizing student volunteer community resource navigators to help patients connect with community-based organizations (CBOs). We then detail initial implementation outcomes and practical considerations for future work. METHODS: We used the Ten Essential Public Health Services Framework to guide program planning of a student "Help Desk" model for a community health center. Planning included a literature review, observation of exemplar programs, development of a CBO directory, and evaluation of the center's patient population, clinical workflows, and data infrastructure. We piloted the model for two months. After pilot completion, we reviewed patient data to understand the feasibility of the student "Help Desk" model. We utilized planning and pilot execution materials, as well as pilot data, to develop and discuss practical considerations. RESULTS: Design and implementation complemented ongoing social needs screening and referral to CBOs by center case managers. Patients were asked if they would accept telephone follow-up by volunteers two and four weeks after the clinic visit. Of 61 patients screened, 29 patients were referred for follow-up. Ninety percent were reached at least once during the follow-up period, and 48% of patients referred reported connecting to at least one CBO. Only 27% of patients required escalation back to case managers, and no emergency escalation was needed for any patients. Students, faculty advisors, and community health center frontline staff and leadership supported the scale up and continuation of the "Help Desk" model at the community health center. DISCUSSION: Successful implementation required multi-sectoral collaboration, well-defined scope of practice, and data interoperability. Student volunteers are untapped resources to support integrated health and social care.

Addressing the Social Determinants of Health During the COVID-19 Pandemic: Ensuring Equity, Quality, and Sustainability.

The COVID-19 pandemic has highlighted the importance of social determinants of health in affecting health outcomes. Populations with high social risk are disproportionately impacted by the virus and its economic consequences. Primary care practices have a unique opportunity to implement interventions to mitigate their patients' unmet social needs, such as food and income insecurity. In this commentary, we outline key considerations for clinics implementing programs that identify and address patients' social needs in a way that promotes equity, quality, and sustainability. We provide examples from our own experience at a federally qualified health center.