by Luke Shulman

Medicaid, the federally financed but state-run insurance program for the poor, now covers 1 in 5 Americans nationwide. In seven states, the number is higher ranging from 24% to 29%. The increasing size and scope is starting to draw attention from government budget directors and policy wonks, but has not drawn the attention of new technology or innovation investment given the tremendous size and market potential.

The California Health Care Foundation (CHCF), a nonprofit grantmaking philanthropy based in Oakland, is trying to change that. They have just launched a coordinated effort to spur more technology and process innovation in their operations and served populations. The group just released their second market intelligence report, Addressing Social Factors in the Health Care Safety Net and it’s a must read for every person working in or around the Medicaid system.

We have highlighted the importance of social determinants of health (SDOH) on the blog before. The fact is that education, housing, income, family stability and transportation have more to do with a patient’s overall health than any of the care they receive. source. For every actor in the health care space, payer, hospital, or clinic, SDOH data can improve the effectiveness of clinical interventions but they also have a clear business imperative as summarized in the table below:

Business Imperative table source

Ok Now What

What can organizations do to use this information effectively?

CHCF lists three essential capabilities that I am going to expand upon below:

1. Get the Data

CHCF focuses on new ways to gather this data from patients at the point of care. There are limits to this approach. As CHCF cites, having a care-team member ask about these issues added nine minutes to the visit. “This burden was so disruptive that the clinic decided it was unsustainable.” Many clinics are easing this burden with kiosk or tablet based forms that can make it easier to collect this data and these tools play an important role but still rely on the patient already being present for their visit. CHCF cites another medical system that hired 100 community health staffers to assess non-medical needs. My back of the napkin math tells me that is almost a $1 Million investment over several years just collect this information. There is a better, faster cheaper way that serves as a starting point for engagement.

This is not how it works in other industries where you can’t afford to just wait for your customers to show up. You need to know who they are and what they need before they even arrive. Even as Medicaid moves into value-based payment systems, clinics and their payer partners are still waiting until they arrive before learning and engaging them.

There is oft-repeated comment that geography is destiny and just knowing a patient’s average can provide good proxy values for this patient. That data is readily available through amazing work by non-profits like County Health Rankings or from the US Census directly.

There are also commercial data sources, the same ones that have revolutionized retail product marketing that can be used to provide that missing whole-patient view. What’s more, they are available as soon as the customer, or patient, is known.

At Algorex Health, we provide a single platform that combines all of these sources purpose built to deliver insight on social determinants at the point of care.

Map Snippet Algorex Health Neighborhood Stress Map

2. Analyze Social Needs and Facilitate Hand-Offs

When a patient’s access to transportation is preventing them from attending prenatal appointments? When aircraft noise is waking a child each night?

How directly can clinics meet this need? There are some clinics that are piloting the use of ride-sharing in their appointment process but many of these social challenges need to be addressed by community experts.

By the way, that aircraft noise issue is no joke. In Boston where I live, families living in these corridors are eligible for free installation of noise abatement insulation and windows. The exact health effects I can’t say but over $150 Million has been spent over 20 years on the effort.

The fact is that medical clinics or hospitals aren’t equipped to handle all of these issues and must rely on community partners. CHCF highlights several collaborative initiatives that are trying to keep up to date lists of community resources each associated with a clear vocabulary of these needs they address.

3. Ensure Community Connectivity

Referrals out to these community partners have to be ‘two-way’. Clinics and providers need to know where these patients have been referred and whether those referrals are effective. Organizations need to tie the data from EHR, claims but also from the work that these partners are performing. One example that I recently saw presented was established linkage to EMS dispatch data so that callers could be referred to non-emergency services when they call. The Staten Island Heroin Overdose Prevention & Education (HOPE) program is achieving near double-digit reduction ER utilization and has received local acclaim.

Staten Island’s program was featured by the New York State Medicaid Redesign Team where you can see the slides.

Another example is Hennepin’s Health Medicaid delivery ACO, which is entering its fifth performance year. Now well documented in multiple sources, the core of the program was a lifestyle assessment that expanded beyond a medical history asking patients “How often do you have access to a telephone?” or “How often do you have access to transportation?”. This assessment helped determine the best channel to reach these members with some receiving regular phone calls others being referred to high-touch community case workers who could reach patients in jails, shelters, or wherever they could find them. That data from corrections, foster services, and local housing agencies is provided to Hennepin to close the loop.

These examples perfectly encapsulate CHCF’s call to action. That Medicaid innovators get actionable data that can be tailored to the specific context of patient’s and provider’s who are going to rely on it everyday.

Part of our mission, at Algorex Health, is to make this as easy as possible with prebuilt tools and data sources that can identify unstable housing or food insecurity with data integration needed to get it into the EHR or wherever it can be the most effective.

Check out all of CHCF’s “PRIMED” series at