Integrating Social Care into the Delivery of Health Care Moving Upstream to Improve the Nation's Health (2019) / Chapter Skim
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In considering how health care systems should address these social determinants, a number of important questions arise, including how to integrate social care (that is, services that address health-related social risk factors and social needs) into clinical practice and what kinds of 1A list of social determinants of health is included in Table 1-1 of this report.
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Specifically, the committee was asked to assess several factors: the approaches to social care integration that are currently being taken by health care providers and systems as well as any new or emerging approaches and opportunities; the current roles in such integration that are being taken on by different disciplines and organizations as well as new or emerging roles and types of providers; and the current and emerging efforts to design health care systems in such a way as to improve the nation's health and reduces health inequities. The committee also was asked to recommend how to expand social care services, to better coordinate roles for social care providers in interprofessional care teams in diverse health settings, and to optimize the effectiveness of social care services to improve health and health care.
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After a review of the evidence base on existing and emerging activities and opportunities for integrating social care into health care, the committee identified three key necessities for successful integration: an appropriately staffed and trained workforce, health information technology innovations, and new financing models. FIGURE S-1 Health care system activities that strengthen social care integration.
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The social care workers on the team may include nurses; physicians; social workers; community health workers; social service navigators, aides, assistants, and trained volunteers; home health aides; personal care aides; family caregivers; case managers; gerontologists; lawyers; and others. The committee found that • Effectively integrating social care into the delivery of health care requires effective interprofessional teams that include experts in social care.
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• For interprofessional teams to effectively address social care in the context of health care financing structures need to be aligned. Federal, state, and institutional barriers exist that may limit the adequate payment of social workers, gerontologists, and other social care workers.
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• With an increasing number of stakeholders sharing protected health information in order to coordinate care, data privacy and security remain challenging elements to manage. • Digital approaches to integrating social care into health care may increase existing health disparities by exacerbating the digital divide and by codifying bias within health systems.
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o Medicare's new supplemental benefits guidance to Medicare Advantage plans, made possible by the Creating High Quality Results and Outcomes Necessary to Improve Chronic Care Act of 2018 (CHRONIC Care Act) ,3 has created new opportunities to integrate social care into the health care of Medicare beneficiaries.
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• Quality and accountability o Definitions of health care services and conditions have his torically provided insufficient clarity and guidance for inte grating and addressing social care. o Population outcome measures for accountable entities, or ac countable care organizations, are numerous and highly vari able among the states.
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Health systems often use models of care requiring research, diagnostic codes, and technical special ization, which adds cost and complexity, with the ultimate result being effects on population health that are neutral or negative. o The administrative costs of social care providers could in crease as a result of efforts to integrate social care into a health care setting based on a medical model for consultation and referral.
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Those goals are to 1. Design health care delivery to integrate social care into health care, guided by the five health care system activities -- awareness, adjustment, assistance, alignment, and advocacy.
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Public and private payers should create standards for the reimbursement of social care, including assessment and such treatment as chronic care management, behavioral health integration, and transitional care management. Medicare/Medicaid payment advisory commissions should evaluate models in which social workers and other social care workers are reimbursement-eligible providers of social care services.
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Curricula should include evidence on the social determinants of health, protocols for working in interprofessional teams to address social needs in health care settings, interpersonal and organizational approaches to advancing health equity and decreasing health disparities, and competencies relating to collecting, securing, and using data and technology to facilitate social and health care integration. Schools of health professions should also engage social workers in instructional roles in order to model their participation in interprofessional teams and to provide information on social risk screening and social care resources and referrals.
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Recommendation 3d. The Federal Health Information Technology Coordinating Committee should facilitate data sharing at the community level across diverse domains such as health care, housing, and education so as to support social care and health care integration.
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State Medicaid agencies should use the flexibility described by the Centers for Medicare & Medicaid Services in the social care that Medicaid pays for as a covered service and make the opportunities and limitations associated with that flexibility clear to health plans and health care and social care service providers. Recommendation 4c.
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The Centers for Medicare & Medicaid Services, state Medicaid agencies, employers, and health plans should accelerate the movement to alternative payment models. The measurements aimed at assessing value in these models should include activity-based measures for social care integration and outcome measures that reflect social risk and protective factors.
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Recommendation 4l. States should pursue opportunities to align their hospital licensing requirements and public reporting with federal regulations regarding community benefits to ensure consistent obligations for health systems and to explicitly link their community benefits to the provision of social care.
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should develop a consensus on and use a common core of measures reflecting social risk and protective factors as well as key health and social outcome measures. These measures should not be limited to clinical or economic metrics, but should include patient-reported outcomes and other outcomes relevant to a range of stakeholders, including patients, families, caregivers, communities, social care organizations, health care organizations, and payers. The Agency for Healthcare Research and Quality should curate these measures in a publicly available item bank.
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