Clinical Interventions Addressing Nonmedical Health Determinants in Medicaid Managed Care

Gottlieb LM, Garcia K, Wing H, Manchanda R
Source: Am J Manag Care
Publication Year: 2016
Patient Need Addressed: Financial insecurity, Food insecurity, Homelessness/housing, Transportation
Population Focus: Medicaid beneficiaries
Demographic Group: Urban
Intervention Type: Service redesign
Study Design: Review
Type of Literature: White
link: https://www.ncbi.nlm.nih.gov/pubmed/27266438
Abstract

OBJECTIVES:
We aimed to examine how interventions addressing social determinants of health (SDOH) have been adopted in the context of Medicaid managed care organizations (MMCOs), which serve a large proportion of patients with social and economic barriers to good health.

STUDY DESIGN:
We designed a systematic literature review to examine how SDOH interventions have been adopted in MMCOs.

METHODS:
The review included published articles from PubMed, Scopus, and Business Source databases, as well as review articles published in the gray literature and articles recommended by the study’s National Advisory Committee to identify interventions describing how MMCOs have invested in interventions that address patients’ SDOH. To be included in the review, an article had to describe an intervention that was based in the United States, be supported financially by an MMCO, focus on at least 1 SDOH, and be integrated into clinical care delivery.

RESULTS:
Twenty-five programs were identified in either commercial Medicaid or Medicaid-only MCOs that involved interventions integrated into clinical care and related to SDOH. Interventions varied widely in terms of target populations and target SDOH, and rarely included rigorous evaluations. The majority of programs described “case management services” that did not clearly distinguish between the delivery of medical and social interventions.

CONCLUSIONS:
Despite a growing interest in clinical interventions that address SDOH, little information is available in the published literature about the extent to which these interventions have been adopted by MMCOs, where they are likely to have early traction based both on capitated funding structures and the low-income populations served.

Insights Results

Overview of article

  • Medicaid managed care organizations (MMCOs) have increasing incentives to support interventions addressing the social needs of the low-income patients they serve because they serve individuals disproportionately affected by poverty and associated material deprivation, including food and housing insecurity, poor habitability, unsafe drinking water, social exclusion, low education levels, and unemployment. These conditions are known to reduce opportunities, limit choices, and threaten health
  • This study aimed to answer key questions about the implementation of social determinants of health (SDH) interventions through a systematic review. The goal of the systematic review was to identify published literature on clinical SDH interventions supported by MMCOs, the design and integration of these programs into healthcare delivery systems, and the determinants addressed and the target populations served by these programs
    Methods
  • The authors conducted a literature review examining how commercial and Medicaid-only MMCOs invest in interventions that address SDH for their patients or their network clinics’ patients. To be included in the review, an intervention or program had to meet the following inclusion criteria: 1) Based in the United States; 2) Financially supported by an MMCO; 3) Address at least 1 social determinant of health (housing, employment, food, education, safety, legal services, or transportation); and 4) Be integrated into the healthcare services delivery system. The definition of SDH varies in different contexts, so the search focused on SDH not typically addressed within the current healthcare delivery system. As a result, we excluded papers describing interventions related to health behaviors, including behaviors like tobacco use and physical activity. We also excluded papers describing interventions exclusively related to healthcare access
  • The authors developed an electronic search strategy to scan for references in the following databases: PubMed, Scopus, and Business Source. The search was limited to publications dated 2000 to 2014 and combined search terms using “AND” to capture at least 1 term from each of 3 major categories: SDH, healthcare settings, and intervention studies

Results

  • The electronic search strategy yielded 3975 unique references from PubMed, Scopus, and Business Source. A total of 111 articles were identified that included SDH interventions. These 111 articles were screened to determine whether they described interventions integrated into healthcare delivery systems and whether they were funded by MMCOs. Although many described serving Medicaid populations, only 13 articles described Medicaid managed care–supported interventions addressing SDH integrated within a clinical setting. The final data set included 25 interventions and programs described within those 13 articles
  • The review revealed several instances of case management programs for high-risk patient populations that include both social and medical components. This blended approach of social and medical case management may be an important target for scaling nonmedical health interventions within MMCOs
  • Specific intervention components include team-based approaches, which include case managers, social workers, community health workers, and other nonprofessional staff integrated into clinical teams
  • Overall, the 25 programs captured are geographically dispersed across the United States and across multiple MMCOs. The strong majority of programs identified target high healthcare–utilizing patients with specific chronic health conditions. Within target disease groups, programs frequently focus on specific racial or ethnic groups and low-income, homeless, or other specific sociodemographically defined populations. The existing literature provides no empirical data showing that MMCOs engage in universal social screening, needs assessments, or resource mobilization to address the social needs of all members. Based on our theoretical model, these findings suggest that MMCOs are making low, or at most, low to moderate investments in SDH interventions and are not yet systematically engaged in comprehensive SDH strategies to improve health or change healthcare utilization patterns of enrolled patients

Key takeaways/implications

  • Overall, the review found that MMCO investments are focused on social needs interventions for high healthcare utilizers and on members anticipated to become high utilizers based on specific health conditions, like hypertension and diabetes
  • In addition, few studies identified indicate that MMCOs are making organizational commitments to social screening or social interventions. The 25 program descriptions identified provide little detail on key program characteristics or MMCO decision-making processes that could help establish and disseminate best practices, such as the role of internal or external financial or other drivers or barriers to undertaking these interventions; any relevant community needs assessments on which interventions are based; or the role of executive sponsors, project owners, and key stakeholders in shaping the interventions. Similarly absent are descriptions of the return-on-investment calculations required to sustain these types of programs. This lack of information on organizational decision making, “readiness” assessments, and management processes, combined with the lack of rigorous evaluation of the impacts that these types of interventions have on health outcomes or health services, limits the capacity to understand and disseminate best practices in SDH-related interventions among MMCOs
  • Lastly, the review highlighted that more information is needed on MMCOs’ organizational decision making around nonmedical health interventions, the funding streams supporting these interventions, and their impacts on health outcomes and health services use
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