Defining Success in Resolving Health-Related Social Needs
The U.S. healthcare system is increasingly testing programs to address patients’ social needs. Examples include large integrated delivery systems such as Kaiser Permanente and pilots funded through the Centers for Medicare and Medicaid Services (CMS) such as the Accountable Health Community (AHC) model and Comprehensive Primary Care Plus (CPC+) initiative. Within the next year, the number of patients and beneficiaries screened for social needs and referred to community services will jump from thousands to millions.
As we move toward a more person-centered and equitable healthcare system, the ongoing analysis of these and other related programs will shape our understanding of how such approaches affect the total cost of care, patterns of utilization, and health outcomes. Yet with all this experimentation and innovation, we lack a shared definitional framework of what success looks like in addressing social needs.
Overview of article
- This article describes the challenges and ways in which to define success in addressing social needs
- The lack of common definitions for interventions addressing social needs makes comparison across populations and interventions difficult, and it jeopardizes efforts to understand how such interventions impact overall value (e.g., cost, experience, and health outcomes)
- The CMS AHC model reflects this challenge. The goal of the AHC model is to “test whether systematically identifying and addressing the health-related social needs of community-dwelling beneficiaries, including those who are dually eligible [for both Medicare and Medicaid]…impacts total healthcare costs and inpatient and outpatient healthcare utilization. “Without clearly defining criteria for what such resolution means and committing to securing that information in a reliable way, the risk of misattribution and spurious findings is extremely high. By defining what resolution of a need means, CMS can increase the chances of generating more meaningful results that can be linked to cost and utilization, in addition to learning which implementation strategies are most successful at resolving beneficiaries’ need
- To ensure the successful evaluation of social needs programs in the AHC model and beyond, we advance 3 key principles: 1) Define success from the patient’s perspective; 2) Tailor success by social need domain (e.g., a measure of success for food insecurity may be 75% of patients secured sufficient healthy food); and 3) Define a range of success (e.g., understanding what it means to respond, partially respond, or not respond to treatment of depressive disorders requires definitions of success/progress across both biological and behavioral outcomes)