Addressing Social Determinants Lowered ED Utilization in Medicare

Social Determinants Lowered ED Utilization

A CMS-run care delivery model focused on addressing social determinants of health has effectively identified higher cost and utilization patients while reducing potentially unnecessary emergency department (ED) visits, a new report shows.

The Accountable Health Communities (AHC) Model reduced hospital ED visits by 9 percent for Medicare fee-for-service beneficiaries screened for health-related social needs, including housing instability, food insecurity, and transportation difficulties, RTI International reported earlier this month.

The first evaluation report for the model also found a high acceptance of care navigation and some utilization reductions among the high-need population targeted by the AHC Model.

Launched in May 2017, the five-year AHC Model tests whether connecting Medicare and Medicaid beneficiaries to community resources can boost health outcomes and reduce costs by addressing health-related social needs, which are adverse social conditions that impact health and healthcare spending.

The CMS Innovation Center has tapped funded entities known as bridge organizations to implement the model in collaboration with clinical delivery sites, community service providers, state Medicaid agencies, and other community organizations. The 29 initial bridge organizations started beneficiary screening in 2018, with hospitals and health systems taking the lead with universal screening, referrals, and navigation.

Bridge organizations screened nearly 483,000 beneficiaries, according to the evaluation report. Of those beneficiaries, about 15 percent were eligible for navigation services.

Beneficiaries are eligible for navigation services via the AHC Model if they have one or more of the five core health-related social needs targeted by the model—housing instability, food insecurity, transportation problems, utility difficulties, and interpersonal violence—and self-reported having two or more ED visits in the 12 months before screening.

Navigation-eligible beneficiaries had more than three times as many ED visits and two times higher spending three years before screening compared to beneficiaries screened through the model who had at least one need but did not meet the ED utilization requirement, the report showed.

Additionally, these beneficiaries had consistently higher inpatient admissions and unplanned readmissions than beneficiaries who met only one criteria in each of the three years before AHC screening.

The AHC Model was effective at identifying high-cost, high-use beneficiaries and acceptance was high among eligible beneficiaries, researchers stated in the report.

However, the early findings showed limited success in resolving health-related social needs. Among the navigation-eligible beneficiaries who competed a year of navigation, for example, 14 percent had at least one health-related social need resolved whereas another 4 percent had been connected with a community service provider but had not resolved any health-related social needs.

Additionally, the navigation outcome was unknown for almost a third of those with a navigation case closed.

Factors resulting in low documented resolution rates included difficulties with data reporting, loss of contact with beneficiaries, difficulty managing large caseloads, a lack of transportation to needed services, and insufficient community resources, the report found.

Despite these challenges, the AHC Model holds promise for reducing ED use and potentially further utilization and expenditures across high-cost, high-use beneficiaries, researchers stated.

Bridge organizations could avoid total Medicare expenditures, overall inpatient admissions, and admissions for major chronic conditions like diabetes and hypertension through appropriate ambulatory care, the agency explained.

Researchers plan to conduct further evaluations to estimate the expenditure impact the model has on Medicaid beneficiaries, which comprise about three-quarters of the navigation-eligible population.

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