A new report from the National Academies of Sciences, Engineering, and Medicine identifies six promising practices to improve health care for individuals with social risk factors for poor health care outcomes, such as people who are in a low socio-economic position, reside in disadvantaged neighborhoods, identify as a racial or ethnic minority, or possess limited health literacy. The committee that carried out the study and wrote the report said it is possible to deliver high-quality care to these populations. With adequate resources, providers can feasibly respond to incentives to deliver high-quality and good-value care to socially at-risk populations. This is the second report in a series of five1 that addresses social risk factors that affect the health care outcomes of Medicare beneficiaries and ways to account for these factors in Medicare payment programs.
The committee reviewed case studies and published literature to identify common themes of what high-quality health systems that serve socially at-risk populations do to achieve good health outcomes for their patients.
The common themes describe practices delivered within a system of collaborating partners, mainly composed of medical providers, partnering social service agencies, public health agencies, and community organizations. Six system practices that provide a continuous process to improve health care for these at-risk populations are:
- Commitment to health equity. Value and promote health equity and hold yourself accountable.
- Data and measurement. Understand your population’s health, risk factors, and patterns of care.
- Comprehensive needs assessment. Identify, anticipate, and respond to clinical and social needs.
- Collaborative partnerships. Collaborate within and across provider teams and service sectors to deliver care.
- Care continuity. Plan care and transitions in care to prepare for patients’ changing clinical and social needs.
- Engaging patients in their care. Design individualized care to promote the health of individuals in the community setting.
Both the availability of resources and alignment of financial incentives are prerequisites for the adoption and sustainability of these practices, the committee said. Resources can provide the incentives to reduce disparities by targeting interventions at socially at-risk populations and incorporating equitable care and outcomes into accountability processes. Interventions that improve health and quality of care or reduce utilization and cost are only sustainable if the provider’s profits are higher with the intervention than without. Most of the efforts presented by the committee involve fixed costs and potentially shared benefits across multiple payers, so their economic feasibility depends on Medicare’s payment system and that of other payers. Environments in which a greater share of a provider’s revenue derives from payments related to health outcomes will make it more sustainable for them to invest in programs that improve quality and reduce cost.