Healthcare providers across the U.S. are recognizing the building need to improve care for individuals with complex medical and social needs, such as those who suffer from homelessness, mental health issues, financial hardship, chronic disease, and lack of basic social supports. As a matter of costs, wellness, and safety, the challenge to provide effective care for these populations is a mounting pressure for communities.
On the front lines are Federally Qualified Health Centers (FQHC). These federally-funded, nonprofit health providers play a pivotal role in these efforts by providing care programs and services to medically underserved populations regardless of their ability to pay. According to Centers for Medicare and Medicaid Services (CMS), “Federally Qualified Health Centers include community health centers, migrant health centers, healthcare for the homeless health centers, public housing primary care centers, and health center programs.” These wide-ranging resources are often referred to as “safety net providers” to illustrate the key role they play in the healthcare system. FQHC’s impact and reach to high-needs individuals is unique and presents a significant opportunity to adopt innovative ways of improving care and reducing health costs.
One such innovation, The Protocol for Responding to and Assessing Patient’s Assets, Risks, and Experiences (PRAPARE) assessment, can vastly improve FQHC’s effect on vulnerable populations while reducing costs to the community. How is this to be achieved?
PRAPARE is a national organization that partners with health centers and other care providers to collect data on a patient’s social determinants of health (SDOH), looking at how to treat the person instead of simply reacting to emergencies. The data is collected using their research-backed assessment that includes a total of 16 social determinant measures such as housing stability, transportation, employment status, and social support, all of which contribute to the vulnerability and insecurity of those under the FQHC’s care. The goal of addressing and assessing SDOH is to shine a light on any previously unknown barriers that may hinder a patient’s well-being and to enable providers to evaluate, document, and integrate a patient’s social risks into a comprehensive care plan. This would empower FQHC to pool and coordinate community resources to look beyond the tip of the iceberg, go beyond the four walls of the doctor’s office, and address the root cause of their patients’ problems.
The tremendous value of integrating SDOH methods (e.g. PRAPARE’s assessment) into care programs can be seen in the ShelterCare Medical Recuperation program, a nonprofit human services organization based in Eugene, Oregon. ShelterCare, in partnership with local community health centers, local care organizations, and the local hospital, developed a medical respite program specifically aimed at addressing the SDOH for homeless individuals—quite often the demographic suffering from the greatest combination of unmet needs.
By integrating SDOH and connecting multiple community resources, the shared-purpose effort of their developed care network resulted in increased care effectiveness—to say nothing of the hospital savings of $1.26 million in 2014 alone. Even though ShelterCare’s medical respite program focuses solely on the homeless population, FQHC’s patients share many of the same challenges and barriers to wellness. The success of ShelterCare’s innovative program is a remarkable demonstration of the feasibility and value of care coordination integrated with SDOH.
When the focus in healthcare is shifted from responding to emergencies to addressing the social determinants of health—from treating symptoms to treating people—healthcare can move beyond traditional, inefficient models and begin to involve an entire community of resources. When individuals are not suffering from food insecurity or from undiagnosed and untreated behavioral health crises, and are matched with the resources to address their unique situations, the resources and costs of healthcare will not be nearly so strained, and as a result, the highest-needs population will be healthier and better able to get the resources they need when emergency strikes. As demonstrated by ShelterCare’s program, and many other innovating programs like it across the country, Federal Qualified Health Centers are well positioned to adopt a care coordination model that treats the specific medical and social needs of their patients, and ultimately move the model of community health forward.