Industrialized nations spending more on social services than health care achieve better health outcomes, according to a recent report from the National Academies of Science, Engineering, and Medicine. The study, Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health, made a case for upfront spending on social services to reduce medical costs.[i]
Specifically, the U.S spends a dollar in healthcare costs for every 90 cents spent on social services. In contrast, other industrialized nations spend two dollars on social services for every one dollar outlay on direct healthcare costs. The findings are supported by a 2018 published in The Journal of Social Work in Health Care predicted that integrated care “may be leveraged to improve population health across the life course.”[ii] Specifically, the article found:
– Social worker-led management has a positive impact on hospital readmission rates, length of stay, and costs for inpatient super-utilizers.
– Social worker coordination of complex health services is critical for populations with chronic, complex conditions.
– Social workers are vital in partnering with primary care providers in a pediatric setting.
– Social workers are positioned to deploy comprehensive and integrated services to address the physical and social determinants of health (SDoH).
A 2016 white paper by the Woodrow Wilson School of Public & International Affairs at Princeton University laid out specific strategies for social service integration.[iii] The analysis concluded that policymakers need to bridge the gap between social services and health care delivery impacted by SDOH factors. Such SDoH influence includes factors related to economic stability, housing, education, relationships, neighborhood, and other environmental influences such as domestic violence.
“Efforts that stop with health care delivery miss opportunities to make significant improvements for individuals, particularly the most vulnerable, and their community,” the authors wrote.
Six Strategies to integrate social and health services
The findings cited six potential integration strategy categories based on state examples cited in their paper. These include: shared governance: financing and payment models; integration assessments and care teams; data linkages; procurement and grant funding efforts; and performance and quality metrics. The strategy list was compiled from several state initiatives, including:
Shared Governance: Oregon and Washington implemented programs to create representation from a cross-section of decision makers and stakeholders. The resulting collaboration helped bridge disparate and service delivery structures between health and social service systems at the state and local levels. For example, Washington state provided financial support and technical assistance to nine regional Accountable Communities of Health to improve health in the regions. The effort included participation from community partners such as health care, public health, and social service providers.
Financing and Payments Models: Virginia and Vermont are working on solutions to federal funding levels with “blended” and “braided” arrangements. Blended funding combines budgets into one source with one combined tracking requirement (as opposed to tracking for each source). Braided funding also combines funding sources, but does require separate tracking. For example, in Virginia, the state has been combining funding from the Department of Social Services, Juvenile Justice, Education. And Mental Health agencies for the past 20 years. This allows the system to address health-social issues of high needs, low-income, and at-risk children and their families.
Integrated Assessment and Care Teams: Medical and social services providers are working together in Minnesota and Oregon to align services for better outcomes and cost reduction. In Minnesota, for example, the Hennepin County Health Department uses a screening tool that considers social issues in coordination with medical screenings. In Willamette Valley, OR, the Early Learning Hub developed a portal to share developmental screening results from school, homes, and other settings with medical providers.
Data Linkages: Public agencies in Michigan and Washington at the state and local levels are expanding the collection and use of data to support and enhance social and health services integration. Michigan requires providers under contract in its Medicaid health contracts to collect SDoH information and to develop a performance metric related to addressing such factors.
Procurement and Grant Funding Efforts: Leveraging social and health integration into service contracts and grants has been a strategy used in California and Michigan. California’s Whole Person Care pilot programs require that care be integrated for a cohort of Medi-Cal beneficiaries with poor health outcomes and who are high users of multiple systems. Michigan requires Medicaid contract providers to conduct home visit assessments and arrange such social needs as housing and heating support.
Performance and Quality Metrics: Vermont and Oregon require monitoring and reporting of performance measures to demonstrate the integration of social and medical services as part of contracting. Vermont’s Accountable Care Organization requires that statewide data on school completion and unemployment rates be linked to health services. Oregon, through its Child and Well-being Measures Workgroup, developed a 15-point dashboard to include childhood experiences and long-term well-being as part of health assessments.
“Low-income at-risk populations served by state health care purchasers often need – and may be eligible for – assistance with social services and supports to improve or maintain their health status,” concluded the study authors. “No single strategy or lever will suffice in forging these linkages, but working together, disparate public and private entities can design reimbursement and delivery systems better positioned to effectively address health-related social services needs and improve population health.”