How an ACO, FQHC Model Leveraged Social Determinants of Health

Community Care Cooperative’s (C3’s) unique accountable care organization (ACO) model enables population health management to overcome the social determinants of health needs of their patients.

Christina Severin, MPH, president and chief executive officer of C3 discussed her organization’s population health strategy and the role social determinants of health play in that strategy in a recent episode of Healthcare Strategies, an Xtelligent Healthcare Media podcast.

“We differentiate between social determinants of health and health-related social needs,” Severin said. “We consider social determinants of health to be largely driven by institutionalized racism and poverty.”

Poverty and institutional racism are often associated with health-related social needs but are on their own distinct. 

Meanwhile, health-related social needs are non-clinical factors that impact patient clinical outcomes.  A patient experiencing homelessness is more likely to be readmitted quickly if he does not have a stable home to recover in, Severin explained as an example of a health-related social need.

One of the biggest challenges to addressing patient health-related social needs is funding the services. Providers are reimbursed for clinical care, even though connecting a patient to housing could have a greater impact on his health than medical care.

“Healthcare organizations that have historically produced economic efficiencies with the price of the bundle of goods they’re serving have been under compensated in the healthcare system. Federally qualified health centers are an example of this,” Severin argued.

Federally qualified health centers (FQHCs) have 24 percent lower total spending compared to patients receiving care in traditional primary care settings, according to research from the American Journal of Public Health.

Yet federally qualified health centers remain traditionally under-funded. To overcome this challenge and continue meeting the needs of their patient population, C3 submitted a proposal for an innovative ACO model.

The organization began as a conglomerate of nine federally qualified health centers that took on the full financial risk for patient care. C3’s financial and clinical outcomes for Medicaid patients overperformed the industry’s average outcomes in the first year of the contract, according to Severin.

Today, the organization has grown to include 19 FQHCs, making it Massachusetts’ largest Medicaid ACO.

A population-level examination of the health-related social needs of their patient population is enabling this success.

“If you took a public health view on the adverse impacts on chronic disease prevalence, morbidity, and life expectancy or mortality caused by living in poverty and or the experience of living with institutionalized racism, the findings are quite clear,” Severin concluded.

Listen to the full podcast to hear more details for turning social determinants of health data into action. And don’t forget to subscribe on iTunes, Spotify, or Google Podcasts.