Accountable Health Communities Grant Cut Healthcare Utilization

By implementing a cross-sector community health program to address a communitywide social determinant of health, Reading Hospital, an Accountable Health Communities (AHC) model grantee, addressed food insecurity and reduced healthcare utilization.

In Reading, nearly 36 percent of households headed by folks who are 65 years and over receive Supplemental Nutrition Assistance Program (SNAP) benefits. Additionally, about 43,000 people within Berks county, where the hospital is located, are considered food insecure.

Specifically, researchers found that nearly 69 percent of respondents within the local community stated they worried about food access during the past 12 months.

To address the community health concern, the Centers for Medicare & Medicaid Services (CMS) awarded Reading Hospital $4.5 million to implement the Accountable Health Communities (AHC) model.

Specifically, the model examined how addressing health-related social needs can impact healthcare costs and utilization.

Under the AHC model, a consortium of clinical and community-based organizations was brought together to improve health outcomes and optimize community capacity.

“We focused on the gaps in community capacity to address SDOH needs that we thought we could close in the next couple of years,” Tanieka Mason, hospital director of health equity at Reading Hospital, said regarding the consortium, named the Community Connection Project (CCP).

The CCP launched focus groups performing outreach with community members through telephone surveys to further understand their challenges when navigating health and social services. Community members highlighted a lack of access to full-service supermarkets, leaving them to rely on lower-quality food from convenience stores.

Although dozens of food options were located across Berks country, the food options were not culturally relevant, increasing inequity for patients unfamiliar with the provided choices.

“If I go to the food pantry and they don’t have the foods I normally cook with, I’m going to be inclined to not take it,” Rick Olmos, COO of Centro Hispano, a non-profit serving the large Hispanic population in Berks County, said in the report. “And even if I take it, I don’t know what to do with it, and it ends up going bad and I throw it out.”

Alongside the CCP’s effort to increase food access, they also created a cross-sector referral platform to build a collaborative community network and streamline patient access to social services.

The study showed that among the nearly 750 patients with resolved food insecurity, emergency department (ED) visits decreased by 32 percent, hospital admissions declined by 32 percent, readmissions were reduced by 30 percent, and healthcare costs lowered by 31 percent.

Researchers stated that the study indicates the value collaboration between hospitals and community-based organizations brings to SDOH work.

“Access to fresh, healthy food was a serious gap in our community, and it was impacting other aspects of our residents’ health," said Desha Dickson, vice president of diversity, equity, inclusion, and community wellness at Tower Health. "I was thrilled to see all of these partners coming together to tackle this challenge, and the results speak for themselves. Addressing food insecurity has been a critical step in improving our community’s overall wellness."

This collaboration is the latest to address food insecurity through community collaboration.

A California-based study also found that cross-sector coalitions can directly improve health outcomes in urban communities of color. United for Health, a cross-sector community health coalition, used community-engaged approaches to improve food insecurity across five underserved communities in Los Angeles.

“Community-engaged approaches to nutrition-related disparities research can lead to highly effective, sustainable health improvements in diverse communities,” lead study author Denise Diaz Payán, PhD, MPP, said. “And one of the ways we can do that is by convening partners from different sectors to form a coalition that addresses these issues collaboratively and directly with impacted community members.”

The researchers found that maintaining a sense of mutual purpose, enhancing diversity, and increasing the availability of professional development opportunities were key strategies that contributed to the overall success of the food insecurity intervention.