Managing Health-related Social Needs: The Prevention Imperative in an Accountable Health System

January 10th, 2017 | Viewpoint


In its Accountable Health Communities (AHC) Model, the Center for Medicare and Medicaid Studies (CMS) uses the term “health-related social needs” (HRSN) to describe health-harming conditions such as food insecurity and housing instability. The AHC model is intended to expand and improve effective and efficient connections between the healthcare and human services communities (aka “clinical-community linkages”). CMS is funding pilot initiatives, with plans for long-term implementation of systematic screening, navigation, and system alignment for HRSN to improve health outcomes and reduce healthcare costs.

Approaches to addressing health-related social needs—invoking this same language—are now being integrated into emerging Accountable Care Organization (ACO) designs. This attention to HRSN from health policy leadership is important recognition of social, economic, and environmental drivers of health that have been long overlooked.

As the field of evidence-based strategies to “treat” HRSN grows—as it surely will in the coming years—it is critical that healthcare and human services leaders embrace a prevention framework for HRSN-systems design, not an “emergency room” framework. The risks of designing the latter—an acute care model for HRSN—are very high. Given short-term measurement of return on investment, health reform’s prioritization of avoidable emergency department utilization, and cautiousness inspired by uncertainty about the Affordable Care Act, healthcare and human services leaders will be examining anew the direction and promise of the U.S. health system serving vulnerable populations.

That said, improving health and reducing the cost of health care will remain central to the future of healthcare delivery in the U.S. In order to get there, healthcare and human services systems should prioritize early identification and mitigation of HRSN, carried out by a workforce that is equipped to do so successfully. (This reference to “workforce” is flexible and embodies both healthcare-based staffing models and vendor relationships with human services agencies—practices that for a range of reasons will have to evolve and adapt within the four walls of the medical clinic regardless of whether that clinic “buys” or “builds” infrastructure to respond to HRSN).

A Prevention Approach

How would a prevention approach to screening and “treating” health-related social needs (HRSN) be operationalized?

Let’s take housing as an example. Many healthcare-based strategies to stabilize housing focus on patients who confront imminent displacement and homelessness because they cannot afford the rent. These certainly are acute situations with high stakes for health and safety. But an eviction notice does not materialize out of nowhere. Like some medical conditions and diseases, many health-related social needs have “courses” that involve increased acuity over time. This graphic illustrates the full course of housing instability based on non-payment of rent—starting with a household’s distorted income-to-rent ratio and concluding several steps (and often months) later with physical displacement and homelessness. (While the jargon in this graphic is Massachusetts-specific, the trajectory if fairly universal.)


One can see clearly the boundary at which a housing instability risk—being behind on the rent—converts into a formal court proceeding through which individuals and families often find themselves unrepresented by legal counsel and unsuccessful in maintaining their tenancy.



A person-centered, cost-sensitive system will focus resources to help people at the beginning of this housing insecurity cycle as opposed to the end of that cycle. The stakes—for individual and family health outcomes, for quality care, and for cost containment—are simply too high to default to another emergency room, crisis management approach for health-related social needs.

How can accountable care organizations and insurers successfully address housing instability before a patient is court-involved and on a fast path to eviction? Policy change is an obvious upstream answer, and there are exciting efforts underway to leverage Medicaid funding for housing. But health and human services leaders also should be focused on important health workforce development strategies—including new staffing models, revised job descriptions, and updated competencies and workflow design—to move the dial on HRSN in a preventive posture, improve health outcomes, and reduce healthcare costs.

MLPB is the nation’s founding medical-legal partnership (an approach that builds on earlier holistic innovation in the HIV&AIDS service provider community) and is on the front lines of HRSN system co-design with the HHS workforce. Our team is participating in a range of formal research, evaluation, and QI efforts that measure the impact of “high dose” care coordination/case management combined with “low dose” legal problem-solving support on case managers, social workers, community health workers, and family support staff. In a pediatrics-based randomized controlled trial, a version of this intervention (Project DULCE) produced lower emergency department visits, better adherence to preventive care, and accelerated access to concrete supports such as SNAP benefits and continuous utility service. In the geriatrics context, a three-year pilot of coordinated case management and legal problem-solving support resulted in a 94% overall rate of homelessness prevention for ~120 of the most medically complex, mentally ill, and socially isolated older adults in Eastern Massachusetts who faced housing instability.

If accountable care is to be accountable for all stakeholders in our healthcare and human services system (including individuals and families on whose lives and bodies HRSN play out), a prevention imperative must inform both design and implementation of HRSN framework, including how the care teams of the future are constituted and supported. MLPB is honored to partner with so many early adopters in this work.

This guest post is written by Samantha Morton.

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