A Massachusetts accountable care organization (ACO) is using social determinants of health to shift how Medicaid care is delivered and dollars are spent — an initiative to take Medicaid payments into the hands of the providers themselves.

Community Care Cooperative (C3), a group of 13 federally qualified health centers (FQHCs) operating as an ACO, is building a model of care and associated systems and processes that integrate social determinants of health and behavioral health services with primary care to optimize health outcomes, says Christina Severin, president and CEO. The companies also will deploy a common technology platform across C3 health centers with a goal of unifying data aggregation, clinical stratification, and coding and documentation workflows across C3’s FQHCs, which leverage a variety of electronic medical record platforms.

Massachusetts has long been at the forefront of innovative healthcare approaches, passing universal coverage in 2006. In November 2016, CMS and the state announced the renewal of Massachusetts’ 1115 waiver, paving the way for work to restructure Medicaid delivery to support the move to ACOs and allow for innovative ways of addressing the social determinants of health. Massachusetts is the first and only state embedding social determinants of health into risk scores, ensuring that health-related social needs are recognized for the true effect that they have on an individual’s cost of care.

According to a November 2016 study in the American Journal of Public Health, FQHCs provided a more cost-efficient setting for primary care for Medicaid patients. Those who received the majority of their primary care from FQHCs had lower use and spending than non-health center patients across all services, including 22% fewer visits and 24% lower total spending. (An abstract of the study is available online at: http://bit.ly/2ucDMhj.)

C3 is currently working with hospitals to reduce readmissions.

“The core philosophy of the program is that if we can lay eyes on physicians and caregivers while the patient is in a hospital bed, and establish a relationship, we can reduce readmissions by being part of discharge planning. We can ensure that the discharge planning includes the least restrictive community setting, for example,” Severin says. “If the patient could be discharged to home but there are social determinants that might prevent that from happening, we can send someone to the patient’s home for an assessment, provide an air conditioner, remove rugs, and make any other needed accommodations. We might also make the assessment that the home isn’t the best option for this patient and bring that recommendation back to the hospital.”

In addition, the C3 representative should be at the hospital bedside to establish a relationship before discharge, Severin says. That makes home visits more productive when the patient recognizes the representative and understands why he or she is visiting. The C3 representative generally works with the discharged patient for about 30 days, making sure basic needs are met and follow-up care is taking place as expected, and then assesses the next step for the patient. That might be inclusion in a general population health program, a more intensive population health program, or a specific program for an issue like diabetes or depression.

C3 also is looking at working with EDs to address patients who are admitted only because emergency staff determine the patient has no safe environment to which he or she can be discharged.

“Emergency department nurses responded so well when we suggested helping with these patients, because they admit them, appropriately, when they don’t know if the patient has a home to go to, or whether they’re going to be hungry at home or without any means for seeking follow-up care,” Severin says. “We can help by making the necessary arrangements for the patient, taking that burden off the staff of the emergency department and spending money if we have to. We can get that person a refrigerator full of food, put them in an Uber to get them to the clinic — whatever it takes to get that person discharged in a safe and appropriate way.”

Addressing social determinants of health is a key way that hospitals benefit from an ACO relationship, Severin says.

“You add value when patients and families feel supported throughout the patient experience, and particularly post-discharge, which can be a really stressful time for patients and caregivers. Once you establish a meeting of the minds between an ACO and the hospital, that opens opportunities to do the programmatic work,” Severin says. “The idea of doing this kind of intervention for every patient in the hospital is daunting, but that’s not what has to be done. You can stratify inpatients so that you’re focusing on those cases most likely to result in a readmission, the patients where the data analytics tell us there is the most risk and the most value.”