Clinicians and care providers have long known that patients with unmet social and economic needs have more barriers to getting the care they need. As researchers noted in a 2018 study published in The Permanente Journal noted, “Prioritizing one’s health can be difficult under the best of circumstances, but it can be so much harder when people struggle with so many more pressing issues—challenges such as affording a safe place to live, tenuous employment, difficulty paying for healthy food, [and] social isolation.”
In 2021, the Centers for Medicare and Medicaid Services (CMS) issued its first guidance for addressing these social determinants of health (SDoH) as part of the Children’s Health Insurance Program (CHIP). With the launch of ACO REACH in 2023, SDoH will now be an essential part of ACO models.
REACH ACOs must be able to collect and analyze SDoH data to provide more effective care to their Medicare beneficiaries, and report on that information for CMS. For many organizations, this will require new software tools that can effectively pull in data from the Area Deprivation Index (ADI), EHRs from key partners, surveys and assessments collected at the point of care, and other sources. Often this information is siloed and not easy to access or share with a broad care team.
In addition to SDoH, ACOs need tools to coordinate care and improve care management, particularly for higher-cost patients with chronic conditions. Comprehensive analytics insights are a good first step, but that information is only effective if you can translate it into actionable workflows for your nurse navigators and care managers. You also need a way to measure the effectiveness of outreach and intervention on patient outcomes.
Cedar Gate’s Population Health and Care Management application is purpose-built for SDoH data collection, analysis, and workflow management. It also helps your ACO design care coordination and care management efforts centered around health equity plans. The application connects seamlessly to our Enterprise Data Management solutions that pull in disparate data from 35 sources and normalizes it to create usable and actionable workflows for managing individual patient and patient population needs.
Contact us today to learn more about how our Population Health and Care Management solution can help you achieve ACO REACH goals.
