SDOH: The Next Frontier? Part 2: Referring to Social Services and Supports

Given research that shows the overwhelming influence of social determinants of health (SDOH) on positive health outcomes, addressing these factors has become key. Many managed care organizations (MCOs), providers, and policymakers see addressing SDOHs as an opportunity to improve an individual’s health and well-being, improve their health care experience, and simultaneously manage rising health care costs. States are more frequently requiring their managed care partners to screen for social needs and coordinate referrals and/or linkages to services and supports to address the identified needs.

Providing pathways to community services.

The scope and complexity of referral/care coordination platforms can range from a simple excel spreadsheet kept at the care coordinator level to fully automated and integrated systems that consolidate local services and connect members to local organizations.

Historically, many local providers have relied on home-grown databases of local community-based organizations as a referral “network.” While valuable in identifying local resources, these basic solutions tend to rely on care coordinators and/or the member to make the connection with the local community provider. Determining if the connection was made or if a specific outcome was achieved using these basic platforms requires a manual process of connecting directly with local community providers to gather that data. 

More recently, many MCOs and providers utilize third-party stand-alone SDOH data and referral platforms like Healthify and UniteUs to connect members to community-based services and support. These digital platforms have the capability to collect information on local social service providers across multiple domains including but not limited to housing, food, transportation, legal services, and workforce and job supports.

Newer referral/care coordination solutions also allow for cross referrals between health care providers and community-based organizations. For example, if a MCO assesses that a member is in need of housing they can make a direct referral to a community-based organization (CBO) that specializes in housing services. If the housing organization identifies other needs, such as food insecurity or the member’s goal of gaining employment, these systems allow for the housing specialist to make a direct referral to a food bank or a workforce development specialist. With the consent of the member (and per HIPAA regulations), health care providers and community-based organizations can see when additional services are added.

North Carolina implements referral platform.

North Carolina has moved aggressively in developing a standardized, statewide screening tool and aligned resource platform to address the SDOH needs of their population. NCCARE360 will be North Carolina’s resource database of community-based providers and will be open to all Prepaid Health Plans (PHPs or Medicaid MCOs), providers, and the public.

The statewide platform is a collaboration between the state’s 2-1-1 information referral system, UniteUs, Benefits Data Trust, and Expound Decisions Systems. North Carolina’s platform is unique in that it establishes a statewide resource directory of local social service providers and CBOs. As individuals and families work with PHPs, providers and even current CBOs, and new social needs or barriers are identified, NCCARE360 can be used to identify community agencies that offer needed services and supports, make a direct referral to these agencies, allow for cross referrals at the community level, and measure outcomes of community engagement.

Because of the platform’s ability to be used across the health and social service sectors, there is no need to make additional referrals once social needs or barriers are identified. If a housing agency realizes that a family is in need of food, NCCARE360 can connect them to the local food bank or the SNAP eligibility office. If a provider identifies a transportation need during a health visit, they can use NCCARE360 to connect them to local transportation services to meet their needs. This ability to leverage the platform across sectors, and having a centralized database of social service providers, will increase individual and family engagement with CBOs while better aligning the needs of individuals and families with the services offered by local CBOs.

As these efforts to align and integrate social services and health care take root, old challenges related to integrating the health care and social services systems continue to emerge while new opportunities to address the social determinants of health show promise for the long term. In the next post, we will discuss the challenges of this trend to focus on social determinants of health in the health care system and the opportunities to integrate the health and social services to ensure better health outcomes for individuals and families. 

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