Where people are

born

live

learn

work

play

worship

age

are Social Determinants of Health and significantly
affect people's overall health and quality of life

More health plans have prioritized their
beneficiaries' social health needs in recent years.

They've focused on four main areas:

SOCIAL ISOLATION

TRANSPORTATION

HOUSING

FOOD

But addressing seniors’ health-related
social needs remains a challenge.

DATA GAPS &
TECH LIMITATIONS

LACK OF INCENTIVES

SOCIAL SERVICES
DISCONNECT

… are factors that inhibit health systems from addressing
their older patients’ social needs

Where people are

born

live

learn

work

play

worship

age

are Social Determinants of Health and significantly
affect people's overall health and quality of life

More health plans have prioritized their
beneficiaries' social health needs in recent years.

They've focused on four main areas:

SOCIAL ISOLATION

TRANSPORTATION

HOUSING

FOOD

But addressing seniors’ health-related
social needs remains a challenge.

DATA GAPS &
TECH LIMITATIONS

LACK OF INCENTIVES

SOCIAL SERVICES
DISCONNECT

… are factors that inhibit health systems from addressing
their older patients’ social needs

In a study commissioned by the Better Medicare Alliance's
Center for Innovation in Medicare Advantage,
NORC at the University of Chicago analyzed the SDOH landscape

NORC explored best practices in 3 areas.

DATA SOURCES +
BENEFICIARY
ID

INTERVENTION

EVALUATION

NORC found 12 organizations with inspirational examples of care focused on social determinants of health.

DATA SOURCES & BENEFICIARY ID

Highlighted below are three best practices by organizations focusing on capturing individual-level data to better understand seniors’ needs and resources.

HEALTHIFY

BEST PRACTICE 1

Alleviating referral “friction”
with data analytics

Recently acquired digital health company Healthify scaled a platform for SDOH that identifies social needs, finds local services, and coordinates referrals in a network of community-based organizations.

The organizations can then confirm that the service was delivered, alleviating a major pain point for health plans and providers.

It's been a core tenant of our company:
What doesn't get integrated, doesn't get used. - Manik Bhat, CEO and Co-founder Source: BMA SDOH Policy Report

UNITEDHEALTHCARE

BEST PRACTICE 2

Partnering with doctors
to share social health data

UnitedHealthcare, the nation’s largest provider of Medicare Advantage plans, worked with the American Medical Association to propose 23 new Z codes in the International Classification of Diseases, used by doctors and health plans worldwide.

The new Z codes codify social factors that influence health, such as food insecurity, transportation, home safety, ability to pay for medication, and caregiver needs. UHC has trained providers on the new codes to encourage wider adoption.

1.3% of all Medicare beneficiaries
(Traditional FFS and MA)
whose social needs were tracked
with Z-Codes in 2018 Source: NORC Spotlight on Health

Humana

BEST PRACTICE 3

Creating an advanced data ecosystem

Humana, a health plan which serves 4.8 million Medicare Advantage beneficiaries nationwide, created an advanced data ecosystem to understand its beneficiaries’ social needs and prioritize outreach.

Humana also developed its own member social risk index representing five health-related social needs of focus, using an array of sources, including Humana’s wellness and home care programs, telephonic care management, and validated screeners such as the USDA Hunger Vital Sign and the UCLA Loneliness Scale. Individual-level data (vs. community data) are considered a “gold standard” to predicting clinical risk.

of Humana's MA members have at least one social need

Source: Humana

SCAN HEALTH PLAN

BEST PRACTICE 4

Assessing risk and tailoring
SDOH interventions

SCAN Health Plan, a non-profit serving more than 220,000 Medicare beneficiaries in California, performs health risk assessments on the majority of its beneficiaries and assigns them to care management tiers.

Across all tiers, beneficiaries are assessed for SDOH-related needs and provided support to address those needs, including caregiver support, transportation, or food benefits. SCAN also uses artificial intelligence to predict who may be at risk for preventable hospitalizations.

% of SCAN’s 50,000 caregivers
who report needing support

Source: SCAN Health Plan

INTERVENTION

Seven innovators are directly connecting Medicare Advantage beneficiaries to services that address their social needs.

SUMMACARE

BEST PRACTICE 5

Partnering with vendors to expand
supplemental benefits

SummaCare, a regional, provider-owned health plan in Akron, Ohio, heard from their case managers that beneficiaries were missing doctor appointments because they lacked transportation.

SummaCare responded by offering a new Medicare Advantage supplemental benefit: they worked with one of their valued, longtime partners to add door-to-door transportation for patients needing rides to appointments.

1,429 The number of rides SummaCare
provided its members in 2020 Source: SummaCare

meals on wheels america

BEST PRACTICE 6

Partnering to address hunger
and loneliness

Meals on Wheels, which supports more than 5,000 senior nutrition programs across the nation, has partnered with Medicare Advantage plans to provide extra services that address social isolation.

For example, Humana beneficiaries who score within a certain range on the UCLA Loneliness Scale are eligible for an extra visit each week from Meals on Wheels. This access gives care managers deeper insights into what’s happening with that individual and what they need.

9.1%

Americans 65 and over who were food insecure in 2019
(about 4.5 million)

Source: American Journal of Managed Care

NOWPOW

BEST PRACTICE 7

Deploying community health workers to coach and coordinate care

Technology company NowPow offers community resource referral software that connects health plans and providers with social service organizations.

For example, Horizon Blue Cross Blue Shield of New Jersey uses the technology in its Neighbors in Health program, which deploys community health workers to provide coaching and care coordination for beneficiaries with SDOH needs.

25% Reduction in Cost of Care The result that one Newark, N.J.
health system saw after using
Neighbors in Health. Source: BMA SDOH Policy Report

CHENMED

BEST PRACTICE 8

Employing social workers
internally to serve patients

ChenMed, a family-owned network of almost 100 primary care clinics, was founded by a physician who wanted to ensure that his lower-income patients never experienced the impersonal, uncoordinated care he experienced after his own cancer diagnosis.

ChenMed employs its own internal social workers to identify SDOH needs, share clinically relevant information across the care team, and intervene directly.

The minute something is identified,
[we] get social work involved to dig a little bit
deeper and try to see what's really going on. – Colleen Mourra, Associate Director of Population HealthSource: BMA SDOH Policy Report

Partners in care foundation

BEST PRACTICE 9

Bringing care coordination
services into the home

The Partners in Care Foundation is a California non-profit that brings SDOH services directly into individuals’ homes.

One program includes home visits, which places eyes and ears in the home to identify risk factors that may affect the person’s health or recovery. Addressing those risk factors up front drives proper recovery, re-stabilization, and effective use of health care.

“Is there food in the house? Is there mold and mildew from roof leaks?”

– June Simmons, President and CEO

Source: BMA SDOH Policy Report

AETNA

BEST PRACTICE 10

Innovative supplemental
benefits address SDOH

Aetna, a CVS Health company with more than 2.87 million Medicare Advantage beneficiaries, developed an enhanced care model for beneficiaries with congestive heart failure and offered supplemental SDOH benefits such as non-emergency medical transportation.

During the pandemic, Aetna doubled-down on its food and social isolation programs, delivering healthy meals to homes and offering companionship, car rides, and help with household chores and technology through a partnership with Papa.

of Americans 65+
are socially isolated.

Source: National Academies of
Sciences, Engineering, and Medicine

EVALUATION

Three organizations have found effective ways to track health outcomes and the ROI of direct interventions.

UNITE US

BEST PRACTICE 11

Building a strategy to
evaluate interventions

Tech company Unite Us connects health and social care providers.

Providers send and receive referrals through the Unite Us platform, which tracks whether services were delivered and gathers information about the outcome of the referral and services provided. Unite Us works with its partners to evaluate provider efficacy, timing of service delivery, and health outcomes.

Unite Us networks have positively resolved

Source: Unite Us

SUMMACARE

BEST PRACTICE 12

Working with Papa to innovate
and evaluate interventions

In 2020, SummaCare began working with Papa, a startup that fights social isolation by sending in younger “Papa Pals” to provide seniors companionship and help them with household chores and transportation.

Instead of canceling during the pandemic, they pivoted to virtual visits and helped close care gaps such as missed wellness visits, overdue mammograms and colon cancer screenings. The Papa partnership extended to evaluating program results using the UCLA Loneliness Scale and CDC Healthy Days measures.

less loneliness

reported by seniors involved
in the SummaCare/Papa pilot

Source: BMA SDOH Policy Report

SNP Alliance

BEST PRACTICE 13

Sharing SDOH lessons learned
across the industry

The SNP Alliance is a group of leading specialized managed care programs representing Medicare Advantage Special Needs Plans and Medicare-Medicaid Plans.

Its annual survey of SDOH efforts allows members to track industry progress on health-related social needs, and members share the lessons they’ve learned at SNP’s twice-a-year conferences. The SNP Alliance reported that it sees more sophistication in how plans understand SDOH as a result.

14 in 20 Plans reported housing instability / transience as a top observed arisk factor in 2020 Source: SNP Alliance

LOOKING FORWARD

test

As these case studies illustrate, Medicare Advantage plans are actively partnering with providers, community-based organizations, and technology companies to solve for social determinants of health.

The lessons they’ve learned are a roadmap for other health care providers and policymakers looking to adequately address seniors’ social health needs.

Where people are

More health plans have prioritized their beneficiaries' social health needs in recent years.

They've focused on four main areas:

But addressing seniors’ health-related social needs remains a challenge.

Where people are

More health plans have prioritized their beneficiaries' social health needs in recent years.

They've focused on four main areas:

But addressing seniors’ health-related social needs remains a challenge.

NORC explored best practices in 3 areas.

Alleviating referral “friction” with data analytics

Partnering with doctors to share social health data

Creating an advanced data ecosystem

Assessing risk and tailoring SDOH interventions

Partnering with vendors to expand supplemental benefits

Partnering to address hunger and loneliness

9.1%

Deploying community health workers to coach and coordinate care

Employing social workers internally to serve patients

Bringing care coordination services into the home

Innovative supplemental benefits address SDOH

of Americans 65+ are socially isolated.

Building a strategy to evaluate interventions

Unite Us networks have positively resolved

Working with Papa to innovate and evaluate interventions

less loneliness

Sharing SDOH lessons learned across the industry

LOOKING FORWARD

More health plans have prioritized their
beneficiaries' social health needs in recent years.

But addressing seniors’ health-related
social needs remains a challenge.

More health plans have prioritized their
beneficiaries' social health needs in recent years.

But addressing seniors’ health-related
social needs remains a challenge.

Alleviating referral “friction”
with data analytics

Partnering with doctors
to share social health data

Assessing risk and tailoring
SDOH interventions

Partnering with vendors to expand
supplemental benefits

Partnering to address hunger
and loneliness

Employing social workers
internally to serve patients

Bringing care coordination
services into the home

Innovative supplemental
benefits address SDOH

of Americans 65+
are socially isolated.

Building a strategy to
evaluate interventions

Working with Papa to innovate
and evaluate interventions

Sharing SDOH lessons learned
across the industry