Hospices seeking to build stronger relationships with other community-based organizations may be able to adapt some of the strategies that health systems and Accountable Care Organizations (ACOs) have implemented.
These community partnerships have become a key strategy to address social determinants of health, improve health equity, and educate the public about hospice and palliative care. The work done through these relationships can help patients stay in their homes and foster greater interest in hospice among the public.
But some providers may have a learning curve as they extend their missions beyond the traditional scope of clinical care and bereavement services, according to Rob Mechanic, executive director for the Institute for Accountable Care, speaking at a recent conference by the National Association of ACOs.
“Doing this work, frankly, is not what most of your organizations were built to do. You were built to deliver medical care. This is not something that you can do by yourself, you need partners from the community …” Mechanic said. “ You need them because, number one, they have deep roots in the community. They’ve been working in your communities for a long time. They know where the resources are. They’re trusted by the population that they serve.”
Knowing where and how to start has been a hurdle for some hospices as they develop and deploy targeted initiatives.
New York-based Mt. Sinai Health System has been expanding its home-based and palliative services, in part through its joint venture with the Amedisys Inc. (NASDAQ: AMED) subsidiary Contessa Health.
The health system has also worked during the past two years to establish an internal department to identify and address patients’ social determinants needs with community partnerships as an essential element.
“At a high level, our strategy is to reliably identify social needs, and then to identify social resources that go with them to establish a credentialed network of preferred community-based organizations to make closed-loop referrals through those organizations, track the impact and outcomes of the various programming and referrals, and then secure sustainable funding for partnerships,” Ashley Fitch, director of community partnerships for the Mt. Sinai Health System, said at the event. “And then ultimately, to scale our screening and resources and advocate for systematic change.”
Among the health system’s first steps was to develop a standardized [social determinants of health] assessment that evaluates patient needs. Social workers and care management professionals generally conduct these assessments, which are integrated into patients electronic health records (EHR).
Mt. Sinai also began including social determinants questionnaires within their online patient portal to foster additional communication, according to Fitch. When specific needs are identified, Mt. Sinai pursues relationships with organizations with the resources and expertise to address them.
To match the patient with the appropriate community partner, Mt. Sinai developed an online community resource guide, as well as a referral and data tracking platform that is also integrated into the EHR.
In addition to their own outreach, the health system opened an application process to vet prospective partners, reviewed by an internal committee. If the organizations were accepted into the network, they would undergo a contracting and onboarding process, with a focus on regular communication, program engagement, and compliance training.
“For the [community-based organization] network, we wanted to be able to have partners that we worked more closely with, and maybe just an organization that was listed on a platform that could provide reliable, high-quality services that would accept referrals from us, and that wanted to do some level of data sharing,” Fitch said.
Virginia-based Bay Aging likewise sought to form a collaborative with a range of community-based organizations with the capability to assist patients with nutrition, transportation, home modifications, and other social determinants.
This initiative included a significant component focused on care transitions, particularly between the facility-based and home settings, according to Kathy Vesley, president and CEO VAAA Cares and CEO of Bay Aging. The program benefited from the organizations’ ability to “blend and braid ” their own range of services with those of their partners.
“We train our health coaches, who are very similar to community health workers. They are working within our organization and working in these communities every day, but we train them provide the training for many evidence-based programs,” Vesley said at the conference . “We coordinate services. Every day, we coordinate transportation and nutrition. That’s what our bread and butter has been for 45 years, so you can’t go wrong with that.”
Some of these programs are funded by grants in Bay Aging’s home state of Virginia.
Addressing patients’ social needs through this collaboration made a substantial dent in hospital readmissions. Among Medicare beneficiaries, readmission rates dropped to less than 9%, down from 23.4%. For Medicare patients, readmissions fell to 7.1% from 25%.
“You can understand why these types of data are what can drive people to make decisions and help them trust community-based organizations, and — as a bottom line — what I’m talking about is moving away from the hospital-centric care to a larger continuum of care where folks can go home and get long-term community supports in their home.”