Accountable Health Communities: Addressing Social Needs

Ashley Linder*, A. Brianna Sheppard-Willis, PhD, MA
WVU Institute for Community and Rural Health, West Virginia University, Morgantown, WV 26506

Presentation Category: Health Sciences (Poster presentation)

Student’s Major: Biomedical Engineering

Purpose: The purpose of this study was to evaluate the Accountable Health Communities Model implementation at an Awardee organization in West Virginia. Methods: The Model requirements consisted of screening emergency room patients in-visit for core health-related social needs (housing stability and quality, utility needs, food security, transportation, and personal safety) and supplemental needs (physical and emotional disability). Patients were eligible to participate if they were considered community-dwelling Medicare, Medicaid, or CHIP beneficiaries. Beneficiaries who screened positive for one or more core needs and had visited the emergency room twice in the past twelve months were considered high-risk. 30% of the high-risk beneficiaries were randomized into the control group, 70% into the intervention group. The control group received a Community Resource Summary (CRS) containing personalized referrals to community resources. The intervention group was sent a CRS and contacted by a navigator who assisted them in addressing identified needs. Results: Of the 265 eligible beneficiaries screened from January 2019 to April 2020, 59 were considered high-risk. The most common need cited was reliable transportation. Lack of housing/poor housing conditions and food shortages were the next most common. At the end of this evaluation period, 58% of identified needs were resolved in navigation cases, 29% of cases remained open, 10% were unresolved, and 3% of needs were identified by clients who could not be reached. Conclusions: This implementation of the Accountable Health Communities Model successfully identified high-risk patients, allowing future studies to analyze the patterns of beneficiaries’ cited needs.

Funding: U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services

Program/mechanism supporting research/creative efforts: WVU's Research Apprenticeship Program (RAP) & accompanying HONR 297-level course and Partners in Health Network