Convener Model Helps Healthcare Providers Address Social Determinants of Health

A state-funded organization in New York builds partnerships between healthcare providers and social care providers.

A New York­–based organization is pioneering a novel approach to help healthcare providers address social determinants of health.

Social determinants of health (SDOH) such as housing, food security, and transportation can have a pivotal impact on the physical and mental health of patients. Through finding ways to address SDOH, healthcare organizations can help their patients in profound ways beyond the traditional provision of medical services.

Troy, New York­–based Alliance for Better Health is pursuing a new model to address SDOH. The state-funded organization is acting as a convener—playing the role of intermediary between healthcare providers, payers, and community-based organizations (CBOs). If the new model spreads nationwide, it would provide an alternative SDOH approach for healthcare providers, which have been either making direct investments in social needs services or establishing direct partnerships with CBOs.

"We are in the early stage of this model nationally. What has been great for us is that the health plans have agreed that there is value in addressing social determinants of health—they are just waiting to see how much value there is before they devote more resources," says Jacob Reider, MD, CEO of Alliance for Better Health.

How the convener SDOH model works

In Alliance for Better Health's convener model, healthcare providers do not make direct investments in social needs services or forge direct partnerships with CBOs, Reider says. A key element of Alliance for Better Health's model is a subsidiary of the organization, an independent practice association called Healthy Alliance IPA that has the regulatory authority to execute contracts with managed care plans on behalf of healthcare providers.

"The IPA is the solution. Our IPA, which has funding through the New York State Delivery System Reform Incentive Payment program, is focusing on the social needs and the medical providers are not part of that picture. Doctors are not the answer to address social determinants of health—the social network is the answer," he says.

Alliance for Better Health and Healthy Alliance IPA build partnerships between healthcare providers and social care providers, Reider says. "We are brokering these partnerships, helping with the referrals for social needs network activities, and building trust from end to end."

For healthcare providers, working with Alliance for Better Health to address SDOH has several advantages, including creation of an infrastructure for social need services ensuring that referrals to CBOs are timely and effective. 

Over the past 18 months, Alliance for Better Health and its IPA have focused on the Capital District of the State of New York. There have been two important steps to convening partnerships between healthcare providers and social care providers, he says.

1. Social care network: "The first thing you need to have is willing participants to provide services in communities. In our community, we started with food, housing, and transportation, which is not everything but it's a good start," Reider says.

He says the social care network is an indispensable building block, making a reference to a 1989 film. "It's like the Field of Dreams concept. We need to build these networks, and then the social determinants screening will happen, and the referrals will occur."

2. Technical infrastructure: Alliance for Better Health has developed an IT platform to manage referrals from healthcare providers to social care providers, Reider says.

"You need an information technology infrastructure, so that when you refer patients into a social needs network you don't have to know exactly where the patient needs to go. You just need to know the services that are necessary."

In addition to the platform, Reider says Alliance for Better Health also has a referral center. "The referral center takes the referrals for services, then our referral coordinators take those referral requests and get them to the facilities that can meet those requests."

He continues, "What happens with the information technology platform is it holds everyone accountable and it allows us to watch the referral workflow so that we know if people fall through the cracks."

The IT platform facilitates referrals, Reider says, adding that for the referral center to work efficiently, social care organizations and medical providers must be able to receive and send electronic referrals, otherwise the participants cannot "properly engage."

Role of payers and generating ROI

Payers play an essential role in Alliance for Better Health's convener model, he says.

"In general, healthcare providers don't bill a payer for a referral. The social care providers such as food pantries, homeless shelters, and transportation providers should bill the health plan. The reason they should bill payers is their services reduce the total cost of care—they diminish the likelihood that patients end up in a hospital or get readmitted to a hospital," Reider says.

Healthy Alliance IPA manages the billing process, he says. "The way we have found for social care providers to bill a payer is through an aggregator—we call it a trusted broker. To play this role, we created the independent practice association. The IPA aggregates the services of the social care providers and bills payers for those activities."

Healthy Alliance IPA has established contracts with three payers, including Schenectady, New York-based MVP Health Care. "Alliance for Better Health is sharing the cost with the health plans. Our goal over time is for them to own all of the costs because there is return on investment," Reider says.

Alliance for Better Health only has preliminary data indicating that its SDOH program is lowering total cost of care, but transportation has been shown to have an ROI impact, he says.

"Medicaid pays for transportation to and from medical appointments, but it doesn't pay for things like trips to a pharmacy or social services, which we do pay for. We have found a positive correlation between reduced emergency department visits and free rides to Narcotics Anonymous. That speaks to the value of NA—in the context of the opioid epidemic, it is important," Reider says.