Health-Related Social Needs – The case for Philadelphia

Philadelphia routinely ranks lowest among the large cities in most domains of health-related social needs (HRSN). Prevalent health inequity also indicates an overwhelming need for solutions. The good news is that Philadelphia is well positioned to create a collaborative, multi-domain strategy to address HRSN, including systemic disparities that create HRSN.

• We have a strong contingent of top tier medical and education institutions that incorporate HRSN support in practice and are engaged in solution-focused research.

• The city is a sustainable business corridor for major industry and supports small businesses with initiatives such as the newly announced Catalyst Fund.

• Several civil society and community-based organizations (CBO) are actively providing these essential services – such as food, housing, and education support for children – daily with a commitment to drive permanent change.

• There are already collaborative efforts underway, which is promising because a sustainable solution will necessarily require a coordinated, multifaceted approach.

Current efforts and their impact

Housing instability/homelessness is a key driver of wellbeing and health equity and related to other drivers of wellbeing. Several states already require Managed Care Organizations (MCOs) to explicitly address this issue in their care models or community reinvestment strategies. Pennsylvania is one of the states uses a managed care model and delivers healthcare exclusively through a select group of MCOs. In several states, MCOs provide direct case management for homelessness and housing through housing coordinators, coordinate with housing agencies to provide permanent supportive housing, and invest after-tax profits to address housing instability. At least 16 states, including Pennsylvania, require Medicaid contractors to screen for housing instability. Initial impact from several states including New York, Illinois, and Oregon, with partnership between MCOs and housing providers, showed reduction in Medicaid and emergency room visits and costs.

Another popular model is community care hubs (CCH) – entities that support a network of CBOs that provide services that address health-related social needs by centralizing administrative and operational functions through federal social program funding. The US Department of Health and Human Services recognizes the value of and promotes the creation and evaluation of this strategy as a sustainable model for health and social care coordination. In addition to bringing efficiencies into the process, CCHs maximize the ability to provide coordinated care with shared information, intentional collaboration and planning, and leveraging each other’s trusted partners. They also have operational advantages in the form of comprehensive funding strategies and shared referral and technology platforms. While CCHs focus on individual needs, they have the ability to collaborate with public health departments to stay aligned with their priorities and strategies.

For example, an integrated network in western New York (WNYICC) connects 30 organizations across mental health, health care, food and nutrition, and social services to address specific health-related needs by closing gaps in care and improving patients’ participation in their own health care. Direction Home in Ohio is another statewide CCH that provides community-based, in-home health and prevention services to support independent living among older citizens and those with disabilities.

Federal support for managed care

Medicaid has several funding mechanisms for health systems and MCOs that provide comprehensive services that include medical and HRSN support. They include waivers for community for home-based services and to test new approaches and services, CHIP health services initiatives, and in-lieu of services and settings (ILOS) – which allows for alternates to traditional Medicaid services and settings.

Medicaid’s section 1115 demonstrations are opportunities for states to develop new and innovative programs to further the objectives of Centers for Medicare and Medicaid Services (CMS) to improve health. Almost every state has at least one approved program under the 1115 waiver and 21 states have used it for HRSN waivers. Several of these HRSN demonstration projects are in the form of community care[MC11]  hubs, which includes WNYICC.

The PA Department of Human Services requires HRSN screening for all Medicaid recipients as the first step towards improving health and wellbeing. Pennsylvania’s 1115 waiver demonstration program, Keystone for Health, focuses on health-related social needs to prevent acute, expensive care and create better health. It has four components – reentry from correctional facilities, housing support, food and nutrition support, and multiyear continuous coverage for young children.

Opportunities in Philadelphia

Keystone for Health can serve as a starting point to develop a CCH in Philadelphia that serves a wider section of the population and potentially uses a place-based approach. Pilot standalone programs, and efforts in medical and educational institutions that embed HRSN directly or indirectly are currently being implemented. These include:

Integration of HRSN in medical care settings:  CHOP’s Food Pharmacy provides ongoing support for families of hospitalized children who face food insecurity by providing prepared meals, produce delivery and financial planning for six months. A separate pilot program also explored documenting HRSNs with a view to understanding how this information can be sensitively collected in a trusting environment and used to improve patient health while maintaining safety and privacy. The Children’s Hospital Association advocates screening for social drivers of health and for hospitals to build community partnerships to deliver appropriate supports and services. 

Engaging the school system: Recognizing the symbiotic relationship between health and emotional, behavioral, and academic wellbeing, BenePhilly services are offered in the School District of Philadelphia, with pilot funding from the American Academy of Pediatrics. Families of students can use this free service to enroll in public benefit programs to support gaps in health-related social needs such as health insurance, food assistance, heat and utilities.

Guaranteed Income: There are at least two pilot initiatives that provide guaranteed income as a way to tackle health disparities by empowering families to address basic social health needs. Initial results of the Guaranteed Resources Optimize Wellbeing, which provided cash benefits to E-TANF recipients for one year suggests positive impact on HRSN. Based on the idea that economic vulnerability contributes to poor maternal and infant health, current research is examining whether cash supports can improve health outcomes by closing the social safety net gap. The Philly Joy Bank is one such model that provides cash support from pregnancy through the child’s first year, along with home visits and other supports.

The need for innovative collaboration

Emerging revised guidelines and funding cuts from the federal government undermine and potentially pose legal challenges to many of the initiatives in Philadelphia and nationwide that are focused addressing needs to improve wellbeing and achieving health equity. While there will be restrictions around gender and race-based strategies, alternate approaches, such as place-based community hubs can still address structural inequities in health related social needs to achieve health equity.

There is an increased need for partnership across public and private institutions, and community-based organizations and funders. Solutions will require innovative collaboration models that are centered around community health and informed by community needs. It will require existing collaborations to push the envelope further, and funders to step in. Hygieia Consulting and others have already begun the work of facilitating engagement and exploring connections that can optimize the wealth of talent, systems, and resources in Philadelphia for improved and equitable health.

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