There is a growing body of research indicating that there is a direct relationship between the social determinants of health, such as housing, transportation, and food insecurity, with the physical and mental health of individuals. However, the health care system and the social services sector still tend to operate in siloes. The result, often, is that overburdened primary health care providers try to address both medical needs and social barriers to care without having the tools or time needed to coordinate with or follow up with social service organizations. Meanwhile, social service agencies see unmet health needs, and all the sectors face administrative and budgetary obstacles if they do try to coordinate services.
The lack of coordination between these systems leaves the individuals in need of such services with the burden and confusion of navigating different systems on their own – in addition to age-related factors, language, disability, and other barriers. Moreover, complex health, social service, housing and other systems generally do not work well together to provide assistance that is coordinated and dependable over time. These navigation and coordination problems frequently lead to a higher incidence of emergency department visits, hospitalizations, and increased costs of care, and often blunts the impact of social services.
One of the challenges in addressing these problems is to find ways of overcoming the “wrong pockets problem.” This problem arises when one institution or sector gains most from a collaboration, such as reduced costs for Medicaid, but it is another sector, for instance a housing authority or social service agency, that would face most of the organizational, data-sharing, and service costs. One of the ways to deal with this is for a higher level of government to catalyze and/or finance at least part of the cost and other obstacles to collaboration.
What the LINC to Address Social Needs Act would do
The Leveraging Integrated Networks in Communities (LINC) to Address Social Needs Act (S.509) will award grants to states to develop or enhance collaboration between health care organizations and social service sectors. The legislation, co-sponsored by Senators Dan Sullivan (R-AK) and Chris Murphy (D-CT), authorizes $150 million in funding for states that would be awarded by the Secretary of Health and Human Services to develop or enhance cross-sector data sharing capabilities and “closed loop referral systems,” which leverage technology-based community service inventories to support identified health-related social needs of individuals. The objective is to address longstanding challenges in communication on referrals, capacity management, and outcome tracking across sectors. The funding approach would allow states to pursue a variety of approaches to fit local circumstances and foster innovation. The money provided by the LINC Act would help states to do such things as:
- Leverage community resources and strengths to create a support framework for food, housing, job training, and other social needs by connecting both the health care system and social service sector;
- Establish or enhance technology platforms to enable coordination of public and private social service providers and health care providers across the state (recognizing privacy concerns with such sharing, the legislation directs networks to ensure that “appropriate privacy, security, protections are in place, in accordance with applicable Federal and State privacy laws.”);
- Improve data sharing amongst community organizations and health care providers to measure the impact needed social interventions have and subsequently prioritize resource allocation through data evaluation;
- Create sustainable funding models to enable long-term accessibility of the community integration network to enhance cross-sector collaboration.
Some examples of approaches that LINC might help replicate or expand
Community resource referral platforms such as Aunt Bertha, UniteUs, or Healthify coordinate referrals and the provision of social services — data that otherwise may not necessarily loop back to the health care system. Some states, however, have established their own public-private partnership programs to enhance social service delivery and data sharing with the health system. Examples of the types of approaches that might be expanded or replicated if LINC funds became available include:
North Carolina: NCCare360
NCCare360 is a state-wide coordinated care network comprised of a statewide resource directory with a dedicated call center, a data repository to ingrate and share resource data, and a statewide shared technology platform that enables North Carolina’s health care providers and community-based organizations to communicate with each other. The program is a public-private partnership between United Way of North Carolina and the Foundation for Health Leadership and Innovation. Available in every county of North Carolina, as of June 2020 it has onboarded 2,200 community-based service organizations throughout the State.
Washington State: Accountable Communities of Health
Accountable Communities of Health (ACH) are independent and region-based coalitions, started as part of Washington’s Medicaid Transformation project – itself a product of the federal government’s ACH program. ACHs work with communities throughout the State of Washington on local/regional social needs and health care-related programs. ACHs are comprised of local health and long-term care providers, health insurance companies/managed care organizations, public health departments, school districts, criminal justice agencies, nonprofit social service agencies, legal services organizations, tribes, and philanthropic agencies. They collaborate with the state to implement health-related projects and provide guidance to state agencies to address health/social needs within specific regions to improve overall social/health care coordination and gaps to care.
Arizona: Whole Person Care Initiative (WPCI)
In February 2021, Arizona selected NowPow to create a closed-loop referral system for the whole state in order to address social determinants of health needs for Arizonians. This vendor will connect both health care and community service providers on a single statewide technology platform to enable better communication, easier access to social services, and provide confirmation to the health system when a patient utilizes a social service.
Improving the coordination of health care and other services is essential to good health and the economic mobility for individuals and communities. Many strategies are needed to address poor coordination and collaboration. Solving at least part of the wrong pockets problem at the local level through federal financing assistance for integrated data system