Q&A: Addressing social determinants of health in ACOs

August 14, 2019
Medicare Web

Q: What are some examples of programs that address social determinants of health (SDoH) in an Accountable Care Organization (ACO) setting?

A: ACOs have joined the masses focused on the SDoH by developing strong collaborative relationships with community resource providers. These groups of doctors, hospitals, and other healthcare providers voluntarily merge forces to provide coordinated care to their Medicare clients. ACOs were born through the Affordable Care Act and geared to capitalize on delivering high-quality care and spending healthcare dollars more wisely. In this way, ACOs and their strategic partners share in the in the savings achieved for the Medicare program.

Food insecurity is among the most common of the SDoH, and several model programs have been developed by ACOs in response. For example, Advocate Health Care launched two quality improvement initiatives in 2014 to counteract high hospitalization costs and advance value-based care.

  • Nutrition Care Program: Screened all patients upon admission using an electronic health record (EHR) workflow for malnutrition risk. Patients with a score equal to or greater than 2 on the malnutrition scoring model received an oral nutritional supplement within 24 to 48 hours.
  • Enhanced Nutrition Care Program: Patients with a score of 2 or more received a nutritional supplement within 24 hours of a hospital admission, nutrition education, and postdischarge instructions. They also received follow-up phone calls and coupons for retail oral nutritional supplements.

For more information, see The Social Determinants of Health: Case Management's Next Frontier.