Innovations in Community Health

Issues such as being exposed to toxic chemicals, lacking clean drinking water, and living in a food desert are not typically at the forefront of clinicians’ minds when developing care plans and educating their patients. However, researchers are finding greater evidence that such factors can be key determinants of people’s health. Given these developments, health plans and providers are increasingly seeking to address these factors to better promote health.

Earlier this year, CVS Health announced the roll-out of its new Building Healthier Communities initiative. This $100 million project is funded by CVS Health and the CVS Health and Aetna Foundations to better prioritize community health. Support for low-income and socially disadvantaged members will come from a partnership with Unite Us, a platform that coordinates access to social services for Medicaid and dual-eligible members within Aetna. Certain Aetna members will have access to a network of social care providers, helping to better empower control over any social and environmental circumstances that may impede health and well-being. These networks will be in select locations in KY, FL, and LA later in 2019.

Eleanor Health is the first provider of addiction and mental health services focused on long-term recovery and value-based care. It launched its first outpatient clinic in North Carolina in early September and plans to open at least 10 more within the next year to treat addiction as a chronic disease. Collaboration with Blue Cross and Blue Shield of North Carolina will help expand access to its services. Another example of an innovative collaboration involves the new Healthy Alliance Independent Practice Association (IPA) announced in August. This IPA receives payment from the managed care organization MVP Health Care and then covers services from 29 community-based organizations, such as a supportive housing center and food pantry. This partnership will involve provider referrals and will track patient outcomes to demonstrate its effectiveness in improving patient health.

Our Role

At Avalere Health, our expertise and access to robust data sets enable us to understand how certain factors like lack of access to healthy food and clean water can affect patient outcomes. Avalere’s Center for Healthcare Transformation has engaged in multiple projects to bring social determinants of health to the forefront of healthcare decision-making. The Malnutrition Quality Improvement Initiative works with more than 250 hospitals and clinics around the country to improve the quality of care provided to malnourished patients, ultimately improving outcomes for both patients and the system. As sites advance their engagements in quality improvement and their interests evolve, we support their sharing of best practices in integrating nutrition care (such as grocery delivery or follow-up visits with a registered dietitian) into discharge planning for malnourished patients and ensuring such care continues across transitions of care. Other work with the Robert Wood Johnson Foundation, Meals on Wheels America, and Aetna has deepened our insight into the obstacles faced by community-dwelling citizens in accessing necessary care or fundamentally living in health-promoting environments.

We look forward to continuing and expanding on this important work with more partners. For more information on how we assist our clients in evaluating their opportunities and risks in addressing social determinants of health and accessing nutrition care, please contact Kristi Mitchell.

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