Studies & Articles

The combination of social service access with comprehensive case management support was significant in driving the use of preventive services in a primary care setting while social service access alone was not.

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Researchers sought to understand if participants enrolled in Medicare Advantage plans who accessed social service referrals would be more likely to utilize fewer health service resources than those who do not access a social service referral. 

Among the 502 subjects in the sample population, 52% accessed a social service referral. Approximately 95% of accessed referrals included services such as food, housing, transportation, disease-specific support services, medical expense assistance, free cellphones, patient and family support services, as well as personal goods and services. Individuals who did not access a referral, subjects that accessed social services had a 36% reduction in inpatient length of stay (p=0.04). This reduction in inpatient length of stay resulted into $4,059 in cost savings in the year after the social service referral.

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The purpose of this study was to evaluate the effectiveness of the Facilitating the Community Health Improvement Process training in increasing the capacity of nongovernmental public health partners to serve as facilitators and supporters of community health improvement coalitions. Ten members of WellCare Advocacy and Community-Based Program teams (CommUnity Advocates) serving communities across the country were identified to participate in the pilot training group. They completed pre- and post-training surveys to evaluate knowledge of community health improvement process models and facilitation techniques, as well as qualitative interviews to assess use of training material 6 months after the training. Results of the project revealed successful use of content from the training, which enhanced the impact of nongovernmental public health partners as facilitators of community health improvement planning and implementation.

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An MCO-based social service referral program represents an alternative approach for coordinating a system’s capacity to link patient to community resources. In implementation a program design to help members address their unmet social needs, a new social support role was created – the CommUnity Liaison. Interviews revealed that CommUnity Liaisons mostly worked part time. Many CommUnity Liaisons were recruited through state vocational rehabilitation agencies, recruitment firms specializing in employment for people with disabilities and the MCO’s employment website. The ideal qualities of a CommUnity Liaison included being empathetic, engaging, and investigatory and having similar “lived experience” as participants. CommUnity Liaison utilized an extension software suite. The CommUnity Liaisons entered referral information into a dedicated “social service electronic health record” that was shared with clinical case managers. CommUnity Liaisons delivered referrals in 10 languages, including American Sign Language.

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Social health surveillance systems, that can identify social needs and connect people to community resource, may support medical and social care integration. Active social health surveillance uses screening tool to directly identify patient social needs at medical facilities. However, medical care providers may lack the time, training, and resources to effectively conduct social screenings or link patients to community resource providers. THis study compared self-identified social needs with inpatient readmissions within 30, 60, 90 and 180 days. After examining claims and social service referral data for more than 27,000 patients, researchers founds that nearly 70% of the population identified at least 1 social need resulting nearly 25,000 social service referrals. Results show that individuals with social needs have higher odds of 30-, 60-, 90- and 180-day inpatient readmission compared with individuals without a social need.

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This study evaluation the savings associated with a managed care organization’s call center-based social service referral program that aimed to assist participants address their social needs, such transportation, food/nutrition insecurity, etc. The program evaluation linked social service referral data with health care claims to analyze expenditures in 2 annual period, before and after their first social service referral. The study compare the change in mean health care spend. The study estimated the associated savings of social services, after controlling for group differences. The results showed a decrease in the second year mean for the group that reported all of their social needs meet was $2,443 (10%) greater than the decrease in the second year mean spend for the group who reported none of their social needs met, after controlling for group difference.

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In this report, KPMG and the Commonwealth Fund compiled information on several programs in order to create the foundation for needed data for a business case to invest in social care programs. Included in their study was a deep review of the CommUnity Health Investment Program, a 6-year program through which a managed care organization invested in community based social services organizations to exchange data on shared populations. Through this program individual enrolled with the managed care organization would be connected to community resources for their social needs to met. in a pre-post evaluation study, The study revealed a $3,200 per member per year (PMPY) savings on a $700 PMPY cost. The calculated return on investment was determined to be $3.47 for every $1 invested in the Center for CommUnity Impact (the center of excellence responsible for overseeing and administering the program).

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