Source: Cleveland.com
By Brie Zeltner, The Plain Dealer
April 12, 2017
CLEVELAND, Ohio--Starting in about a year, United Way of Greater Cleveland will begin deploying its 2-1-1 specialists into seven area hospitals and health clinics to offer low-income patients screening for social service needs such as housing, food and transportation.
With a $4.5 million, five-year grant from the Centers for Medicare and Medicaid Services (CMS), United Way will partner with the Cleveland Clinic, MetroHealth, St. Vincent Charity Medical Center and Care Alliance Health Center to screen 75,000 patients a year and connect them to community resources.
It's part of a federally funded effort called Accountable Health Communities that's testing whether systematically screening for, identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries will reduce health care costs and use of the healthcare system.
"If you have people who have these social service needs -- lack of food or housing, or if you can't keep the lights on -- you can't really focus on healthcare outcomes," said Helen Forbes Fields, United Way vice president of community impact and general counsel. "If we address these things, hopefully we'll see a correlation with reduced healthcare costs."
2-1-1 is a free, confidential helpline and website supported by United Way affiliates nationwide that connects people by referral to health and human services, 24 hours a day, seven days a week. United Way of Greater Cleveland's help center answers more than 200,000 calls a year.
"A significant amount of a person's health is influenced by what happens outside the healthcare setting," said Dr. Brian Donley, Cleveland Clinic chief of staff. "That's why this is so important."
The service will be available to Medicare and Medicaid recipients who are residents of Cleveland, East Cleveland and Warrensville Heights, which have high poverty levels. Partner hospitals and clinics include:
Cleveland Clinic South Pointe Hospital;
MetroHealth's Main Campus, Broadway Health Center, Old Brooklyn Health Center and Thomas F. McCafferty Health Center;
St. Vincent Charity Medical Center;
Care Alliance Health Center's Central Neighborhood Clinic.
Over the next year, the partners will prepare for a May 2018 launch, said Diane Gatto, United Way's 2-1-1 director. Twelve 2-1-1 help center specialists will be dedicated to the program, with eight deployed to the clinic sites to meet with and screen high-risk patients face to face.
High-risk patients are those who have self-reported two or more emergency department visits in the past year.
CMS provided the screening questions, Gatto said. The same questions will be used by 31 other grantees nationwide, including Ohio's only other recipient, The Health Collaborative in Cincinnati.
The service is similar to a small pilot called Health Leads launched about a year ago in a few pediatric and prenatal care offices at University Hospitals. There, patients are connected to community resources by a staff of 24 student volunteers.
One of the big differences between that pilot program and the current CMS-funded grant is the scale, Gatto said. To receive funding, the hospitals had to collectively commit to screening 75,000 patients a year.
Hyland Software of Westlake will provide technical assistance to the partners to help integrate the social service questionnaire, referrals and follow-ups into a patient's electronic health record. Doctors will be able to see the information and use it in their care, Gatto said.
"Most of the time this type of work happens by referral," she said. "This is systematic screening. It's a tremendous effort and a credit to the clinical partners that they recognize the importance of these things to a person's wellness."
Most healthcare providers have long known these "unmet social needs" have a huge impact on the health of their patients, said Tracy Carter, MetroHealth's senior director of state and federal government relations.
"We know we can do better in supporting these populations," Carter said. MetroHealth had been working with United Way 2-1-1 to create a similar partnership before the CMS grant opportunity was announced.
"Right now, the social service is something we tend to do after the care delivery process," Carter said. "This makes sure that 2-1-1 and our social services are at the table from the start so that there's an increased chance of them getting the support they need."
A patient with asthma, for example, who lives in a home with mold, dust and cockroach allergens, will have fewer asthma attacks and hospitalizations if the home is healthy and safe, Carter said.
"Healthcare has been very focused on disease treatment, and this allows us to work on prevention and keeping people healthy so that they don't even need to come into the hospital," Donley said. "It's been frustrating when it's been difficult to get patients the resources they need. This is exciting for doctors and healthcare providers to have this opportunity."