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Uncovering and addressing disparities in health-related social needs, social needs screening and navigation: Using data to drive change

Dickey J, Behrens D, Ogbue C, Mohamed IS
Presentations from 2022 SIREN National Research Meeting: Racial Health Equity in Social Care

Uncovering and addressing disparities in health-related social needs, social needs screening and navigation: Using data to drive change [PDF]

Speakers: Jennifer Dickey (Mathematica), Dan Behrens (Allina Health), Christine Ogbue (CMS/CMMI), Imam Sharif Mohamed (Open Path Resources)


The Accountable Health Communities Model (AHC) from the Centers for Medicare and Medicaid Services (CMS) tests whether addressing Medicare and Medicaid beneficiaries’ health-related social needs (HRSNs) through screening, referral, and navigation services will reduce health care costs and use. The model addresses the gap between clinical care and community services and, over five years, has helped its participants test service delivery approaches meant to link beneficiaries with community services that address their HRSNs (that is, needs related to housing, food, utilities, interpersonal violence, and transportation). The session shares model-wide racial and ethnic evaluation findings regarding screening and navigation and ways to address them, highlights how one participant and its partners tried to reduce bias and discrimination in social needs screening, and explains how lessons from that experience inform the organization’s efforts to engage community partners to drive health equity. Presenter 1: The AHC lead project officer summarized the AHC Model design and describe the mixed methods analysis employed to assess characteristics associated with HRSN screening, navigation eligibility, and racial ethnic minorities. Early analysis shows that racial and ethnic minorities are overrepresented in the navigation-eligible population. She will share qualitative findings that explain possible reasons for disparities in screening and needs resolution. Presenter 2: A staff member from Allina Health System shared how its data revealed that despite Black, Somali, and Latinx patients having twice the need for HRSN services, they were offered HRSN screening at 10% lower rates than White, non-Hispanic patients who spoke English as their first language. Their team used these data as a launching point to engage with an equity team for process improvement, including conducting focus groups and interviewing clinic staff to understand barriers to HRSN screening and designing training to address these barriers. The team took lessons from the AHC Model to inform its system-wide efforts to effectively engage community partners and members to drive health equity. He will also describe the coalition of providers, payers, Minnesota Medicaid, and community members are developing a community-wide approach to connect resources and use referral technology platforms. Presenter 3: A staff member from Open Path Resources (OPR), a community-based organization serving local East African immigrant families and community members, described OPR’s partnership with Allina to address disparities in colorectal cancer screening. Together, they created a multipronged intervention: OPR developed and provided cultural awareness training for health care providers and is developing tools to help frontline staff provide culturally responsive care. Allina employs a community health worker to bridge access and communication gaps between community members and providers and help patients with HRSNs. The staff member will describe OPR’s experience partnering with a large health system and considerations for similar partnerships. Facilitation: The team used MURAL, a digital workspace collaboration tool. After each presentation, participants will share what resonated with them and what questions it raised. After the three presenters finished, the participants reflected on those comments and use human-centered design principles and MURAL to engage participants and unearth lessons for patients, community and health service providers, health systems and state and federal policymakers.

Learning Objectives

  1. Understand how race as a social and cultural construct affects assessment and redress of social needs.
  2. Apply mixed-methods data with community engagement to inform program implementation and policymaking.
  3. Consider how you can apply the lessons learned from the Accountable Health Communities Model in your setting.
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