Health care providers operating under new population-based payment models, such as ACOs, often recognize the importance of social factors in driving health care outcomes and costs and improving population health (as opposed to medical factors alone). As a result, a growing set of health care providers are working to assess patients’ non-medical needs—such as food security, housing stability, or social support—and meaningfully integrate medical care and social services. Our project aims to understand how ACOs are thinking about integrating social and medical care; barriers to integration; and the methods and strategies ACOs use to integrate care. Our results will provide insight for stakeholders such as providers, policymakers, and local communities into strategies to bridge care for patients’ social and medical needs. Effectively integrating such care could improve patient outcomes, reduce stress and obstacles for patients, improve health care outcomes, and reduce health care costs.
Researchers on our study team are using qualitative methods to understand how ACOs are integrating social services. Our team conducted comprehensive phone interviews with 20 ACOs in the spring of 2017. Additionally, we are in the process of collecting data from annual, in-depth site visits with four ACOs over a three-year period, including both semi-structured interviews and observational data, with quarterly phone calls with sites in between site visits. We code our data as it is collected, and analyze using qualitative methods. Our work is funded by AHRQ and The Donaghue Foundation.