THE CHALLENGE

Investment in social services like food and housing support can have a powerful impact on health outcomes and the total cost of healthcare. But ensuring people successfully connect to social services can be a challenge. To better address unmet health-related social needs, Community Care Cooperative (C3), an Accountable Care Organization (ACO) in Massachusetts, leveraged their portion of MassHealth’s Flexible Services Program to deliver food and housing support to its most complex members. MassHealth created the $149 million program not only to pilot evidence-based approaches for addressing social determinants of health, but also to test reimbursement strategies for long-term program sustainability.

As the state’s only ACO founded and governed by Federally Qualified Health Centers (FQHCs), C3 worked with 19 different health centers, more than 20 community-based organizations (CBOs) and 14 distinct nutrition and housing programs to establish a system through which its patients could have their health-related social needs addressed. C3 needed a way to securely coordinate care between all these organizations, facilitate successful referrals, track member outcomes and compensate for services provided. The solution also needed to provide operational insight into what was working and what wasn’t, so C3 could identify members who needed further support for successful handoffs, demonstrate how to effectively invest in social services and continue to drive further improvements to health outcomes.

OUR GOAL

To establish a multidirectional data management solution for C3, health centers and CBOs that supports collaboration while enabling successful member referrals, extensive program data collection and monitoring, outcomes reporting and contract management.

THE HYPHEN SOLUTION

The Hyphen connected-care platform made it possible to manage closed-loop referrals across community partners and leverage operational insights to optimize community network resources. Using Hyphen’s platform, community health workers at the FQHCs screened and identified health-related social needs of C3’s Medicaid members, captured member characteristics to verify their eligibility for the Flexible Services Program, and facilitated connection to the contracted community resources. Finally, CBOs received the referrals, worked with members, and directly updated member records with case notes, services provided and requests for additional services not prior authorized. Some CBOs chose to leverage Hyphen’s services to seamlessly receive and send required data so they could stay within their own agency’s workflows. This comprehensive solution allowed CBOs to receive proper reimbursement for addressing social determinants of health — providing new streams of revenue independent of the grant cycle and empowering them as healthcare service providers.

Hyphen also provided tools to support ongoing program oversight, so C3 and its partners could identify and close resource gaps, building additional capacity into community resource networks.

“Hyphen’s multidirectional solution uniquely offers us real-time monitoring of our community partner referrals to ensure we are fully addressing social needs. We empower our partners to invoice for services provided, improving reimbursement, utilization, and sustainability of these vital social programs. We wouldn’t have seen these statistics without Hyphen,” said Kim Prendergast, Vice President, Social Health, C3.

POPULATION HEALTH IMPROVEMENTS

• 93% of referred members were successfully connected to social supports
• More diabetic members achieved hemoglobin A1c goals (average reduction 0.9%)
• Fewer members visited the emergency room (31% vs. 41% with 2+ ED visits in 6 months)

TAKEAWAY

Together, Hyphen and C3 demonstrated the power of connected-care: When Medicaid populations are connected to health-related social supports in their communities, it drives measurable improvements in health outcomes. Notably, Hyphen helped C3 establish a 93% success rate for community referrals — far above previously reported rates, which can range between 5% and 33% when the burden is placed on the member to initiate outreach or follow up on their own. Hyphen’s platform provided C3 visibility of which members successfully connected with services and those who did not, enabling the ACO to implement follow-up workflows to engage the remaining 7% of members. These connections have driven measurable improvements in population health and early data shows a lower overall cost of care.

The positive impact of the first waiver demonstration helped MassHealth secure and expand the Flexible Services Program under the new 1115 Medicaid Waiver for an additional five years, which will allow C3 to serve more Medicaid members in Massachusetts during the next waiver phase. Now C3 works with 22 FQHCs and one affiliated practice to coordinate whole-person care for more than 200,000 members using Hyphen’s platform. C3’s success in Massachusetts also serves as a blueprint for Section 1115 Medicaid demonstration waiver programs in other states.