Wish List Follow-Up: Why Community-Based Resources Remain Crucial to Patient Care

Joe Nicholson, DO – Chief Medical Officer

Earlier this year, I expressed my wish for better information-sharing between health care providers and community-based organizations (CBOs). I noted we cannot deliver optimal care for our communities if we fail to address social determinants of health (SDOH) – socioeconomic and environmental factors that can significantly impact a patient’s health outcomes. I also suggested, in my ideal world, compliant conversations would be facilitated by a federal information exchange platform.

We still have a long way to go to make that dream a reality. Nevertheless, the Centers for Medicare & Medicaid Services (CMS) is continuing to emphasize the importance of community resources and addressing SDOH. The 2024 Medicare Physician Fee Schedule Proposed Rule includes provisions for Community Health Integration Services, SDOH Risk Assessment, and other services. The agency’s upcoming States Advancing All-Payer Health Equity Approaches and Development (AHEAD) model will also aim to strengthen relationships between community resources and primary care providers.

I welcome the recognition that community-based resources are integral to better health care. It is an idea that we at CareAllies have long embraced. We often witness the powerful outcomes that are a result of providers and community organizations working together to enable the patient-centered care that lies at the heart of value-based care models.

For example, our SDOH team works alongside physicians to help their patients resolve cost, access, and other SDOH barriers to care. The SDOH team includes social workers who have knowledge of nonprofit and community-based resources available to help patients. They may contact patients to discuss their needs and connect them to resources as well as educate them on how to apply for prescription assistance programs, obtain low-income subsidies, or use lesser-known benefits. 

The story of one 82-year-old woman is a perfect example. She went to her physician for relief from chronic pain, and the physician referred her to our SDOH team after learning she was about to become homeless. The SDOH team helped her get on the waitlist for income-based housing and encouraged her to speak with her landlord about a solution until the housing became available. It is important to remember when one need is identified, patients often have more. The SDOH team is able to assist by screening for additional barriers. In this case, the team explained how to apply for Supplemental Nutrition Assistance Program (SNAP) food benefits, and, for her future reference, offered a list of resources that supply durable medical equipment.

As a result of the team’s intervention, the patient was able to stay in her home until she obtained her current income-based apartment. She is receiving SNAP food benefits, as well as behavioral health support. What could have become a dire situation was avoided by connecting the patient to existing community resources.

High-quality clinical care is always top of mind for providers. But if we want patients to achieve their best outcomes, we must recognize and address non-clinical barriers as well. Fortunately, we do not have to do it alone. Our communities are full of terrific organizations that stand ready, willing, and able to assist. We just need to encourage patients to discuss these topics with us, so we can facilitate the connections.