MercyOne ACO Moves Upstream to Engage Patients on Social Needs

The MercyOne ACO is a statewide organization comprised of more than 2,300 doctors and 500 practice sites organized into regional ACOs and clinically integrated networks in Iowa. Its analytics and population health service organization is moving “upstream,” as its work has shifted from just looking at claims and EHR data to help predict individual patient risk to a broader view of the patient experience, including social determinants.

In an Aug. 27 webinar hosted by David Nace, M.D., chief medical officer of health data insights platform vendor Innovacer, MercyOne ACO executives described their efforts to engage patients in discussions about food, transportation, and housing issues and the addition of community health workers to help them navigate the relationship between health systems and social service agencies.

“We started our journey focused on clinical data elements from claims and the EHR,” said Nathan Riggle, division director of analytics for the MercyOne population health services organization. “We have spent time on that data to understand our patients’ risk and how we can serve them better. But as we have evolved as a population health organization, we have moved to other sources of public data, such as ZIP code-level data from the Iowa Department of Health. But what is really transformative is collecting data from patients and having them tell us about their social needs. We are finding new uses of social data and patient-reported data.”

Emily Fletcher, ambulatory care program manager for MercyOne, admitted that she was initially naïve about the impact of social factors on health. “I would never have guessed that 1 in 5 patients has social needs, such as challenges with feeding their family or paying rent. When you have those things going on, how do you focus on your A1c or taking your medications correctly?  We often wonder why a patient isn’t following through on our guidance,” she said. “This brought a new understanding, and a new lens for providers to see the total health of the patient and what is going on outside the clinical setting.”

The MercyOne team created an iPad app to do a social needs screening in clinic waiting rooms. As they set out to implement a screening tool, one step was to engage the clinicians. “We have found that everyone wants to help patients,” Fletcher said. “But we need to give them the tools. Providers want to know about socioeconomic issues, but they don't want to ask unless there is a care team to wrap around the patient and someone is going to take the next step.” She added that the app allows MercyOne teams to reach out to patients who need help before they even leave the clinic.

With the app MercyOne did 11,000 social needs screenings in a year and identified 700 patients to help with social needs. Now it is looking at expanding its use across the state. “We are starting to prioritize where we can roll it out,” Riggle said. “We have a scalable technology solution with the app and iPad.”

 The work at MercyOne has been incremental. It started with RN care coordinators working with patients on behavioral changes and added social workers a few years ago. Now it has added community health workers to help patients navigate getting the services they need and want.

Fletcher stresses that the community health workers are the key to success. “It is a new clinical role for us. They are experts in navigating social services and health. They are self-motivated, compassionate, and are very successful in doing this work.” She gave an example of a patient who had food insecurity but also had anxiety. Traveling on a crowded bus to a crowded food pantry would be difficult. The community health worker knew the food pantry staff and was able to arrange a time the patient could visit off-hours and also found a paratransit transportation service.

She described where MercyOne is now as “mid-stream,” working with individual patients to address their needs. Further upstream is working on social issues addressing the health of whole communities such as livable wages, affordable housing, and walkable neighborhoods. “Those require more policy and legislative work,” she said.

Also speaking during the webinar was Adrienne White-Faines, M.P.A., fomer CEO of the  American Ostepathic Association and an Innovacer advisor. She said more health systems are starting to appreciate the full journey of the patient and the community and population from which they come. “These are exciting times to embrace aggregating as much information as possible about the patient and their environment and how they will take information back to the community in which they live,” White-Faines said.

 She added that it is important to address these efforts from a health equity lens, and understand a patient’s hierarchy of needs. “Unless you appreciate what is important to them, you are going to be blocked on moving forward on care,” she said.

White-Faines suggested that health systems constantly have to go back and improve on all their activities. “Check back with users to make sure your programs are doing what you hope they are doing.” Success with these efforts may have to do with how well a healthcare institution is integrated into a community and whether it has established trust, she added. “Until you establish trust, you can’t gather the information you need on patient perspective.”