N.J.-Based ACO Partners to Improve Social Determinants Focus

New Jersey-based Shore Quality Partners (SQP) is designed to help its participants improve patient care through quality and cost improvements. Robert Shea Wisler, the accountable care organization’s director of population health and analytics, says that a partnership with a company called Spatially Health is helping it better address social drivers of poor health outcomes.

Shore Quality Partners has been around since 2014 with its first contract starting in 2015. It is owned by Shore Medical Center, a regional hospital in southern New Jersey. It has about 43,000 lives in total in four different value-based contracts between Medicaid, commercial and the Medicare Shared Savings Program.

Miami-based Spatially Health offers a cloud-based, technology focused on pioneering new methods in geospatial analytics and location intelligence to better understand and improve social determinants of health. It works with several organizations participating in CMS’ ACO REACH program.

Shore Quality Partners is incorporating Spatially Health's technology platform to conduct a thorough assessment of each patient's social determinants of health and propose personalized interventions to overcome specific barriers. Spatially says the platform adapts dynamically with every new patient dataset, ensuring precise and enduring recommendations for enhancing patient health outcomes.

Shea Wisler spoke about why SQP began working with Spatially Health. “Everybody talks about health equity and social determinants, but nobody really does it well,” he said. “Spatially is at the forefront of things. And we are getting more into it now, with CMS regulations coming down and payers looking more at it. We can really affect patients by identifying these barriers. It's really important to start identifying some of those barriers and helping patients when you can. We saw this as something we need to do. We can't sit on the sidelines.”

Spatially has good public data focused on patients geographically, Shea Wisler explained. “It can identify if they're not close to public transportation and don't have a car. We've got the clinical data to say, these patients have certain diagnosis,” he added. “These patients haven't shown up to their appointments. They're no-shows 40 percent of the time. This could be a big issue. They also go to the ER a lot rather than coming into the primary care practices. Well, by marrying up the data that Spatially has with the data that we have, now we can identify that the barrier is that they just can't get to the office. So now we can send them an Uber when they need it. We want them to avoid going to the ER if they have an issue. We found that kind of data can be really impactful for us in our practice.”

Shea Wisler added, “Part of our job at the ACO is that we try and serve up actionable items that the primary care practices can do right in their office as soon as we give them that data, because the staff is so busy. If we have 5,000 members, and a use case that only identifies 20 members, that's okay, because that use case is going to be really important to the patient. Let’s say that we've got a heat wave coming. We've got patients with COPD, they live alone and don't have air conditioning. Out of a 5,000-patient panel, that may only be 15 or 20 patients, but to those 15 or 20 patients, it is going to be hugely impactful to reach out because if not, they're either going to go to the ER or it's going to be an even worse outcome for them. Those are the kinds of things that speak to the practices because they can do those things right now. After we started giving data to the practices, we realized that we needed to get way more specific.”

Hillit Meidar-Alfi, CEO of Spatially Health, described initially working with a local nonprofit called the Health Foundation in South Florida during the pandemic, when it was obvious that COVID-19 was hurting the most vulnerable communities.

“We developed a tool for them to really be able to hone in way past the Zip code. A Zip code is convenient, but it doesn't help you understand what's happening on the ground,” she said. “We developed a tool for them to let their partners who are actually on the ground understand how to target their efforts from a demographic perspective. Are they bringing somebody who speaks Haitian? Are they really being effective and efficient in using the resources and the time that they have to reach these people? Then when CMS came out with ACO REACH, we saw it as a huge opportunity to really start impacting big, deep social problems.”

“We can actually take any location and determine exactly what are the health barriers at that spot,” she added. “We identify and quantify the SDOH risk at the individual level. This allows us to bring very impactful insights to the users.”

Shea Wisler believes that provider groups are still in the early stages of learning how to survey patients for SDOH information and figure out what to do once they have the data. “That is why it is a good relationship with Spatially — to marry up our data to their data to get a better picture of the patient.”