Building the Infrastructure to Integrate Social Care in a Safety Net Health System

Abstract

A recent National Academies report recommended that health systems invest in new infrastructure to integrate social and medical care. Although many health systems routinely screen patients for social concerns, few health systems achieve the recommended model of integration.

In this critical case study in an urban safety net health system, we describe the human capital, operational redesign, and financial investment needed to implement the National Academy recommendations. Using data from this case study, we estimate that other health systems seeking to build and maintain this infrastructure would need to invest $1 million to $3 million per year.

While health systems with robust existing resources may be able to bootstrap short-term funding to initiate this work, we conclude that long-term investments by insurers and other payers will be necessary for most health systems to achieve the recommended integration of medical and social care. Researchers seeking to test whether integrating social and medical care leads to better patient and population outcomes require access to health systems and communities who have already invested in this model infrastructure. (Am J Public Health. 2024;114(6):619–625. https://doi.org/10.2105/AJPH.2024.307602)

The National Academies of Science, Engineering, and Medicine (NASEM) concluded that social care must be better integrated into the delivery of health care.¹ Previous NASEM reports, as well as the World Health Organization, concluded that social determinants of health and related social care issues contribute directly to health disparities and preventable chronic conditions.^2–6 The 2019 NASEM report suggested that to improve individual and population health, health systems must attend to social care as well as medical care. To realize these improvements in health, the NASEM report recommended substantive investments in the health care infrastructure including “the redesign and refinement of workflows, technical assistance and support, staff with the ability to support the redesign, champions of the redesign, information on best practices, health information technology to enhance integration, and support for community partners and their infrastructure needs.”^1(p11)

The goal of this essay is to describe a critical case study of a safety net health system seeking to build and sustain this recommended infrastructure without support from third-party payers. Although many federal agencies advocate for health systems to attend to social factors, third-party payers do not reimburse health systems for investments in the infrastructure to support this integration,^1,7 and potential cost savings do not necessarily accrue to the health system supporting the investment. Although many health systems already report efforts to routinely screen and refer patients to community resources, we are not aware of previous studies reporting on the resources and costs of health system redesign at the level of complexity recommended by the NASEM report.

In one of the larger demonstration projects to date, Lindau et al. used health information technology to enhance integration and provide technical support to staff.⁸ Funded by the Center for Medicare and Medicaid Innovation, the team reported the outcomes of CommunityRx: “a scalable, low-intensity intervention that matches patients to community resources.”^8(p600) Not only did CommunityRx, a list of available resources generated through data in the electronic health record, increase patients’ confidence in accessing community resources, but the patients also shared the resource information with others. An independent analysis of CommunityRx showed that the intervention was associated with a decrease in hospitalizations and an increase in primary care visits, but the study was not designed to determine if patients actually connected with the community service agency.⁹ In a summary analysis of the Center for Medicare and Medicaid Innovation Accountable Health Communities, the authors found no significant increase in the rate of community service connections among patients with social needs referred to these service agencies.¹⁰ Thus, the extant literature shows the potential of connecting patients reporting social needs with available services but also demonstrates that a more robust infrastructure may be needed to actually resolve the social needs. Here, we report on the challenges and costs of implementing the full palette of NASEM recommendations in a safety net health system serving a patient population burdened with both medical and social needs.

METHODS

We used the framework of a critical case analysis because the targeted health system offers unique opportunities to field test implementation of the new social care infrastructure.^11,12 We recognize that the setting is unique in some respects but also that our lessons learned may generalize to other settings. While we used the framework of a critical case study, some methodological frameworks might denote this approach as an extreme case, a positive deviance case, or an instrumental case study.^11,12 For example, from a financial perspective, this is a low-resource setting, outside the context of a research study, without substantive support from third-party payers for social care, and in service to a large population of urban-dwelling patients with a high prevalence of medical and social care needs. However, from a system’s strength perspective, this safety net health system benefits from a strong existing neighborhood-based infrastructure, culture, and local community assets and trust. The challenges and lessons learned in this critical case study may offer the opportunity to instruct other health care systems who may be earlier in their evolution toward integrating social care and medical care. We report cost data using actual expenditures recorded in the health system’s financial databases, which includes costs incurred by the health system but supported by philanthropic resources.

Eskenazi Health is the safety net health system serving Marion County, Indiana, which includes the city of Indianapolis. This health system meets the NASEM definition as Indianapolis’ core safety net health system.¹³ Among patients cared for over the past 5 years at Eskenazi Health, 41.3% identified as White, 33.4% as Black or African American, 1.9% as more than 1 race, and 1.4% as Asian (all other racial groups < 1%). In this same population, 12.5% self-identified their ethnicity as Hispanic. Among all patients, 11% preferred communication in Spanish, and 2% preferred to communicate in languages other than English or Spanish. Payor mix included Medicaid (45%), Medicare (28%), self-pay or uninsured (11%), and commercial (14%).

Eskenazi Health engenders a high level of trust in the local community and is recognized as the leading health system in Central Indiana for providing community benefit.¹⁴ This health system includes a network of 14 neighborhood-based primary care centers (designated as a federally qualified health center) and 5 community mental health centers (a certified community behavioral health clinic). Each of these neighborhood-based centers is served by the same enterprise electronic health record (EHR) as the health system’s inpatient and specialty services (Epic).

Eskenazi Health and the Marion County Public Health Department are divisions of the Health and Hospital Corporation of Marion County. These divisions collaborate on multiple efforts to improve the health of Indianapolis. This partnership includes colocation of medical care and public health services in the neighborhood-based clinics as well as collaboration in community outreach (e.g., vaccination), policy development (e.g., needle exchange), education (e.g., antiracism), and building the infrastructure to address the social determinants of health, including food insecurity, transportation, housing, and mental wellness. Thus, in these neighborhood-based clinics, we have colocation of primary care, behavioral health, and public health professionals.

RESULTS

Table 1 summarizes expenditures across all 6 NASEM-recommended infrastructure components.

TABLE 1—

Annual Expenditures of Key NASEM-Recommended Health Care Infrastructure Components: 2019–2021

Infrastructure Component	Intramural Funds, $	Extramural Funds, Including Philanthropy, $
Champions of the redesign	629 000	111 000
Redesign of workflows	90 000	0
Health information technology	132 000	48 000
Technical and support staff	0	1 000 000
Community partners and their infrastructure needs	0	200 000
Information on best practices	100 000	50 000
Total	951 000	1 409 000

Note. NASEM = National Academies of Science, Engineering, and Medicine.

Champions of the Redesign

In 2018, Eskenazi Health leadership began the process to build a systemwide infrastructure to integrate medical care and social care, including direct financial support for a new team of leaders. We constructed this team to include a balance of expertise in the care of individuals and whole communities. The expertise in community-based care required external recruitment of champions with experience in community partnerships, neighborhood redevelopment, and economic development. This “champions of redesign” team was recruited over 3 years and now includes 7 leaders contributing a total of 3.8 full-time equivalents of effort. We value the current financial support for this leadership team at $740 000 per year. Philanthropy funded 15%, and the health system supported 85% of these costs over the past 3 years.

Redesign and Refinement of Workflows

Over the past half century, primary care successfully integrated multiple new activities into the workflow of the typical office visit. In addition to examples such as screening and treatment of hyperlipidemia, other activities integrated in the past few decades include counseling for smoking cessation, weight gain prevention, and other age-specific preventive health services. The basic workflow to integrate social care into health care includes familiar components: screening to identify individuals with problems followed by the options of counseling, treatment, or referral to address the problem, and then follow-up care to assure the problem is addressed.

However, 4 realities render the social care workflow more complex. First, there are no pharmaceutical or procedural options to assist in treatment of any of the social determinants of health. Second, social care interventions are not reimbursed by insurers. Third, most of the available services and supports to address social care problems reside outside of the health care system. Fourth, although this is a growing area of research, we need higher-quality studies supporting the scalability and sustainability of social care programming, including demonstrating improvements in patient-level outcomes or total health care costs.^15–17

Community-based primary care is a logical service on which to integrate social care and medical care, if we provide appropriate additional resources in this setting. Our new care workflow relies on the workflow paradigm of screening, treatment or referral, and follow-up. This workflow also relies on a team-based care model already existing in our network of neighborhood-based health centers. Concurrent with investments in social care, Eskenazi Health invested $90 000 per year in consultant fees to work with our leadership and staff to build team-based approaches into the delivery of high-quality, efficient, patient-centric primary care. These new approaches address the responsibility and accountability of individual team members within the highly dynamic environment of primary care. Thus, integration of the social care role into the workflow of the expanding health care team represents a major infrastructure and cultural challenge.

Health Information Technology

Since 2018, the EHR at Eskenazi Health has supported screening for social determinants of health, and this information is displayed to providers like other health care data or reminders. Screening data can be collected by providers in clinic or by patients through the patient portal. The EHR also supports referral to a limited number of internal services such as financial counseling or assistance with application for the Supplemental Nutrition Assistance Program. Although Eskenazi Health invests substantially in the EHR, this enterprise system (like many others) includes the main features needed to support screening and internal referral, so we do not attribute any financial investment in this key infrastructure directly to social care integration. The EHR can also provide written instruction for accessing a web-based directory of external community-based resources (https://www.findhelp.org). Accessing this directory and integrating it with the EHR in a format useable by patients and providers requires an average investment of $80 000 per year, which has been supported by philanthropy (60%) and the health system (40%) for the past 3 years.

The EHR does not capture data on whether a patient accessed services external to the health care system or the outcome of those services. Collecting such data requires follow-up communication with the patient or their advocates. Our inability to electronically “close the loop” between the health system and the community-based resources represents a major gap in the “screening‒treatment‒follow-up” paradigm. Although social network software can assist in finding resources, and to a limited extent can provide the technical capabilities to report back if a referral was completed, the process of closing the loop to better understand if services were requested by the patient and if they resolved their issue(s) remains underdeveloped for myriad technical, cultural, and regulatory reasons. We view these social network platforms as important tools but likely not sufficient alone to improve patient outcomes or health care costs.

As noted, the incremental cost of health information technology to support the screening components for social care is minimal, but the cost of building the workflow to address appropriate referral and follow-up is substantial. We value this EHR information technology support at a cost of $100 000 per year based on the hours of required programming and the cost per hour of the personnel to complete the programming. To date, this cost is borne primarily by the health system, and closing the communication gap with external resources is an important future step in innovation that could add substantially to costs.

Technical Assistance and Support Staff

The sum weight of all current recommended preventive care and chronic care management activities cannot be accomplished in a single ambulatory care visit by a single provider.^18,19 As noted, team-based care is now the norm within the framework of the neighborhood-based clinical practices. However, the composition of this team continues to evolve. We seek innovation in the composition of these teams to offset the new demands of integrating social care. Where a team might have consisted of a physician, nurse, social worker, and medical assistant over the past 10 years, this team now includes mental health social workers, registered dieticians, health coaches, community health workers, doulas, peer counselors, navigators, and financial counselors, among others, depending on the clinical site. While these new team members represent a welcomed new workforce, third-party payments fail to underwrite the full costs of this labor. In addition, these new roles require new enhancements in clinical communication and local adaptations based on local needs to assign roles, responsibilities, and accountability. We also identified an early need for a new role to help primary care patients navigate the ecosystem of community-based services. “Community weavers” identify resources in the neighborhoods surrounding each of our clinical sites, develop relationships with the leadership of these resources, and help patients navigate access. These 20 positions are funded through a combination of federal support to the primary care centers and local philanthropy.

Support for Community Partners

In the modal “screening‒treatment‒ follow-up” medical paradigm, the entire process occurs under the umbrella of the health care organization. Although fragmentation and miscommunication continue to trouble this medical system, EHRs support communication about the outcomes of intramural referrals. When the referral process expands to include community-based organizations, we enter a much more complicated and heterogeneous network of services with unaligned technology and expectations. This heterogeneity stems from differences in what services are available in any given locality because of variation in the size, longevity, and administrative capacities of the organization. The range of information technology capabilities represents 1 example of this heterogeneity. Some highly valuable local organizations do not use software programs or, when available, such programs may be beyond the training available to their volunteer workforces. In some situations, the community-based organization, the client, or the health care system may be unwilling to allow sharing of information. For some larger organizations, such as Area Administrations on Aging, Eskenazi Health achieves a bidirectional flow of information, but these singular successes rarely generalize to other organizations.

Health care systems such as Eskenazi Health play an important role as anchor institutions in the neighborhoods where they provide services.²⁰ In this role, the health system provides employment and capital investment opportunities for local communities and offers administrative support for other activities, such as collaborative grant applications. Eskenazi Health offers the potential to expand administrative capacity in these organizations, but partnership also offers the potential to expand service capacity in these organizations. Patient needs exposed by widespread screening conducted by health systems easily overwhelm many community-based organizations.

As an example of a role for an anchor institution, Eskenazi Health partners with community-based organizations to achieve economies of scale for activities such as food service logistics, training and related workforce development, and neighborhood redevelopment. For these partnerships to be successful long-term, many community-based organizations need an extension of the health system’s or public health system’s administrative resources, a reliable flow of funds over time, shared recognition in successes, and long-term support from the health system as an anchor institution in the neighborhood. We recognize this must be accomplished by equally recognizing the autonomy, expertise, and mission of the community-based organization. Currently, the social care champions at Eskenazi Health include 1.0 full-time equivalent with a specific focus to develop and sustain community partnerships, although many team members participated in building these relationships.

Information on Best Practices

Best practices exist as consensus recommendations of experts rather than experimental evidence.^1,21 Eskenazi Health benefits from partnerships with researchers from the Indiana University School of Medicine, the Indiana University School of Public Health, and the Regenstrief Institute Inc, among others. A combination of Eskenazi Health resources, local philanthropy, and a mosaic of state and federal funding support Eskenazi Health’s role in collaborating with research teams to identify best practices. We monitor the structure and process of care for individual components of the social care infrastructure using existing EHR infrastructure, quality improvement resources, and pilot project funds. Examples include training, deploying, and monitoring the activities of the new workforce, documenting rates of screening and referral for various social determinants of health, and cataloguing the development of new referral networks and resources in the community.

At the level of patients, we also monitor individual patient change in key quality indicators (e.g., HbA1c, blood pressure, preventive health interventions) and couple these outcomes with an accounting of the dose of social care interventions received by individual patients. At the level of communities, we seek to catalog the challenges, opportunities, and successes among potential and established community-based partners, including an accounting for shared extramural funding and related shared resources. This monitoring system is in development. The health system supports $100 000 per year for efforts to monitor the process of the new social care workflows with an additional $50 000 in support from philanthropy.

Summary

Although the cost of this infrastructure will vary across different communities, we anticipate that most health systems would need to invest at least $1 million to $3 million per year to build and maintain this infrastructure for 5 to 10 years. We estimate such a wide range based on the wide range of existing capabilities across health systems regarding social care. Ultimately, we must demonstrate value to third-party payers to engage these funders in support of this work. We do not include this type of program evaluation (demonstrating longer-term improvements in patient outcomes and costs) in our cost estimates. Notably, our cost estimate would also not include the millions of dollars in financial support for the day-to-day operations of social care services potentially supported by the health system to improve food, housing, or transportation insecurity. For example, Eskenazi Health receives approximately $500 000 per year in philanthropic funding to address food insecurity alone, but we do not include this in “infrastructure” costs. In this critical case analysis, we focus on the cost of the infrastructure needed to integrate social care into the workflows and operations of a health care system.

DISCUSSION

This essay describes a critical case analysis of the human capital, operational redesign, and financial investment needed to implement the National Academies’ infrastructure recommendations on integrating social care into medical care.¹ This information is particularly relevant to safety net health systems contemplating a greater role in social care. Expansion of care services to integrate social care with medical care requires change in multiple facets of the health care organization. In effecting these changes, we also note that champions of the redesign will encounter cultural debates about the medicalization of social problems and dilemmas about opportunity costs for competing medical care priorities. Notably, a substantial part of this new social care infrastructure must reach outside the health system and integrate the capabilities and limitations of numerous community-based organizations, including the public health system.^22,23 This “bridging” function between multiple organizations requires administrative and communications capabilities not inherently present in the typical health care system.

We explore the challenges and opportunities through the lens of a safety net health system that includes a federally qualified health system with multiple primary care locations in neighborhoods of high need. These are settings where investment in social care offers the best opportunities to improve health. However, state, federal, and industry funding for social care activities in this setting tend to rely on short-term demonstration projects.²³ Short-term funding will not stimulate the costly investments needed for a durable infrastructure. Given the low to negative margins in the overall budgets of safety net health systems, these realities suggest that much of the support for the longer-term investments currently must come from philanthropy. Sadly, the reliance on philanthropy can place the health system in competition with partnering community-based organizations who also seek support through philanthropy and related funds.²² Although value-based care offers the potential to support the integration of social care in a future state, delivering on the promise of quality, value-based care requires the infrastructure we describe in this report and investments in demonstrating the financial value of these activities to third-party payers.

Although this critical case analysis focused on the cost of infrastructure, there are other practical and cultural barriers to this integration. For example, our community partners seek to raise awareness that social determinants of health and health disparities share common roots in systemic racism, limited educational attainment, and limited economic opportunity. These partners caution against medicalizing these problems and simply growing the resources of an increasingly consolidated health care industry. People want to receive care in their own neighborhood and to rebuild and rely on the strengths of that neighborhood. We hear a strong chorus from community partners that much of this work requires health care providers and their administrative and financial levers to move into these neighborhoods. This colocation in neighborhoods of great need represents a major strength in the current deployment of Eskenazi Health services. Health care systems can best serve as partners and anchor institutions in local neighborhoods by operating in those neighborhoods, hiring people from those neighborhoods, training people from these neighborhoods, and buying goods and services from their neighbors.²⁰ Economic development is a potent form of health care.

As health systems engage more directly with their local communities, they will of course find that there are many other health care organizations, governmental programs, public health agencies, and faith-based organizations, among others, who also address the social determinants of health. Working toward collaboration across these many organizations equals the complexity we have already described within the ecosystem of a single health care system. High-need patients often put their trust in safety net health systems, the local public health system, and partnering community-based organizations. This is due in part to colocation in high-need neighborhoods, longstanding relationships among these local community-based organizations, and long-term commitment to underserved populations. Third-party payers, as noted by Butler and Nichols, are “learning that effective infrastructure is technology combined with trust, the kind of client trust that community-based organizations and their network curators have and that does not transfer easily to large health plans or new technology vendors.”^22(p1245) In this essay, we focus on building infrastructure within the health care system and building bridges to community-based resources. However, in some neighborhoods, these community-based resources are strained or nonexistent. Thus, investment in the community-based component of the network is also necessary to realize the gains in the investments discussed here.

The NASEM report and other recent consensus reports provide a blueprint for the infrastructure needed to support integrating social care into medical care. While health systems with a robust existing foundation may be able to bootstrap short-term funding to initiate this work, we conclude that long-term investments by third-party payers will be necessary for most health systems to achieve the recommended integration of medical and social care. We also highlight the added complexity and infrastructure needed to grow cross-sectoral partnerships that begin to address the roots of social care issues, including economic development.