Enhance Care Coordination and Social Determinants of Health
Health Policy Matters (HPM) assists ACO partners to identify and enhance referrals to, and coordination of, services that target Social Determinants of Health (SDOH). We also have experience identifying cost-effective strategies to address food insecurity for the low- and moderate-risk population. While the rate of COVID-19 infection is slowing, and more individuals are receiving vaccinations to protect against COVID-19, the social support needs of ACO and BH CP clients are likely to continue to increase.
Goal: The goal of this TA project is to maximize your organizations’ ability to coordinate SDOH-driven services for ACO and BH CP clients with available community-based services.
- Review coordination strategies with existing community-based organizations (CBOs), and identify opportunities to improve such coordination
- Obtain client feedback regarding coordination of care and the provision of social support services
- Identify additional potential partners with whom to coordinate community-based services that address social supports needs and preferences
- Recommend strategies to improve the delivery of services that address SDOH-driven needs among your clients
HPM will work with your organization to understand how your team currently coordinates care for SDOH-related services and will help you to develop/design improved coordination strategies – as well as achieve outcomes – to meet the needs of the populations you serve.
HPM will customize the projects based on the needs of the ACO or CP.