Field Notes: C3 Addresses Underserved Populations’ Needs Through Its Flexible Services Program

By Christina Severin

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Community Care Cooperative (C3) is a 501(c)(3) nonprofit accountable care organization (ACO) founded and governed by Massachusetts Federally Qualified Health Centers (FQHCs) focused on advancing integrated and coordinated community-based care through risk-based contracts and shared administrative services. C3 serves 156,000 patients under a risk contract with Massachusetts Medicaid (MassHealth). C3 works through its statewide network of 18 FQHCs to provide primary care services in under-resourced communities and supports FQHC’s enhanced patient-care management and other population health activities. The organization’s overall strategy is to strengthen health centers and preserve their independence through leveraging their collective strengths and, in doing so, improve patient care and bio-psycho-social outcomes for the patients and families served.


The Challenge

For members who need additional support, C3 has embedded care management services in the FQHCs, working with members’ primary care and behavioral health providers, and coordinates services from community-based organizations (CBOs). C3 has also implemented the Flexible Services Program to provide food and housing supports for members who need these services in partnership with 19 social service organization (SSO) partners statewide.

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To drive high-quality and cost-effective care under these programs, C3 needed the ability to control its stratification methodology to streamline the identification of those members who would most benefit from receiving enhanced services.

Because FQHCs and CBOs are historically under-resourced organizations, risk stratification is also critical to ensuring that members who would benefit most from certain types of intervention could be efficiently and effectively identified. To improve its approach to this critical process, C3 needed curated data assets to be with merged with longitudinal clinical electronic health record (EHR) data, social determinants of health (SDOH) data, and behavioral data. Special risk stratification of C3’s population allowed us to find and focus on the people who could benefit most from the Flexible Services Program. Additionally, C3 implemented workflow tools to support effective care management, outreach, and team coordination.

The Stakeholders

C3 leveraged a multipronged approach to identify patients who would benefit from flexible services, while being careful to adhere to strict state and federal regulations. First, the organization partnered with Arcadia. to build a series of novel risk algorithms that leverage clinical and claims data to target the right members for care management programs.

To surface members with behavioral health markers and/or chronic medical conditions, the algorithms use Adjusted Clinical Groups (ACG) conditions and ICD codes (including Z  codes) to determine the presence or absence of negative SDOH factors, behavioral and medical health markers, and impactable spend. Then, once eligible patients were enrolled in one of the care management programs, C3 administered individual food and housing security screenings and then enrolled patients in the relevant nutrition and/or housing Flexible Services Program.

The Action Plan

The COVID-19 pandemic created several major challenges for C3, such as reducing FQHCs’ ability to reach members for both complex and routine care. The pandemic also necessitated the shifting of workflows to support the delivery of clinical services and care management services via telehealth. Nurses who had been focused on managing members’ transition of care from hospital to home were asked to additionally assess members’ health related social needs (HRSNs).

Not surprisingly, the pandemic created additional economic stress for the under-resourced population served by C3 and its FQHCs, and this led to the rapid uptake of flexible services as the care management staff screened and responded to the food and housing needs experienced by members during this challenging time.

While new programs―and the accompanying changes to health center workflows―are typically slow to be adopted, there was much more demand for flexible services than projected. This was due in large part to the COVID-19 pandemic and the resulting increase in economic insecurity and accompanying food and/or housing insecurities experienced by C3 members.

In fact, the ability to make referrals to the Flexible Services Program became a bright spot during the pandemic. Care management staff reported that the ability to address members’ most pressing needs related to social issues helped them to develop deeper relationships, improved their ability to address health conditions and medication management, and improved members’ rates of keeping follow-up appointments.

Results and Next Steps

During the period of the pandemic from April through December 2020, the C3 Flexible Services Program achieved strong results. By working with Arcadia to stratify populations and develop risk algorithms that included SDOH data, C3 was able to identify that 61 percent of members in the care management program were experiencing food insecurity and 32 percent were experiencing housing instability or homelessness. They referred members in the Flexible Services Program as the SSO partnerships were launching, enrolling 72 percent of eligible members into nutrition programs and 63 percent into housing programs, representing 2,197 total members across all 18 health centers.

Once referred to the programs, engagement was high. Of the 531 referrals to a flexible services housing intervention for members at risk of eviction or experiencing homelessness, 415 of those members successfully engaged with a housing case manager (78 percent engagement) and received support for housing search, landlord negotiation, and other benefits applications to improve housing stability. There were 1,971 referrals to nutrition programs with 1,636 members successfully connected (83 percent engagement), resulting in support for federal nutrition program applications, nutrition education, and distribution of over $980,000 in grocery store gift cards, $145,000 in kitchen supplies, and 44,283 home-delivered meals.

Lessons Learned

Leveraging a multipronged data and analytics approach helped the C3 Medicaid ACO meet some of the critical needs of an underserved population in one of the most volatile times in US history. As a result of its collaboration with Arcadia, C3 quickly put in place algorithms and systems that will continue to help serve the members in its value-based contracts for many years to come.

One important lesson learned revolves around the importance of addressing patients’ SDOH challenges. This requires a shift in mentality for most providers, who are generally accustomed to focusing their efforts on solving patients’ medical problems. However, research has shown that 60 percent of the factors that impact premature death are based on a combination of environmental, social, and behavioral conditions. Consequently, providers must continue to invest in solutions that enable them to assist patients in solving SDOH challenges.

Another key lesson is that, to target interventions to patients most at-risk and who will benefit most from enrolling in care management programs, it is essential to have the right patient data. That includes longitudinal data from electronic health records, claims, SDOH information, behavioral data, and more. While risk stratification programs may rely on sophisticated algorithms, those algorithms will not produce any worthwhile insights without first ingesting the right data.

Christina Severin is the president and CEO of Community Care Cooperative.

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