Would screening patients for social needs and providing them access to resources in the community improve healthcare outcomes and reduce overall healthcare costs? This was the query of a large experiment conducted among more than a million individuals enrolled in Medicare and Medicaid across 28 communities across the nation that depended on community health workers.

Interestingly, while the experiment did not find an increase in patient connection to community resources or their social needs being resolved, it reduced:

• Emergency department (ED) visits
• Inpatient admissions
• Total Medicaid and Medicare spending on these patients
  

What Did the Pilot Experiment Test?

The idea was to screen those enrolled in the government’s healthcare programs - Medicare (primarily for those 65 and older) and Medicaid (low income) – for five basic health-related social needs (HRSNs):

• Housing
• Food
• Transportation
• Access to utilities
• Interpersonal violence

Those who checked at least one of the above needs and reported that they visited the emergency room at least twice in the prior 12 months, were considered high risk and eligible to receive services of a community navigator.

What Did the Study Find?

• Among enrollees who were screened for social needs:
  • 40% had at least one HRSN
  • 58% had more than one HRSN
• Providing transportation would be key:
  • To connect enrollees to other resources
  • To addressing their other HRSNs
• Access to resources was limited in rural communities
• The pilot experiment significantly reduced expenditures, hospital admissions, and ED use, however,
  • Only 40% of enrollees who received navigation had their social needs resolved
• The greatest impacts were noted among:
  • Underserved racial/ethnic communities
  • Patients with diabetes or mental health issues
• Navigators who went above and beyond their determined role were a vital component of the impact on healthcare outcomes
  • Helping seek unemployment benefits and job search
  • Providing basic financial literacy
  • Sending reminders for mental health appointments

Navigators and Case Workers

The last point is important: navigators and case workers develop a trusting relation with their clients and often dive deeper to understand, and hopefully resolve, specific challenges that can have a boarder impact on the person’s life. For example, an unemployed person who does not have access to healthy food may not be able to eat a healthy diet to keep their diabetes under check. Navigators in hospitals or case workers in community organizations recognize and help bridge these gaps by engaging, building trust, and being an advocate.

Camden Coalition was one of the organizations that participated in this pilot. Here’s an interview with a few of their navigators who share anecdotes and experiences and lend some advice to colleagues.