Aligning clinical and community resources improves health

The new age of healthcare is requiring caregivers and health plans to think outside of the doctor’s office in keeping patients on the right track. 

Healthcare is evolving from the fee-for-service model to value-based care, in which reimbursement is based on the quality and effectiveness of the care provided rather than the quantity. Successfully achieving this transformation will require not just realigning care delivery and payment incentives, but also investing in prevention and public health initiatives that take into account the importance of social determinants of health — the community factors such as living conditions, resource deprivation and education — that impact people’s wellness.

The integration of primary care services into community-based behavioral health is key to this. We need an approach to chronic disease prevention and management that integrates clinical and community systems as an adjunct to primary care — capable of addressing both the health behaviors and social determinants of health that are closely linked to improved health outcomes.

An example of how this works can be found in the diabetes prevention efforts taking place today. Diabetes is one of the most common, complex and costly chronic health conditions in the U.S., affecting approximately 29.1 million people. Research suggests that one in three Americans has prediabetes — and most of them are unaware that they have it.

{mosads}The national Diabetes Prevention Program (DPP) — an intervention based in National Institutes of Health research, authorized by Congress and propelled forward by a public-private partnership of the Centers for Disease Control and Prevention — is an evidence-based, affordable and high-quality lifestyle-change program proven to reduce the risk of type 2 diabetes. Today, trained non-clinical personnel throughout the country deliver the DPP using a standardized curriculum. With a wide range of program offerings delivered in the community, these DPP providers are uniquely qualified to meet the needs and address the challenges of diverse populations, and help them learn to make healthy lifestyle changes.

As non-clinical providers in local communities delivering culturally competent care, these programs represent a crucial resource in battling diabetes. However, a large percentage of the providers whose programs are recognized by the CDC are hampered in their ability to deliver them because they lack the resources and/or expertise to meet the requirements of integrating with the healthcare system.

Many of these providers lack staff to drive and manage enrollment, and don’t have the back-office administration capabilities for billing and reimbursement.  At the same time, the payers have no simple, effective means for contracting with them — or for even finding them in the first place. 

The case for technology-enabled health integrators

What is needed is a new model for linking patients to the disease prevention and management programs and other resources they need to improve their health. Technology can help. For example, in the area of diabetes prevention, there is growing support for the concept of a “health integrator” that can serve to help bridge the gap between people who qualify for the DPP, the health plans that want to offer it, and the hundreds of community and digital DPP providers that exist throughout the country.

The health integrator model offers a high-access, lower-cost network of non-clinical providers as an adjunct to primary care. Enabled by technology, these health integrators can consolidate the highly fragmented group of community-based DPP providers in the U.S. into an integrated national network, and then connect patients and payers to them. This model simplifies the contracting and referral process as well as the revenue cycle for the payers, creating a sustainable revenue model for DPP providers. 

A health integrator can solve many of the challenges associated with scaling the DPP for the many millions of Americans who need it. The benefits of a DPP health integrator for everyone are numerous. A health integrator can:  

• Rapidly expand patient access geographically across the entire country;
• Enhance patient choice and access to a broad and diverse provider network;
• Reduce administrative costs by providing a single point of contact for DPP administration versus direct administration between payers and hundreds of DPP providers;
• Enhance patient success and satisfaction by providing eligibility verification and “best-fit” matches with providers;
• Streamline processes by delivering real-time data and claims review and quality assurance;
• Help manage multiple DPP coaches through an integrated tracking and education system; and
• Ensure compliance for all providers. 

Achieving better health outcomes for our citizens requires aligning clinical and community resources in a systematic, meaningful way.  The health integrator model can help us realize that goal, and yield significant benefits to patients, healthcare providers, payers and community organizations.

Kathleen Sebelius was the Secretary of Health and Human Services from 2009 to 2013 under President Obama and is an advisory board member for Solera Health, a Phoenix-based preventive care benefits manager connecting payers, providers and patients.

The views of contributors are their own and are not the views of The Hill.