Passive social health surveillance helps keep vulnerable populations out of the hospital

Aug. 23, 2019
Integrating social referral data with claims data in a managed care organization may identify patients at risk for hospital readmissions within 30, 90 and 180 days

One way to keep people healthier and reduce healthcare costs is to identify patients at risk for hospital readmissions. A recent study published in the current issue of The American Journal of Managed Care (AJMC) identified the social determinants of health related to vulnerable individuals being readmitted to the hospital for care.

The retrospective observational study examined a managed care organization that created a system of passive social health surveillance whereby a call center referred patients to community services. Linking that information with claims data revealed that individuals who needed any of five social services—financial assistance for utilities, food programs, housing support, transportation, and medication assistance—were 68 percent, 89 percent and 101 percent more likely to be readmitted to the hospital within 30, 90 and 180 days, respectively. However, the fifth social need—medication assistance—was not associated with readmissions when looking at each social factor separately.

The study analyzed claims and social service referral data from January 1, 2013, through October 19, 2017, for 27,189 individuals who were insured by WellCare Health Plan’s Medicaid managed care and Medicare Advantage programs and who had access to the company’s Community Connections Help Line. 

People calling the Help Line with self-identified social needs either had exhausted their health insurance benefits for services such as food programs, transportation or medication assistance or needed a social service that was not a part of the health plan benefit, such as financial assistance and health literacy programs.

Co-author Nnadozie Emechebe, MPH, of the University of South Florida College of Public Health said in a news release, “The study highlights the potential to leverage social care referral data to identify individuals who may be susceptible to hospital readmissions. The study results suggest passive social health surveillance systems operated by managed care organizations could augment existing social screening efforts conducted by primary care providers.”

The passive social health surveillance function highlighted in this study could also be a useful tactic for accountable care organizations (ACOs), the authors noted, because ACOs represent a risk-based financing model of delivering healthcare. The study highlights the potential for nonclinical organizations to support medical and social care integration, the researchers wrote, noting that the findings are also consistent with previous work showing that a variety of social determinants of health relate to inpatient readmissions.