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Medicaid is Leading Efforts to Integrate Social Services into Care for Beneficiaries

Social factors, such as housing, employment and access to nutritious food, can strongly influence an individual’s health status. One program that is demonstrating the importance of addressing a patient’s social needs is Hennepin Health, an Accountable Care Organization (ACO) that operates in partnership with the state of Minnesota. Hennepin Health is targeting “high need, high cost” Medicaid-eligible adults using an approach that integrates Medicaid-covered services with funding from other sources to address social services. The program is producing positive results with respect to both health outcomes and cost-savings. 

Financed with an up-front payment for all Medicaid services, as well as additional county-based social services funds, Hennepin Health has focused on helping high-risk patients find housing and jobs. Early outcomes show that the program has helped shift care from hospitals to outpatient settings. For example, emergency department visits decreased by 9.1% between 2012 and 2013, while less-costly outpatient visits increased by 3.3%. In addition, the percentage of patients that received care for diabetes, vascular conditions and asthma at optimal levels increased. Hennepin Health saved more among its newly housed patients on reduced ER and hospitalizations than it paid for their housing. The program is reinvesting the savings in strategies to further improve care.

CMS is offering links/charts for informational purposes only, facts should not be construed as an endorsement of the organization's programs or activities

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