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Health Aff (Millwood). 2020 Feb;39(2):199-206. doi: 10.1377/hlthaff.2019.01266.

Upstream With A Small Paddle: How ACOs Are Working Against The Current To Meet Patients' Social Needs.

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Genevra F. Murray ( genevra. murray@dartmouth. edu ) is a research scientist at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, in Lebanon, New Hampshire.
Hector P. Rodriguez is a professor of health policy and management, director of the California Initiative for Health Equity and Action, and codirector of the Center for Healthcare Organizational and Innovation Research, at the School of Public Health, University of California Berkeley.
Valerie A. Lewis is an associate professor of health policy and management at the Gillings School of Global Public Health, University of North Carolina at Chapel Hill.


Despite interest in addressing social determinants of health to improve patient outcomes, little progress has been made in integrating social services with medical care. We aimed to understand how health care providers with strong motivation (for example, operating under new payment models) and commitment (for example, early adopters) fared at addressing patients' social needs. We collected qualitative data from twenty-two accountable care organizations (ACOs). These ACOs were early adopters and were working on initiatives to address social needs, including such common needs as transportation, housing, and food. However, even these ACOs faced significant difficulties in integrating social services with medical care. First, the ACOs were frequently "flying blind," lacking data on both their patients' social needs and the capabilities of potential community partners. Additionally, partnerships between ACOs and community-based organizations were critical but were only in the early stages of development. Innovation was constrained by ACOs' difficulties in determining how best to approach return on investment, given shorter funding cycles and longer time horizons to see returns on social determinants investments. Policies that could facilitate the integration of social determinants include providing sustainable funding, implementing local and regional networking initiatives to facilitate partnership development, and developing standardized data on community-based organizations' services and quality to aid providers that seek partners.


Accountable care organizations; Clinical care; Costs and spending; Health care providers; Health outcomes; Health policy; Payment models; Quality of care; Safety net hospitals; Social determinants of health


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