Why Community-Based Organization Integration Matters for Healthcare Costs & Outcomes

80% of health outcomes are influenced by non-clinical factors, which is particularly crucial for Medicaid and Medicare care.

A record number of Americans face housing instability and homelessness, food insecurity is increasing, and one in four adults struggles to afford their medications—demand for Community-Based Organization (CBO) services consistently exceeds available resources.

CBOs help with housing, food, etc., enabling patients to overcome non-clinical factors.

More recently, there has been a push for healthcare organizations to pay CBOs for their services, either through MCOs' "in lieu of services" (ILOS) or through funds from the 1115 waiver.

Recent CMS guidance outlines requirements for states to clearly define ILOS, the target populations, and processes for determining medical appropriateness and cost-effectiveness in MCO contracts.

It seems like a win-win-win scenario.

Instead of CBOs having to raise money through private sources, they can make money through healthcare dollars.

Patients get foundational social needs met.

And MCOs should get to decrease the cost of care by addressing critical social needs.

While studies are sparse, it's my current view that integrating CBOs into healthcare can improve patient outcomes and CBO stability, but several barriers exist. Here are some:

• Social drivers of health are complex to address

• Coordination between healthcare providers and CBOs is challenging

• Patients often don't follow through on referrals by themselves

• Patients find the social service system hard to navigate and may mistrust it

• Barriers like transportation, language, and time hinder access

• CBO interventions are rarely evaluated for effectiveness (this is critical because services have to result in positive health outcomes)

To tackle some of these barriers in states with the 1115 waiver, social care networks have been used.

Currently, here are some of the things on my wishlist to integrate CBOs into healthcare:

• Form MCO-CBO partnerships ensuring CBOs are paid

• Provide data showing CBO capacity

• Enable CBOs to close care gaps with AI or CHWs

• Allow CBOs to show patient outcome data

• Create or leverage distribution channels to reach eligible patients

• Provide low-interest loans to help CBOs get initial funds and support the reimbursement period of services

Aligning incentives for preventative care and supporting CBO participation and formation are key steps.

Despite challenges, greater inclusion of social services is vital for improving care and controlling costs.

I'm always learning, and I would love feedback. What did I miss?