Grant Helps Hackensack University Medical Center Optimize Protocols for Care

Systematically Identifying and Addressing the Health-related Social Needs of Medicare and Medicaid Beneficiaries

Under the direction of Manisha Parulekar, M.D., staff physician in the Division of Geriatrics at Hackensack University Medical Center, the Accountable Health Communities (AHC) Program studies gaps between clinical care and community services, and tests whether systematically identifying and addressing the health-related social needs of Medicare and Medicaid beneficiaries through screening, referral, and community navigation services will impact health care costs and optimize health care utilization.

“We welcome this collaboration with partners in the community to improve the health and well-being of the patients we serve,” says Dr. Manisha Parulekar. “Our community has a variety of dedicated organizations that specialize in meeting these needs. It makes sense for leading health providers like HUMC to collaborate closely.”

The program design includes screening beneficiaries at clinical delivery sites for health-related social needs in the areas of housing, utilities, food, transportation, and interpersonal violence, providing community resource summaries, and facilitating short-term community navigation services for eligible high-risk patients.

All patients who are screened positive for any social determinants get a tailored resource guide based on their need and zip code. High-risk patients, those who have been in emergency department two or more times, 70% are assigned to patient navigators who assist them in getting the necessary resources in the community—while 30% only get a resource guide to act as a control group to aid in the research study by CMMI.

“This project furthers our commitment to improving population health,” adds Andrew Pecora, M.D., chief innovation officer and president of the Physician Services Division at Hackensack Meridian Health. “We will continue to serve as a leader by optimizing protocols and identifying best practices to deliver comprehensive care.”

Hackensack University Medical Center is one of 32 organizations nationwide currently participating in the CMS Accountable Health Communities (AHC) model.

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