Many health outcomes are shaped by non-clinical factors, including social determinants of health (SDOH). Unmet social needs, including food insecurity, housing instability, and lack of transportation access, can present barriers to accessing care, leading to poorer health outcomes, and avoidable hospitalizations and emergency department visits.^2,3  A key part of engaging patients and their families is focusing on unmet social needs, both to improve health outcomes and build positive relationships with dually eligible individuals. Addressing SDOH is particularly important for dually eligible individuals, who have higher levels of unmet social needs than Medicare-only beneficiaries, resulting in poorer outcomes and higher costs.⁴ RIC has developed resources for health plans and providers looking to address SDOH for dually eligible individuals in order to improve access to Medicare and Medicaid covered services and care, while improving health outcomes and reducing costs.

² U.S. Department of Health and Human Services, Assistant Secretary for Planning and Evaluation (ASPE), (2016). Social Risk Factors and Performance Under Medicare’s Value-Based Purchasing Programs. Retrieved from https://aspe.hhs.gov/system/files/ pdf/253971/ASPESESRTCfull.pdf.

³ National Academies of Sciences, Engineering, and Medicine, (2016). Accounting for Social Risk Factors in Medicare Payment Programs: Identifying Social Risk Factors. Retrieved from https://www.nap.edu/catalog/23513/ accounting-for-social-risk-factors-inmedicare-payment-criteria-factors.

⁴ Sorbero, M., Kranz, A., Bouskill, K, Ross, R., Palimaru, A., and Meyer, A. (2018). Addressing Social Determinants of Health Needs of Dually Enrolled Beneficiaries in Medicare Advantage Plans Findings from Interviews and Case Studies. Retrieved from https://www.rand.org/content/dam/rand/pubs/research_reports/RR2600/RR2634/RAND_RR2634.pdf.

Motivational interviewing is a collaborative and supportive counseling approach to help individuals make changes in their behavior through fostering a deeper understanding of individual circumstances and experiences.⁵ Motivational interviewing can be used by primary care providers, care managers, community health workers, and other frontline staff to engage participants in a wide variety of settings, including in behavioral health care, primary care clinics, and communities. RIC has developed resources for providers and health plan staff looking to utilize motivational interviewing as a part of their PFE strategy.

⁵ Miller W, Rollnick, S. (2013). Motivational interviewing: helping people change. Guilford Press.

In a person-centered care model, people are empowered to participate as active partners in discussions and decisions about their care. Person-centered care:

• Considers a person’s diagnosis, condition, and disability in the context of the whole person, and
• Focuses on supporting and communicating with people by emphasizing their strengths, capabilities, and opportunities to reach their chosen goals.^6,7

RIC has developed resources for plans and providers serving dually eligible individuals with guidance and examples for using person-centered language and enhancing delivery of person-centered care.

⁶ Kumar, R. & Chattu, V. K. (2018). What is in the name? Understanding terminologies of patient-centered, person-centered, and patient-directed care! Journal of Family Medicine and Primary Care, 7(3), 487-488. https://dx.doi.org/10.4103%2Fjfmpc.jfmpc_61_18.

⁷ Resources for Integrated Care. (2014). Integrating Behavioral Health Competency within Disability-Competent Teams [PowerPoint Slides]. Retrieved from https://resourcesforintegratedcare.com/sites/default/files/Presentation%20- %20Integrating%20BH%20Comtetency%20within%20DCC%20Teams%20-%20Disability-Competent%20Care.pdf.

Self-management support:

• Is “assistance provided by clinicians and public health practitioners to enhance an individual’s self-efficacy in managing one or more chronic conditions.”⁸
• Increases people’s skills and confidence in managing their health challenges, including regular assessment of progress and problems, goal setting, and problem-solving support.⁹
• Includes a wide range of behaviors on which individuals might focus to maintain their health – such as diet, exercise, sufficient sleep, social outlets, and stress reduction.

When individuals acquire self-management skills and use these skills over time, they gain autonomy over their health and health care choices, which may lead to longer, more satisfying lives. In addition, self-management has been demonstrated to increase individuals’ satisfaction with health care, reduce the cost of care, and improve health outcomes for persons with a variety of chronic health conditions.¹⁰ Other self-management benefits include increased engagement in health care decision-making and stronger member and care team relationships. Providing self-management support is, therefore, a key activity for health care providers seeking to deliver integrated, high-quality health care. Health care providers can utilize the appropriate training, tools, and resources to assist individuals with developing self-management skills and tracking their health progress. RIC has developed many products to help organizations and providers better understand self-management support and to implement self-management support strategies.

⁸ Centers for Disease Control and Prevention. (2020). Self-management support and education. Best Practices Guide. https://www.cdc.gov/dhdsp/pubs/guides/best-practices/self-management.html.

⁹ Adams, K. & Corrigan, J.M. (2003). Priority areas for national action: Transforming health care quality. Institute of Medicine. Washington, DC: National Academies Press.

¹⁰ Lorig, K.R., et al. (2001). Chronic disease self-management program: 2-year health status and health care utilization outcomes. Med Care, 39(11):1217-23.