TULSA – The federal Center for Medicare and Medicaid Services (CMS) has approved the Route 66 Accountable Health Communities (AHC) program for statewide expansion after its initial success screening thousands of patients in Oklahoma City and Tulsa for social needs that impact their overall health.
A $4.5M cooperative agreement, awarded in 2017 to MyHealth Access Network, brought together a coalition of clinical healthcare providers and community resource agencies with the Tulsa Health Department (THD) and the Oklahoma City-County Health Department (OCCHD) to form the “Route 66 Consortium.” This group has now grown to include hundreds of clinics and ERs in many large health care systems, including Utica Park Clinics, Hillcrest Health Care System, SSM Health St. Anthony and OU Medicine working in tandem with social service providers.
This growing coalition has been screening patients in five key areas that contribute to overall poor health outcomes: housing insecurity and quality, food insecurity, utility assistance, interpersonal violence, and transportation needs. Patients seeking medical care in participating facilities are sent a social needs screening on their phones asking questions related to these needs and are then immediately given a list of real time personalized resources based on their home address. This mobile screening and resource referral brings help to the most vulnerable groups in a way that adds no additional burden to clinical staff. In addition, high-risk beneficiaries are connected with AHC community health workers, called “navigators.” THD and OCCHD provide these navigators, who then work with patients and their families to identify social needs and help connect them to community resource organizations such as food banks, shelters, utility assistance programs and reduced-fair ride services.
Initial data assembled by the program shows that social needs are prevalent across all groups; 24 percent of all patients screened reported needing assistance in one of the core social need areas, with up to 45 percent of certain groups needing assistance. The most commonly reported needs were for assistance with food, utilities, and housing. The AHC program has now put over 2,000 of these patients in contact with real-time, personalized resources.
MyHealth CEO Dr. David Kendrick says the early results show how important it is to screen patients for these issues.
“Traditional medical care can only do so much when you don’t know where your next meal is coming from or if you are going home to an unsafe living environment,” said Kendrick. “The Route 66 AHC program is helping Oklahomans gain access to services that can address these needs. It’s also teaching us a lot about why Oklahomans who are getting treatment aren’t getting better, and how to get them the non-medical help they need.”
In Oklahoma City, OCCHD Director Gary Cox said his staff was gaining valuable information on how to better serve residents.
“We’re eager to see the program grow in Oklahoma County, generating more useful data, but more importantly, positively impacting residents who need the tools to overcome factors like food or housing instability, transportation needs, financial insecurity or violence in their homes, which are all barriers to better health,” Cox said.
Tulsa Health Department (THD) Executive Director Dr. Bruce Dart says identifying non-medical needs is a key part of improving the state’s long-term health.
“Our navigators are in the field having daily talks with real individuals who struggle with their health needs,” said Dart. “This cooperative agreement has funded these individuals to start the conversation at the ground level. From these visits, we gain a better understanding of the social determinants of health that keep them from accessing basic care. With this knowledge, we can make a greater impact by connecting them with the community partner resources to provide them with healthy food to eat, a safe place to live, utilities and transportation to employment or school. Over time, we should see an increase in community health improvement as a state.”
CMS’s approval of a statewide expansion means the AHC coalition can continue growing, not just in the state’s largest metro areas, but across Oklahoma.
To support that growth, the coalition is actively seeking new partners. Clinics and health care systems wishing to participate in the AHC program can contact the AHC team at MyHealth by email at AHC@myhealthaccess.net or by phone at 918-703-4766.
- Acknowledgment: “The project described was supported by Funding Opportunity Number CMS-1P1-17-001 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services.”
- Disclaimer: “The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.”