Community-Based Care and Social Determinants of Health

Community-Based Care and Social Determinants of Health

HMA bring experience and expertise in system transformation, care delivery, value-based payment models, and operations to help ACOs and Community Partners (CPs) address the social determinants of health (SDOH). We understand the diversity of the MassHealth membership and the importance of cultural sensitivity in addressing SDOH. We also understand important cultural differences between ACOs, CPs, and community-based social services organizations, and we leverage this understanding to help ACOs and CPs build strong, sustainable partnerships. We bring our expertise in working with providers in Massachusetts and across the country to help ACOs and CPs establish effective partnerships with community providers around a common set of goals.

We fully appreciate the important role of the SDOH and its effects on health and cost outcomes. We help ACOs and CPs integrate the social determinants into screening tools to identify needs and to create concrete ways to address these member needs. We look forward to meeting the needs of ACOs and CPs, and respond to requests for technical assistance in the following additional areas:

  • Roadmap for Addressing SDOH
  • Education and Training
  • Contracting Assistance
  • Resource Guide
  • Operational Assistance
  • Strategies and Interventions
  • Analysis and Evaluation

For more information, contact [email protected]

Meet Our Team

The HMA Community-Based Care and Social Determinants of Health Domain team, which is led by Ellen Breslin, includes local and national experts with experience working to support the needs of ACOs and CPs as they move into an accountable care environment.

Heidi Arthur LMSW

New York, NY

Jaimie Bern APRN, MSN, MPH

Managing Principal
Boston, MA

Ellen Breslin MPP

Boston, MA

Rob Buchanan MPP

Associate Principal
Boston, MA

Liddy Garcia-Bunuel

Baltimore, MD

Missy Garrity MBA, PMP

Associate Principal
Boston, MA

Madeleine (Maddy) Shea PhD

Baltimore, MD

View Our Recent Work

Technical Assistance for Conference for MassHealth Behavioral Health Providers

  • Project Challenge or Goals: To plan a conference to support a large group of behavioral health providers in preparing for MassHealth transformation, to create a conference agenda around sections of information on MassHealth’s DSRIP program, to explain value-based payment and the types of models that behavioral health providers might consider; and, to summarize all information in accessible conference materials
  • Project Period: June-September 2016
  • Project Description: HMA was hired by ABH to develop a full one-day conference for behavioral health providers, to present, to prepare presentations, and to write Issue Briefs to prepare behavioral health providers for the DSRIP initiative
  • Project Achievements: Increased the readiness of behavioral health providers to participate in transformation, with a better understanding of payer and ACO expectations

A Framework and Analytic Model for State of Minnesota to Measure Health Disparities in Medicaid Populations, Accounting for Social Risk Factors

  • Project Challenge or Goals: To determine a framework and methodology to examine health disparities in the Medicaid population based on demographic, medical, and social risk factors, and to develop the analytic file and conduct the analysis, so interventions and strategies could be developed to address these health disparities
  • Project Period: 2016-2017
  • Project Description: The State of Minnesota hired HMA to examine health disparities in the Medicaid population based upon a stratification of the population by demographic, medical, and social risk factors such as poverty, housing, involvement with correctional institutions, and an array of child risk factors such as parental mental illness and trauma
  • Project Achievements: First-ever analysis of Medicaid population and health disparities measured by demographic, medical, and social risk factors including income and housing status. Health disparities were measured for mortality, morbidity, and health care access, use and quality, with a formal Legislative Report summarizing findings

Social Determinants of Health: Adjustment for Payment and Measuring Outcomes

  • Project Challenge or Goals: To provide states with a comprehensive understanding in key considerations in using the SDOH in payment approaches and in measuring quality
  • Project Period: March-July 2017
  • Project Description: HMA was hired by State Health Value Strategies (a program of the RWJ Foundation) to provide states and policy makers with guidance about accounting for the SDOH in payments to ACOs and MCOs and in quality measures.
  • Project Achievements: HMA prepared an Issue Brief for states, providers, and plans, followed by a webinar on this topic. This issue brief explains why it is important to account for SDOH in payment, and what to consider in accounting for SDOH in quality measurement for community-based care. Brief and webinar recording:

Healthy Neighborhoods in Delaware

  • Project Challenge or Goals: To provide a model for funding local neighborhood-based initiatives in four priority areas: maternal child health, behavioral health, chronic disease prevention and management, and healthy lifestyles, community-based care.
  • Project Period: October 2017 – present
  • Project Description: HMA was hired by Delaware’s Health Care Commission to create a model for distributing the funds to neighborhood task forces, to create and implement a sustainability plan, and to provide technical assistance to communities on community-level data.
  • Project Achievement: HMA created an effective funds-distribution process and is currently providing technical assistance to local council and task forces to ensure that community-generated initiatives use evidence-based models, achieve community buy-in, use logic models and data to support community needs, and build detailed budgets. HMA has drafted a sustainability model using a community development financial institute (CDFI) and a wellness trust.