How CommonSpirit’s Primary Care Clinics are Addressing Social Needs

Perspectives from Elizabeth Miller Evans, PhD, Total Health Roadmap, and Adam Manypenny, CommonSpirit Health

Embracing their legacy of working closely with communities, CommonSpirit Health, a nonprofit hospital chain formed through the merger of Catholic Health Initiatives with Dignity Health, developed the “Total Health Roadmap” to guide local systems in integrating universal screening for health-related social needs and providing support for patients through community health workers (CHWs).

To support primary care clinics, CommonSpirith Health designed a screening form to understand each patient’s needs and desire for services. Each pioneer clinic in the health system integrated a full-time CHW to connect patients to needed services and programs. CHWs aligned their work with other care coordination activities, which greatly expanded the supports available to patients and enabled social workers and health coaches to practice at the top of their licenses.

As a result, CHWs have become essential contacts for community partners, helping CommonSpirit’s health systems to more effectively develop practical solutions for increasing community capacity and advancing equitable access to needed services. The Better Care Playbook spoke to Elizabeth Miller Evans, PhD, Director, Total Health Roadmap, and Adam Manypenny, Program Coordinator from CommonSpirit Health to share their insights about the process of implementing social needs screening and integrating CHWs into care.



Q: What have you learned about integrating social needs screening into care?

A universal or payer-agnostic approach is invaluable. At the outset, a common question from our providers was whether this was limited to patients with certain insurance coverage or conditions. The providers said that a universal approach — where everyone is offered the screener and access to a CHW — would be critical to their buy-in. They were frustrated with programs that were payer-specific. They wanted reassurance that any patient they saw could get screened and connected to resources when in need.

Q: What obstacles have you faced in adding CHWs to the care teams?

We are still figuring out how to sustain integration of CHWs. We are looking at value-based contracting and what the Centers for Medicare & Medicaid Services and state Medicaid agencies will do to support clinics that have integrated screening for social needs and the work of CHWs. The best path at the moment is to leverage value-based care and per-member per-month payments to cover the costs of CHWs along with social workers and health coaches. However, this only works to support universal access in markets that have strong accountable care organizations or clinically integrated networks. The payment and sustainability issues are challenging and we are trying to figure out how to make things work in the current infrastructure, where to raise our voices for change, and how to prepare for new infrastructure.

Q: How did you gain buy-in from clinic staff for this work?

Before integrating screening and CHWs into primary care, we spent time with clinic staff to listen to their concerns and ideas. Providers, care coordinators, office managers, and community health leads were part of the conversations. We then maintained close contact with all clinics through our CHW coordinators to work through barriers and make the most of new ideas and successes. The ongoing contact and sustained conversations have been critical to sustain buy-in and continued improvement of our implementation model. We also made sure to share patient success stories, as these stories illustrate the value of this work in individual lives.

Q: Are there any promising results from the pilots?

Early results show improved performance culture in our clinics, reduced identified needs in follow-up screens, reduced acute care utilization in patients with prior high utilization, and improved knowledge of resources and confidence in managing health. We will publicly share the evaluation report in the near future.