Alexander Billioux: Public Health’s Role in Screening for Health-Related Social Needs

July 16, 2019 | ASTHO Staff

Healthcare delivery systems and health insurance carriers are beginning to recognize the value of partnering with community-based organizations to address the needs of their patient populations and beneficiaries that occur beyond the clinic walls. A strong base of evidence highlights the connection between unaddressed health-related social needs of an individual patient—such as food insecurity, unstable housing, unmet utility needs, or interpersonal violence—and poor health outcomes and increased healthcare spending. There is also evidence to suggest that initiatives to improve social determinants of health at a community level (SDOH) have a fundamental impact on a community’s health. However, addressing the SDOH is outside of the responsibility of any single sector and requires long-term activity and investment before any sustained improvement in outcomes or reduction in utilization.

Alexander Billioux, MD, DPhil, assistant secretary of the Louisiana Department of Health, has a vision that moves beyond screening for health-related social needs toward investments in upstream improvements to SDOH in Louisiana. Having previously served as the Director of the Division of Public Health Incentives and Infrastructure at the Center for Medicare and Medicaid Innovation (CMMI), Billioux has dual expertise in the federal and state-level policy landscapes. His work illustrates the role public health agencies play in leading healthcare delivery system efforts to address both individual health-related social needs and community-wide SDOH.

During Billioux’s tenure, CMMI developed the Accountable Health Communities (AHC) Model to test whether systematically screening for and addressing five health-related social needs reduces total healthcare costs or improves health outcomes. The AHC model funds bridge organizations to act as a hub that connects individuals who are dually eligible for Medicare and Medicaid to community service providers. Although the model is early in implementation, some bridge organizations have reported challenges ensuring that community resources are available once a patient screens positively for a health-related social need. Thus, bridge organizations that participate in a sub-track of the AHC model (the alignment track) are additionally tasked with aligning partners at the community level to ensure that community services are available and responsive to the needs of screened patients.

Under Billioux’s leadership, the Louisiana Department of Health is currently piloting a program in St. Landry Parish to screen for health-related social needs and provide community service navigation assistance to high-risk individuals. The pilot mirrors the alignment track of the AHC model but will distinctly include public health leadership. The Louisiana Department of Health will begin rapidly scaling the pilot to five additional parishes over the next six months, with expansion statewide by the end of 2020. The pilot is intended to help collect the data necessary to identify gaps and inform local investments in community services.

By having the state health agency lead the pilot in Louisiana, Billioux is hoping to shine a light on valuable public health capabilities. First, public health agencies’ informatics, data analytics, and visualization capabilities are instrumental to navigating through various data sources and making available information usable by the community and cross-sector stakeholders. Second, public health agencies can help community-based organizations articulate their value proposition and manage incoming funding streams from different financial arrangements and partners, as community-based organizations increasingly enter into contracts with healthcare delivery systems. For example, the state health agency can assist with standardizing reporting and information-sharing expectations across health systems in the state. Lastly, public health agencies can apply inclusive improvement processes used in community and state health assessments and improvement plans—such as community representation on advisory boards or web-based community comment periods—to ensure that policies and activities to address SDOH also advance health equity.

Healthcare organizations that screen for and address health-related social needs are often driven by the pursuit of a short-term cost-savings, achieved by addressing the needs of their highest utilizers. This goal maintains a focus on short-term return on investment rather than population-wide SDOH investments. As public health officials begin to engage in cross-sector partnerships that advance SDOH, Billioux says that “partners ought to focus their attention on ‘big wins’ with an emphasis on community-level returns on investment more than ‘quick wins’ at the individual-level. This is how to achieve sustained, improved health and wellness for a whole population.”

Billioux hopes to see other health officials take a leading role in managing and coordinating AHC and AHC-like models, as well as ensuring that community-driven priorities are held central and opportunities for health and wellness are available to all. In addition, public health’s involvement is instrumental in breaking down potential silos that may be created when community resources are bought up by healthcare systems, as well as ensuring that a community’s capacity to address SDOH is improved. Billioux notes: “If healthcare systems ‘own’ social services, it will replicate the existing systems without improving delivery or integration.”

Billioux emphasizes that healthcare delivery systems and health insurance carriers do not need to be experts in SDOH to help patients navigate community-based services. However, they can be good partners with public health agencies, who have expertise to effectively address SDOH.