Signify Health, a tech-enabled provider of at-home care solutions, has teamed up with health insurer Independence Blue Cross to launch CommunityLink.
CommunityLink is a network of community-based organizations that aim to help improve the social determinants of health (SDoH) in Independence’s Philadelphia member population.
The goal of the partnership with Signify: to address the “traditional barriers between social and clinical care” and improve health outcomes by assisting with non-medical services, such as nutrition, transportation, financial support and house work, among other areas.
The partnership connects Independence’s registered nurse health coaches, Signify’s social care coordinators and local community-based organizations to coordinate care on behalf of Independence’s Medicare Advantage (MA) members.
“What’s happening is our physicians and nurse practitioners are going into the homes of Independence’s Medicare Advantage members and observing issues that members may have outside of the traditional health system,” Nathan Goldstein, Signify’s chief strategy officer, told Home Health Care News. “So when they experience food insecurity, loneliness, lack of access to transportation — things of that nature — they’re now able to trigger referrals directly into this network of community-based organizations.”
Signify Health is a value-based care company that focuses on bringing services to the home and to the community. It is one of the largest providers of house calls in the country, conducting over 1 million in-person house calls and 300,000 telehealth encounters per year through a network of physicians and nurse practitioners.
The company is also the largest convener of the U.S. Centers for Medicare & Medicaid Services’ Bundled Payments for Care Improvement (BPCI) post-acute care program.
Thus far, the CommunityLink network includes these diverse, community-based organizations: Project HOME, Metropolitan Area Neighborhood Nutrition Alliance (MANNA), Penn Asian Senior Services (PASSi), Philadelphia Food Trust, Legal Clinic for the Disabled, Well Spouse and Greater Philadelphia YMCA.
The goal is to get more community-based organizations signed on in the coming months.
Just as seniors have comorbidities from a strictly health perspective, they also have “social comorbidities,” Goldstein said.
For instance, a senior may be missing primary care appointments, but instead of the reason being tied to transportation, it has to do with the fear of leaving his or her partner with dementia at home alone.
“Because at-risk patients have clinical comorbidities and social comorbidities that exacerbate them, we need to bring the same effort to coordinate the social care that we do with the clinical care,” Goldstein said.
Home health and home care organizations have not yet become a part of CommunityLink, but they could have a role in the future. Independence and Signify hope to expand the network quickly, both by adding organizations and stretching its footprint geographically.
“We’re going to expand as quickly as we can,” Daphne Klausner, Independence’s SVP of senior markets, told HHCN. “I think we need to include as many community organizations as possible. But it’s not only about expanding to community organizations, it’s also hospital systems and other types of providers, including [home-based care] agencies.”
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association. It is one of the major health insurance organizations in southeastern Pennsylvania, with about 8 million members nationwide.
The CommunityLink network is based on a holistic approach, combining in-home care with a better way of managing collective health in the community. Each organization can trigger a referral for another one that a patient may need.
For example, say a community-based food organization is referred based on a patient’s inability to obtain fresh and readily available food. Then, when it begins to provide services, it realizes the patient also has transportation struggles. That organization can, in turn, refer within the network to help the patient out with transportation as well.
Beginning in 2021, clinicians and other health care providers will also be able to refer patients to the CommunityLink network.
Home- and community-based care is being leveraged by Independence and Signify, which is already a home-based care company itself. But the program is largely built on the concept that organizations that have helped their local communities for years can come together to collectively lift the population to better health.
CommunityLink is a first-of-its-kind concept, according to Independence and Signify.
“This program came out of our experience from over a decade of doing these home visits and realizing that we were seeing things in the home that were not known to the traditional health system, and that the traditional health system was not particularly well organized to address,” Goldstein said. “But there were organizations in these communities, some with a century of experience in addressing these issues, and we wanted to find a way to connect those to the traditional health system.”
While CommunityLink is new, Independence and Signify have worked together in the past. They began plotting CommunityLink pre-COVID-19.
Its purpose will be particularly useful during and after the ongoing public health crisis, however.
Addressing SDoH has been a trend within health care over the last few years, with home-based care agencies often being called upon to help address them.
Since 2018, CMS has carved out ways for MA plans to address SDoH factors, more specifically with the concept of the broader “Special Supplemental Benefits for the Chronically Ill” (SSBCI) pathway created in 2019. More than 900 plans will be including SSBCIs in their coverage in 2021, a vast increase compared to the 245 plans to do so this year.
Similar to CommunityLink, SSBCIs aim to help with transportation, nutrition assistance and other around-the-house activities.