Organization Overview
SCAN Health Plan, a prominent Medicare Advantage Health Maintenance Organization in California, began its journey in 1977 with a commitment to the health and independence of seniors. Originating as a social service entity, SCAN’s deep-rooted understanding of community needs has been pivotal in its evolution. Its early involvement with California’s Multipurpose Senior Services Program (MSSP) solidified its dedication to vulnerable populations. By 1985, SCAN pioneered the Social Health Maintenance Organization (SHMO), integrating community-based services with medical care, demonstrating a forward-thinking approach to holistic healthcare. Even after the SHMO program concluded, SCAN continued to innovate, launching Medicare Advantage plans and, in 2008, a Special Needs Plan (SNP) tailored for individuals dually eligible for Medicaid and Medicare.
Recognizing the significant impact of social determinants of health on dual-eligible members, SCAN proactively addressed issues like poverty and social isolation. This led to the implementation of comprehensive social needs screening and referral programs across all member categories, aiming to enhance health outcomes and manage care costs effectively. This case study delves into SCAN Health Plan’s impactful strategies for tackling social needs, emphasizing the pivotal role of tools and processes in connecting patients with vital community resources. SCAN’s initiatives highlight the critical function of roles like care navigators within health plans aiming to provide truly holistic patient care, potentially shaping the future of care navigator job descriptions and responsibilities within similar organizations.
| Organization | SCAN Health Plan |
|---|---|
| Project | Standardize social needs screening and referral process, including: – Incorporating standardized social needs questions into the HRA for non-special needs members (called HRA for All) – Contracting with Aunt Bertha to implement community resource directory and referral system |
| Implementation Status | – Screening: SCAN began incorporating social needs questions into its HRA for All three years ago. – Referrals: SCAN contracted with Aunt Bertha and began implementing its community resource directory and referral system in early 2018. – 2019 marks Year 3 of SCAN’s work spreading its social needs screening and referral process to its entire member population. |
| Tools and Methods Tested | Health risk assessment (includes metrics related to social needs); Aunt Bertha screening and referral system |
| Funding Source(s) | This work is funded through SCAN Health Plan. |
Streamlined Social Needs Screening and Referral Workflow
SCAN Health Plan prioritized a seamless integration of social needs screening into existing workflows to minimize disruption and “survey fatigue” among members. Leveraging the existing Health Risk Assessment (HRA) framework was identified as the most efficient approach. California mandates HRAs for newly enrolled dual-eligible members, primarily focused on medical risks but also including homelessness screening and housing referral protocols. For SCAN, incorporating additional social needs inquiries into the HRA was a logical progression, enhancing their ability to understand and address member needs comprehensively.
The results from the HRA not only drive the type of programs we want to produce in the future, but they help inform how we navigate our existing programs: What do we need to focus on? What do we need to add to?
—Project manager
Initially piloted within the SNP health assessment, social needs questions were integrated into the broader HRA for All in 2016. This ensures all SCAN health plan members undergo social needs assessment upon enrollment and annually thereafter. Conducted via phone or in person, the HRA takes 10 to 20 minutes, with care navigators playing a crucial role in administering the assessment and inputting data into SCAN’s care management system. Post-assessment, members receive personalized care plans and may be enrolled in care management programs based on their risk level and needs complexity.
SCAN employs an electronic risk stratification algorithm to categorize members. Referral processes are risk-dependent: high-risk members (e.g., those screening positive for housing insecurity or elder abuse) are immediately connected to intensive care management and relevant community and clinical resources. Moderate-risk members receive tailored responses based on identified social needs and their willingness to accept support. Low-risk members are provided with educational materials and information on local services. This structured approach underscores the importance of care navigator positions in efficiently managing and directing members to appropriate resources.
Essential Roles: Care Navigators and Team Collaboration
The success of SCAN’s social needs program relies heavily on collaborative efforts across various staff roles. Care navigators are central to this operation, acting as the primary point of contact for members during the HRA process. Their responsibilities extend beyond assessment administration to include care plan development and initial resource connection. Complex care managers then step in for high-risk individuals, providing deeper intervention and coordination of services. Project managers oversee the entire program, ensuring smooth operation, data analysis, and continuous improvement. This team-based model highlights the diverse skills required and the collaborative nature inherent in care navigator jobs and related healthcare support roles.
Technology as a Catalyst: Aunt Bertha Platform
SCAN Health Plan strategically partnered with Aunt Bertha (now findhelp.org) to implement a comprehensive online community resource directory and referral system. This platform enhances accessibility for members and streamlines referral processes for staff, demonstrating how technology can significantly augment the efficiency of scan health plan care initiatives. Aunt Bertha’s platform is utilized in three key formats:
- Public Website (Community Connections): Accessible via the SCAN website, this member-facing portal empowers members and caregivers to independently search for resources and share referrals. Users can create personalized resource libraries, fostering self-service and proactive engagement.
- Private Referral Website: This staff-facing version of Aunt Bertha enables SCAN personnel to directly refer members to programs and track referral progress. Data analytics from this platform provide valuable insights into service utilization, popular resource categories, and high-demand organizations, informing strategic program development. Single sign-on integration simplifies staff access, enhancing workflow efficiency.
- Anonymous Staff Website: SCAN is also implementing an internal, anonymous version for staff to confidentially seek personal resources. This demonstrates SCAN’s commitment to employee well-being and recognizes that social needs are not limited to their member population.
These interconnected platforms, all linked to the same resource database, offer varied levels of anonymity and functionality. SCAN aims to deepen partnerships with community organizations to increase the number of “claimed” social service programs on Aunt Bertha, facilitating electronic referrals and enabling closed-loop feedback on referral outcomes. This ambition reflects a broader move towards integrated, digitally-enabled health plan care navigation.
Tangible Results and Future Directions
Since integrating social needs questions into the HRA for All in 2016, SCAN has assessed approximately 16,000 members. In the past year alone, over 18,000 resource searches have been conducted via the Aunt Bertha platform, illustrating substantial utilization and impact. Future steps include full deployment of the internal Aunt Bertha website and enhancing the closed-loop referral feature. While the system supports closed-loop referrals, community organization engagement in this aspect requires further development and training to fully realize its potential. Strengthening community partnerships remains a priority for SCAN to optimize this crucial feedback loop.
Key Takeaways from SCAN Health Plan
SCAN Health Plan offers valuable lessons for organizations embarking on social needs screening and referral programs:
- Phased Implementation of Closed-Loop Referrals: Implementing a comprehensive community resource directory and closed-loop referral system is complex. A phased approach, starting with internal adoption and community directory uptake before focusing on closed-loop functionality, can mitigate challenges and ensure smoother integration.
- Strategic Social Needs Questioning: Selecting and validating appropriate social needs questions is critical and requires careful consideration of regulatory requirements and patient-centered care principles. The “right” questions may vary across organizations, necessitating a tailored approach.
- Leadership Alignment and Care Philosophy: The successful implementation at SCAN was facilitated by pre-existing organizational buy-in for a patient-centered, geriatric approach to care. This holistic philosophy, emphasizing psychological and social factors alongside medical needs, is beneficial even beyond geriatric populations, and crucial for organizations aiming to integrate social needs into their health plan care models. This underscores the importance of a supportive organizational culture when considering expanding care navigator job roles and responsibilities to address social determinants of health.
