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Linking Medical Homes to Social Service Systems for Medicaid Populations

Systems for Action Research-In-Progress Webinar Series


Sarah Schoole, DrPH, MPH

Keri Christensen, MS,
National Committee on Quality Assurance

Social risk factors such as low socioeconomic status are linked to poor health outcomes, increased emergency department (ED) visits and impact health care quality, cost, and use. Assessing and addressing these social risk factors can lead to improved patient outcomes. However, making connections between organizations who provide social services addressing these risk factors and those who provide medical services is very challenging due in part to systems which do not “talk” to each other. In this study researchers will evaluate the linking of information technology systems between patient-centered medical homes and social service providers as a means of improving the health and well-being of Medicaid patients. The research team will investigate if the use of a web-based communication and care management platform that digitally connects medical homes and social service providers improves the identification and delivery of services to address social risks, quality of care, and unnecessary ED utilization. Findings from this study will identify best practices and guidance for other communities.