Accountable care organizations struggle to integrate social services despite commitment and effort

April 20, 2020

The cost and quality of care that many patients receive can be directly impacted by social factors, including housing, transportation, social and economic support, nutrition and more. Many health care organizations are beginning to incorporate strategies to address these factors. One such strategy involves adopting an accountable care organization (ACO) model, which provides funding incentives to create more efficient patient care.

Some organizations have committed to integrating social services by becoming early adopters of an ACO model, but new research shows that commitment alone does not alleviate many of the challenges these ACOs face in addressing the social needs of their patients.

Dr. Valerie Lewis

Dr. Valerie Lewis

Valerie Lewis, PhD, associate professor of health policy and management at the UNC Gillings School of Global Public Health, is senior author on a study recently published in Health Affairs that investigates these difficulties.

The group of ACOs in the study understood the need to address social determinants of health, particularly transportation, food and housing needs. Implementing strategies to do so, however, was not easy, in part because many ACOs had trouble conceptualizing a formal strategy. Questions arose when considering what services were necessary, how they would be provided and the effect on they would have on an organization’s bottom line.

Oftentimes ACOs simply lacked data on their own patients’ needs. Only half of ACOs in the study had a standard screening process in place, and the protocols for documenting and communicating data to relevant decision-makers varied. ACOs also lacked information on the organizations in the community that they could partner with to provide social services. Very few had formal processes in place to understand the quality and capabilities of their community partners. Relationships were often informal, with no procedures to track referrals or understand how social services were being used.

While some ACOs in the study chose to directly offer social services to patients in-house – namely transportation, food and financial support – a large majority found it more feasible to refer patients to community organizations. However, these partnerships were difficult to establish due to limited knowledge and working relationships with potential partners. The formality of these partnerships varied, and while many were coordinated and contract-based, some were informal and lacked a consistent set of services to be provided.

The cost of service integration was also a significant hindrance. Many ACOs in the study felt constrained in their efforts to implement social programs due to limited financial support. Beyond total levels of available funds, organizations ran into challenges from fiscal regulations that came with being an ACO. In the long term, concerns about return on investment and profitability were also a challenge to the sustainability of any service offerings.

Lewis’ team suggested potential remedies to some of the challenges, including a two-pronged intervention designed to improve patient referral to social services through an online referral tool and a series of networking events that would help health care providers and community-based organizations become acquainted.

“While ACO payment models have been inadequate to overcome the chasm between social services and health care,” the team wrote in the study, “payment models layered with strategic connections and shared information between these sectors may prove effective.”

Contact the UNC Gillings Team of Global Public Health communications team at

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