It takes more than just health care to address health concerns, especially for high-need, high-cost patients. That’s why health systems, insurers, and providers are exploring ways to ensure that basic needs like food, housing, heating, and transportation are met. According to a Commonwealth Fund review of the literature, addressing complex patients’ specific social needs can cut costs by reducing emergency department visits and hospital admissions.

Recognizing that it’s difficult to meet these nonmedical needs on their own, health care organizations are increasingly looking to forge partnerships with community-based organizations (CBOs) that provide some of the services their patients need. For example, health care providers are partnering with ride-share companies to help patients make it to doctor visits. Hospitals are coordinating discharges with food banks to provide nutritious food so recovering patients aren’t coming home to bare cupboards.

Evidence to Support Investment

There is promising evidence that providing supportive housing, both with and without case management, to people who are homeless or at risk of becoming homeless can reduce ED visits, admissions, and inpatient days and result in large decreases in health care costs. Similarly, home-delivered, medically tailored meals for those with chronic conditions or at nutritional risk have been found to significantly lower inpatient care utilization, 30-day hospital readmissions, and overall medical costs.

Beyond food and housing, efforts to modify patients’ homes to meet their medical needs, provide transportation to medical appointments, provide care management that links patients to medical and nonmedical supports, and give patients access to legal and other types of counseling all hold promise for better outcomes and lower costs. However, research on the return on investment for addressing health-related social needs is still nascent, and the availability of high-quality studies is limited.

Tools to Support Partnerships

For health care organizations and CBOs to build sustainable and effective partnerships, they will need three things: 1) information on who needs which specific supports; 2) data on the costs and resources required to provide these social service interventions; and 3) tools to estimate the financial risks and benefits from investing in health-related social needs.

That’s why the Commonwealth Fund has supported the Return on Investment (ROI) Calculator, which allows organizations to learn how their social needs investment might pay off in terms of cost savings and changes in the amount of health care complex patients use.

While partnering across sectors presents challenges, it also provides opportunities for organizations looking to provide better care and lower costs for high-need, high-cost adults. Our hope is that the ROI Calculator, developed by Dr. Victor Tabbush of UCLA and based on work conducted by the SCAN Foundation, will help guide partnering organizations looking to provide person-centered care for complex patients.