How MassHealth Tackles Social Health Needs

by Jon Scaccia November 11, 2024

The link between health and social circumstances is undeniable. Factors like housing, transportation, food security, and financial stability, known as health-related social needs (HRSNs), heavily influence an individual’s ability to maintain good health. For Medicaid members, particularly those in programs like Massachusetts’ MassHealth, these needs often remain unmet. This leaves individuals vulnerable to worsening health outcomes, higher medical costs, and widening health disparities.

But here’s the exciting part: addressing these social needs holds the potential to significantly improve lives. That’s exactly what a recent study on MassHealth members aimed to explore. By delving into the experiences of those covered by MassHealth, the researchers wanted to understand how members engage with their healthcare providers to discuss their HRSNs, what barriers they face, and what could be done to help address these unmet needs more effectively.

The results? A mix of hope, challenges, and clear opportunities to better serve those with complex health and social needs. Let’s dive into what this study found and what it means for the future of Medicaid services.

The Importance of Health-Related Social Needs (HRSNs)

Before we jump into the findings, let’s set the stage. HRSNs refer to the non-medical factors that affect a person’s health. Imagine trying to follow a doctor’s advice to eat healthier when you can barely afford groceries or struggling to keep medical appointments because reliable transportation isn’t available. These needs—whether related to housing, transportation, or food—can act as invisible barriers, keeping people from reaching their best health.

These barriers are often more pronounced for Medicaid enrollees. Low-income individuals, who represent the bulk of Medicaid members, frequently experience higher rates of HRSNs, which puts them at an even greater disadvantage when it comes to maintaining good health.

In recent years, efforts to identify and address these needs have ramped up. Healthcare organizations are screening for HRSNs and creating partnerships with community organizations to connect patients with the right support. But how well is this working for those in the system?

What the Study Revealed

Researchers conducted in-depth interviews with 44 MassHealth members, asking about their experiences with discussing their HRSNs in healthcare settings. The study revealed three major themes:

1. Communication About Social Needs Some members felt comfortable discussing all aspects of their needs with healthcare providers, while others felt hesitant. Interestingly, many members preferred discussing their social needs with community-based care coordinators rather than their healthcare clinicians. This reflects a level of distrust or discomfort in clinical settings, possibly stemming from fears of being judged or not taken seriously.
2. Addressing Social Needs While many members reported that their needs were discussed, they noted varying levels of follow-up. Some clinicians referred members to community partners for support, and these referrals often led to positive outcomes. In fact, community-based care coordinators were praised for their role in connecting members to essential services, like housing or transportation. However, not all members had this experience. Some found that even after discussing their needs, no clear action was taken by their healthcare providers.
3. Barriers to Getting Help The study didn’t shy away from highlighting the many barriers members faced in addressing their needs. Transportation issues were a common complaint, as public transit options are often unreliable or inaccessible, especially for those with disabilities. Food insecurity was another big issue, with some members living in “food deserts” where access to nutritious food is limited. Housing instability also stood out, with several members struggling to secure affordable and stable housing.

These barriers were further complicated by the pandemic, which disrupted services and increased demand for assistance. Members often felt that they were left to navigate a maze of fragmented services on their own.

The Role of Community-Based Organizations

One of the most hopeful takeaways from this study was the pivotal role that community-based organizations play in helping MassHealth members meet their social needs. Members overwhelmingly praised these organizations for their hands-on approach and ability to navigate the complex web of social services. Whether it was helping members secure housing, food, or transportation, these care coordinators provided a lifeline for individuals facing significant challenges.

This highlights the importance of integrating community resources with healthcare systems. While healthcare providers are great at addressing medical needs, they often lack the time or expertise to address social needs. Community-based organizations can fill this gap, offering targeted support in areas like housing or financial assistance.

What’s Next? Opportunities for Improvement

The study clearly shows that screening for social needs is a step in the right direction, but it’s not enough on its own. Building strong, trusting relationships between Medicaid members and their care teams—especially those involving community health workers and social workers—will be crucial to addressing these needs in a meaningful way.

Additionally, policymakers and healthcare providers must focus on creating systems that make it easier for members to talk about their social needs without fear of stigma or judgment. This might involve expanding the use of community-based care coordinators or increasing training for clinicians on how to address social needs effectively.

Finally, addressing the logistical barriers members face—like unreliable transportation or long waitlists for services—will require continued investment and cross-sector collaboration. Healthcare providers, policymakers, and social service organizations need to work together to streamline services and ensure that members can easily access the help they need.

Join the Conversation

What are your thoughts on integrating community-based care into healthcare settings? Have you experienced or seen the impact of addressing social needs in a healthcare setting? Share your insights and experiences in the comments or on social media!

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