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Social Risk Factors and Medicare's Value-Based Purchasing Programs: Social Determinants Research

ASPE conducts a variety of research on social determinants of health.

Landscape of Area-Level Deprivation Measures and Other Approaches to Account for Social Risk and Social Determinants of Health in Health Care Payments

As HHS develops policies to improve equity, a key piece is targeting payments to screen for social risk and refer individuals to appropriate services. This environmental scan of area-level indices of social risk; measures used to target areas, providers, or populations with social risk; and existing payment models that use social risk measures identifies options for targeting Medicare payments to providers treating greater proportions of beneficiaries with social risk.

View the Landscape of Area-Level Deprivation Measures and Other Approaches to Account for Social Risk and Social Determinants of Health in Health Care Payments report.

Building the Evidence Base for Social Determinants of Health Interventions

In an effort to help build the evidence base around the social determinants of health (SDOH), the Assistant Secretary for Planning and Evaluation (ASPE) engaged RAND in a project to evaluate the current evidence from programs and policies targeting SDOH and identify the SDOH research questions, data sources, and data gaps that might be used to develop an SDOH research agenda. RAND used a multimethods approach that included an environmental scan of the published and gray literature of SDOH interventions; key informant interviews with subject matter experts; and a convening of U.S. Department of Health and Human Services (HHS) agencies and operating divisions to review the results of the environmental scan and offer insights on the findings. While this project identified a range of health benefits related to SDOH interventions, gaps remain in our understanding of what works to address certain types of social determinants, the specific intervention components that improve health, and which interventions might achieve sustained and lasting improvements in population health. To grow the evidence base, investments are needed from a broad range of funders including philanthropy and organizations within the health care industry. Further, an HHS-driven SDOH research agenda can help support approaches to close these gaps.

View the Building the Evidence Base for Social Determinants of Health Interventions report.

Developing Health Equity Measures

ASPE contracted with the RAND Corporation to identify existing health equity measurement approaches that might fit with Medicare’s value-based purchasing (VBP) programs, quality reporting efforts, and confidential reports. This report describes the methods and findings of the project and delineates potential first steps for the U.S. Department of Health and Human Services to consider as it continues to evaluate the prospect of incorporating health equity measures and domains in Medicare’s VBP and reporting programs.

View the Developing Health Equity Measures report.

Social Determinants of Health Data Sharing At The Community Level

This report represents a landscape review of community-level efforts to address SDOH, followed by interviews with participants in three community-level initiatives that have built networks to coordinate clinical and social services. This report presents a cross-site analysis of the three initiatives, highlighting factors they identified as facilitating their efforts, the challenges they have faced thus far, their plans for continued expansion, and opportunities for federal and state entities, among other actors, to contribute to their efforts.

View the Social Determinants of Health Data Sharing at the Community Level report.

Incorporating Social Determinants of Health in Electronic Health Records

The ASPE patient-centered outcomes research team contracted with NORC at the University of Chicago to interview electronic health records (EHRs) vendors about the collection and use of social risk information. The interviews sought to a) identify vendors’ motivations to develop social determinant software products, b) describe their products and uses, and c) identify facilitators and challenges to collection and use of social determinant data.

View the Incorporating Social Determinants of Health in Electronic Health Records report.

Medicare and Medicaid Use Among Older Adults in HUD-Assisted Housing

This paper describes the results of a pilot test to link HUD administrative data to CMS claims data for 12 geographic areas using 2008 claims. The results show that older adults receiving HUD assistance have higher Medicare and Medicaid utilization than individuals in the community not receiving HUD assistance. When comparing Medicare and Medicaid enrollees (MMEs) (i.e., dual eligible beneficiaries), MMEs receiving HUD assistance also used more health care services than MMEs not receiving HUD assistance.

Picture of Housing and Health: Medicare and Medicaid Use Among Older Adults in HUD-Assisted Housing

Picture of Housing and Health Part 2: Medicare and Medicaid Use Among Older Adults in HUD-Assisted Housing, Controlling for Confounding Factors

NCHS Data Linked to HUD Housing Assistance Program Files

NCHS has linked 1999-2012 National Health Interview Survey (NHIS) and 1999-2012 National Health and Nutrition Examination Survey (NHANES) to administrative data through 2014 for the Department of Housing and Urban Development’s (HUD) largest housing assistance programs: the Housing Choice Voucher program, public housing, and privately owned, subsidized multifamily housing.

More information about the NCHS Data Linked to HUD Housing Assistance Program Files is available.

Evaluation of Support and Services at Home (SASH) Model in Vermont

ASPE and HUD, through a contract with RTI International, have been evaluating the Support and Services at Home (SASH) coordinated care model in Vermont. The SASH program is designed to connect older adults living in affordable senior housing properties in Vermont with community-based health care and supportive services and attempting to slow the growth of health care expenditures.

Support and Services at Home (SASH) Evaluation: Highlights from the Evaluation of Program Outcomes from 2010 to 2016

Support And Services at Home (SASH) Evaluation: SASH Evaluation Findings, 2010-2016

Support and Services at Home (SASH) Evaluation: Highlights from the First Four Years

Support and Services at Home (SASH) Evaluation: Evaluation of the First Four years

Kandilov, A, Keyes V, van Hasselt M, Sanders A, Siegfried N, Stone R, Edwards P, Collins A, and Brophy J. The Impact of the Vermont Support and Services at Home Program on Healthcare Expenditures. Cityscape: A Journal of Policy Development and Research, 2018 20(2) 7-18

Housing with Services for Older Adults

This 2012 literature review was conducted for ASPE by the Lewin Group. This paper reviewed the literature on effectiveness on existing models of affordable housing with health or supportive services. The review found a range of program models, including a variety of types of services, and delivery methods (congregate or scattered-site).

The “Value Added” of Linking Publicly Assisted Housing for Low-Income Older Adults with Enhanced Services: A literature Synthesis and Environmental Scan

Health and Homelessness

Individuals who are chronically homeless, that is, have a disability and have been homeless for over one-year, often use a lot of health care and behavioral health services. Many individuals experiencing chronic homelessness are eligible for Medicaid and/or Medicare. ASPE has many reports on issues related to homelessness and health.

View ASPE’s Homelessness work.

Medicare-Medicaid Dual Eligible Beneficiaries:

Case Studies: Services for Dually Enrolled Beneficiaries by Medicare Advantage Health Plans

ASPE contracted with the RAND Corporation to conduct an environmental scan, interviews, and case studies to identify the types of services that Medicare Advantage plans implement to meet the needs of dually enrolled and other high-cost, high-need beneficiaries, as well as the types of resources needed to implement these services.

View the environmental scan.
View the interviews and case studies.

Minnesota Managed Care Longitudinal Analysis

This project studied the delivery of Medicare and Medicaid-funded services to dually eligible beneficiaries aged 65 and older in Minnesota. It compared fully-integrated managed care to service delivery when Medicare and Medicaid-funded services are delivered independently. The fully integrated Medicare-Medicaid managed care plans had greater primary care physician use and lower inpatient hospital and emergency department use. Similarly, home and community-based services use was greater and nursing home use was no greater. Once enrolled in the fully integrated plan, nearly all beneficiaries chose to remain, rather than switch to the alternative. In Minnesota, the fully integrated plan appears to be an improvement over the fragmented delivery systems of separate Medicare and Medicaid programs, yielding improved consumer satisfaction and service use.

View the full analysis.

Advancing Integrated Care: Lessons from Minnesota

This brief discusses how integrated care has taken shape in the State of Minnesota, highlights findings from a study of beneficiaries in the integrated care program in Minnesota, and discusses how the state is using demonstration authority to further build on this successful model.

View the Advancing Integrated Care: Lessons from Minnesota brief.

Information Exchange in Integrated Care Models

Communicating necessary and timely information to providers across the continuum of care is central to providing coordinated care. This report focuses on the information exchange processes of integrated care models that provide care for populations with long-term service and support (LTSS) needs. Individuals with LTSS needs require a number of people to be involved to provide care and support, and all of these providers require specific information elements about each individual. Integrated care models' primary focus is on care coordination among a large range of provider types. Organizations providing integrated care have invested substantial effort in developing approaches that support information exchange among the continuum of providers.

View the Information Exchange in Integrated Care Models report.

Integration and Coordination of Health and Human Services Programs

This study aimed to explore opportunities for integration and outreach to enroll low-income Americans enrolled in human services programs and health insurance.

The Examples of Promising Practices for Integrating and Coordinating Eligibility, Enrollment and Retention: Human Services and Health Programs under the Affordable Care Act paper presents findings from case studies of selected state-level integration and coordination approaches and identifies areas of notable success or potential which may be of interest to other states.

The Using Behavioral Economics to Inform the Integration of Human Services and Health Programs under the Affordable Care Act paper examines opportunities to apply findings from behavioral economics to specific health/human services program interaction contexts.

The Integrating Health and Human Services Programs and Reaching Eligible Individuals under the Affordable Care Act: Final Report provides an overview of findings from the project and summarizes the challenges and prospects for integration in the future.

View the Integrating Health and Human Services Programs and Reaching Eligible Individuals Under the Affordable Care Act project page.

Health Care Coverage and Employment Opportunities for the Reentry Population

Formerly incarcerated individuals have much higher rates of chronic health conditions, infectious disease, behavioral health problems and substance use disorder than the general population. Upon reentry these individuals also may have a gap in health care coverage and experience greater difficulty in finding employment that offers health care coverage due to their criminal record. The following two publications discuss these barriers and opportunities to overcome them.

The Linking People with Criminal Records to Employment in the Healthcare Sector: 5 Things to Consider report and accompanying infographic, explores how the need for workers in healthcare can be partially met by hiring individuals with criminal records who do not pose a risk to public safety. The report highlights how people with criminals records are uniquely positioned to help others returning from incarceration get connected to the health care services they need.

The Importance of Medicaid Coverage for Criminal Justice Involved Individuals Reentering their Communities brief explains how Medicaid coverage can play a key role in improving the health of justice involved individuals and their communities. The brief also describes the characteristics of the justice involved population and how they access care.

Exploring Cross-Domain Instability in Families with Children

This study examined different types of instability among children and their families, including health care coverage, adult employment, income, children’s moves, and changes in family and household composition. It used nationally representative data on nearly 15,000 children over five years to look at instability both within the key dimensions and cumulatively across them.

The Exploring Cross-Domain Instability in Families with Children brief presents results by household-education level, finding that children in families in the “some college” education group had the most instability in multiple domains, including health care coverage and children’s moves. They also had the highest levels of a cumulative instability, higher than children in less educated households.

The Cross-Domain Instability in Families with Some College Education brief looks more closely at children in “some college” households, finding that those in households with associates’ degrees experienced the least instability among the three subgroups that composed this category. Children in households with “some college but no degree” and “vocational, technical, trade, or business certificates” fared the worst. In fact, children in “some college/no degree” households faced more cumulative instability than children in any other household type, including “less than high school” and “high school only.”

View the Cross-Domain Family Instability project page.