Can taking care of social needs for people utilizing Medicare and Medicaid help them spend less on health care? Can a personalized approach help people connect with services for interpersonal violence, transportation, housing instability, food insecurity and utility assistance?

These are the core questions investigators at the University of Kentucky Center for Health Services Research will answer thanks to a five-year, $4.5 million contract from the Centers for Medicare and Medicaid Services that will create the Kentucky Consortium for Accountable Health Communities (KC-AHC). 

“We don’t want to reinvent the wheel. We want to work with agencies that are already serving needs in Appalachia and in Jefferson County,” said Jing Li, co-principal investigator and associate director of the Center for Health Services Research. To form this new consortium, UK is partnering with the Kentucky Primary Care Association, Appalachian Regional Health, Norton Health Care and Kentucky HomePlace.

The consortium will do broad-based patient screening for health-related social needs and offer patient navigation for identified needs. “Navigating the complex health care system can be challenging for patients,” Li said. “We try to have this navigator understand them, understand their background, understand their social support, so in that way, we will develop a more personalized action plan for them.”

Over the course of five years, the project will screen hundreds of thousands of people and researchers will be able to track, for example, if frequent visitors to Emergency Departments go to the hospital less if they enroll in social programs.

Li explained, “Our goal is to not just to look at what works. We also want to understand why and how it works.”

Hilary Surratt, a co-investigator and substance abuse researcher in the UK College of Medicine, said, “We want to have a sustainable effort so that after the dollars from CMS are gone, we can have a seamless referral process for patients. We’re looking at costs, we’re looking at health utilization, but I think we really have potential to make an impact on vulnerable patients’ health status, so that their quality of life improves and they’re living a life that they want to live.”