I-SPII was an initiative of Integra’s Medicaid Accountable Entity (AE) program to develop partnerships with Community-Based Organizations (CBOs) to plan and pilot interventions to address health-related social needs.
The initiative began with a Request for Proposals (RFP) in 2019 asking Rhode Island nonprofits “what do you think your organization can do about the social determinants of health?” The response was overwhelming. We received 34 proposals to participate in this funding opportunity, with a broad range of communities, strategies, and focus areas represented. Integra selected four partnerships, representing nine organizations, and kicked off the initiative in March 2020 — just as the COVID-19 pandemic was beginning in the United States.
In this rapidly changing context, we engaged in a dedicated three-month planning period and then launched pilot programs to address homelessness, home environment, access to fresh produce, and healthy living. The initiative started at a time when the impact of social factors on health, and the inequities that structure them, had never been more apparent.
Integra views its work to address SDOH as deeply connected to our health equity efforts, and I-SPII offered the opportunity to engage in conversation about racial and ethnic health disparities, as well as healthcare’s role in partnering to address them. Integra worked with Health Resources in Action (HRiA) to provide technical assistance and perform a process evaluation of the initiative. Their report is attached, including the valuable lessons learned and recommendations going forward. Below is an overview of who we partnered with, what we did, what we learned, and what comes next. Download a copy of this report >>
Healthy Housing
Integra partnered with: The House of Hope CDC and RI Coalition for the Homeless
We figured out how to: House homeless members by identifying them with a data match, providing outreach, housing search, case management, and vouchers.
Pilot by the numbers Housing & case management for people experiencing homelessness
- Outreached: 6
- Enrollment In Case Management: 5
- Housed: 5
We learned
- Proof of concept: ACO & homeless service organizations can partner to identify and house members, and coordinate services.
- Housing stock and vouchers are very limited due to systems problems.
- Homelessness is concentrated in, but not limited to, Medicaid.
What’s next
- Expanding scale of housing pilot with House of Hope.
- Convening a healthcare & homelessness working group to focus on systems issues with RI Coalition for the Homeless.
- Evaluating impact on healthcare costs and health outcomes.
Healthy Home Environments
Integra partnered with: Green & Healthy Homes Initiative and RI Builders Association
We figured out how to: Improve home environments for people with respiratory illness by referring families with asthma, assessing homes, and performing remediation.
- Households Enrolled: 6
- Assessments: 5
- Remediation: 4
- Relocations: 2
We learned
- Proof of concept: partners are able to provide home assessment and targeted remediation, leverage funds to address other home safety issues, and coordinate with care team.
- Our existing pediatric asthma program was the strongest referral source, for households with asthma triggers needing remediation.
- Having a skilled third party manage construction contractors is advantageous.
What’s next
- Exploring opportunities to incorporate these services as part of a comprehensive disease management program.
- Developing sustainability strategy, potentially including reimbursement from Medicaid MCOs.
Healthy Food
Integra Partnered with: Southside Community Land Trust, Brown Family Medicine, Pawtucket YMCA, and Groundwork Rhode Island
We figured out how to: Provide biweekly shares of locally-grown produce to patients of the Family are enter in Pawtucket.
Pilot by the numbers: VeggieRx: vegetable shares to food-insecure families
- Households Served: 28
- Individuals Served: 119
- Number of Bags Received: 587
- Pickup vs Delivery: 40% / 60%
We learned
- Proof of concept: CSA-style vegetable shares for food-insecure families are feasible and in-demand.
- A balance of delivery and pickup was helpful.
- Planned cooking and nutrition classes were challenging virtually
What’s next
- Expanding VeggieRx co-located at high-need clinic
- Connecting VeggieRx with other food and equity initiatives
- Developing a working group on health and food access/equity
Healthy Living
Integra partnered with: Clínica Esperanza Hope Clinic
We figured out how to: Enroll Spanish-speaking members with metabolic illness in a lifestyle change program, Vida Sana, to help participants improve their diet, exercise, and disease management.
Pilot by the numbers: Vida Sana: Lifestyle change for Spanish speakers with diabetes & other metabolic illness
- Referred: 14
- Enrolled: 4
- Completed: 2
We learned
- Proof of concept: eligible AE members referred by care managers enrolled and completed Vida Sana program.
- Simple eligibility criteria and referral processes are more effective, especially with community partners.
- Integrating AE members into existing cohorts was more effective than trying to establish classes for AE members only.
What’s next
- Exploring opportunities to incorporate Vida Sana as part of comprehensive disease management programming
