Memphis ranks No. 1 in overall poverty among metropolitan areas with a population greater than 1 million. That statistic motivated our BlueCare team to think differently — and take new actions.
“Multiple studies have shown that social determinants can influence an individual’s health outcome by over 40%,” says Cheri Moreland, director of member experience and engagement for BlueCare Tennessee, a BlueCross BlueShield of Tennessee subsidiary serving TennCare members. “Identifying the areas that have the highest number is a priority to help us drive better member engagement, as well as improve cost and utilization.”
Improving cost is a major factor, as poverty is a key driver in social determinants.
“More than 14% of BlueCare’s total membership resides in the Memphis/Shelby County area, and data showed a trend that many were not accessing care, even for well-child checkups. This was largely due to struggles with social and financial issues that were affecting both their preventive care and maintenance of chronic health conditions.”
In April, United Way of the Mid-South and BlueCare joined together to find new ways of providing these resources to members in those communities.
More than just a Dream
BlueCare became the first TennCare managed care organization (MCO) to join United Way of the Mid-South’s Driving The Dream initiative.
“We view our role as integrating clinical care and supports for our 600,000 low-income members statewide,” says Dr. Cy Huffman, vice president and chief population health officer for BlueCare. “These clinical and social services must be coordinated with providers in the communities where these members live. United Way of the Mid-South has done the necessary work of organizing multiple social service agencies in a unified network.”
That network enhances access to necessary services and a whole-person approach to health for vulnerable citizens of Shelby County.
“Social determinants significantly affect a person’s health status, yet there are limiting factors in clinical settings that inhibit meeting these needs,” says Rev. Kenneth S. Robinson, MD, president and CEO of United Way of the Mid-South.
Dr. Robinson says providers can face:
- Limited time to inquire about social service needs
- Limited knowledge of local resources and programs that address these needs
“Driving The Dream is a solution, a way to help those who dream of a better life of economic advancement,” Dr. Robinson continues. “It combines technology, social work best practices and collaborative relationships to help families climb out of poverty.”
BlueCare was elated to embark on such a collaborative relationship.
“Through the implementation of Driving The Dream, United Way was able to establish a coordinated network of more than 70 human services providers,” says Trish Olivier, manager of provider quality for BlueCare. “On our end, BlueCare taps into this network to connect our members to critical social services like housing, food and child care through a single system.”
Making a Dream a reality
BlueCare serves many families that face multiple, connected challenges. Employment and education issues can make it harder to manage diabetes or hypertension. Living in substandard housing can increase indoor allergens and worsen pediatric asthma. A lack of reliable transportation can limit food security, employment, and access to health care. But the potential for change is enormous.
Dr. Robinson offers this example of a member who went “from crisis to financial empowerment”:
“This client had several challenges to address before she could begin working on her ultimate dream, home ownership,” Dr. Robinson says. “Driving The Dream assisted her with counseling, food and clothing. The Greater Memphis Financial Empowerment Center assisted with financial and credit advice. She also received legal assistance and school supplies for her children.”
“She has been focused and slowly working through each barrier, and now she’s ready to work toward home ownership alongside her United Way care coordinator.”
BlueCare health navigators and member resource coordinators work with members every day, so Katie Sanders, manager of health promotion for BlueCare, worked to develop operational processes and was heavily involved in the staff training of the Driving The Dream pilot. Front line staff make referrals and follow up to assist members get connected to the help they need.
“This tool gives us a deeper understanding of social service needs in Memphis,” Trish says. “We had a very high-level awareness before, but this helps us navigate all of the options and ensure that basic needs are met.”
“During the pilot phase, in a single month we would receive as many as 400 individual requests for connections to resources in their area.”
As this program moves past the pilot phase this summer, United Way of the Mid-South and BlueCare hope it results in fewer preventable trips to the ER and inpatient care facilities by helping people get healthier and practice preventive care.
“To help us assess members’ needs, BlueCare collected sample data in the Memphis area through two provider partners and inquired about members’ social needs through phone outreach,” Trish says. “We used this data as guide to project volume once the project was implemented. Upon implementation, we could impact substantially more than the 400 members per month we assisted during the pilot phase.”
One particular engagement opportunity is with people who might use a food pantry or qualify for WIC, a service provided by the Tennessee Department of Health.
“The Department of Health always asks if the person saw a primary care provider, and if not, they can have the person in need engage with us,” Trish adds.
“We want to see an uptick in provider engagement, and reductions in poor health outcomes.”
For Dr. Robinson, the next phase of Driving The Dream is clear, if ambitious.
“Our goals are to facilitate and help replicate such functional partnerships and collaborations across the health and human services sectors at the local, state, and even national levels,” he says. “To do that, we must encourage a culture shift in how human services are provided to low-income families and those living in poverty in the Mid-South.”
With BlueCare joining the cause, we are committed to help Driving The Dream pick up speed.
“Our hope is that this model can be perfected across the State of Tennessee,” Dr. Huffman says. “We are fully dedicated to fulfilling the dream of Dr. Martin Luther King.”