Assessment of the Massachusetts Flexible Services Program to Address Food and Housing Insecurity in a Medicaid Accountable Care Organization.

Importance: Health systems are increasingly addressing health-related social needs. The Massachusetts Flexible Services program (Flex) is a 3-year pilot program to address food insecurity and housing insecurity by connecting Medicaid accountable care organization (ACO) enrollees to community resources. Objective: To understand barriers and facilitators of Flex implementation in 1 Medicaid ACO during the first 17 months of the program. Design, Setting, and Participants: This mixed-methods qualitative evaluation study from March 2020 to July 2021 used the Reach, Efficacy, Adoption, Implementation, Maintenance/Practical, Robust Implementation, and Sustainability Model (RE-AIM/PRISM) framework. Two Mass General Brigham (MGB) hospitals and affiliated community health centers were included in the analysis. Quantitative data included all MGB Medicaid ACO enrollees. Qualitative interviews were conducted with 15 members of ACO staff and 17 Flex enrollees. Main Outcomes and Measures: Reach was assessed by the proportion of ACO enrollees who completed annual social needs screening (eg, food insecurity and housing insecurity) and the proportion and demographics of Flex enrollees. Qualitative interviews examined other RE-AIM/PRISM constructs (eg, implementation challenges, facilitators, and perceived effectiveness). Results: Of 67 098 Medicaid ACO enrollees from March 2020 to July 2021 (mean [SD] age, 28.8 [18.7] years), 38 442 (57.3%) completed at least 1 social needs screening; 10 730 (16.0%) screened positive for food insecurity, and 7401 (11.0%) screened positive for housing insecurity. There were 658 (1.6%) adults (mean [SD] age, 46.6 [11.8] years) and 173 (0.7%) children (<21 years; mean [SD] age, 10.1 [5.5]) enrolled in Flex; of these 831 people, 613 (73.8%) were female, 444 (53.4%) were Hispanic/Latinx, and 172 (20.7%) were Black. Most Flex enrollees (584 [88.8%] adults; 143 [82.7%] children) received the intended nutrition or housing services. Implementation challenges identified by staff interviewed included administrative burden, coordination with community organizations, data-sharing and information-sharing, and COVID-19 factors (eg, reduced clinical visits). Implementation facilitators included administrative funding for enrollment staff, bidirectional communication with community partners, adaptive strategies to identify eligible patients, and raising clinician awareness of Flex. In Flex enrollee interviews, those receiving nutrition services reported increased healthy eating and food security; they also reported higher program satisfaction than Flex enrollees receiving housing services. Enrollees who received nutrition services that allowed for selecting food based on preferences reported higher satisfaction than those not able to select food. Conclusions and Relevance: This mixed-methods qualitative evaluation study found that to improve implementation, Medicaid and health system programs that address social needs may benefit from providing funding for administrative costs, developing bidirectional data-sharing platforms, and tailoring support to patient preferences.

Changes in healthcare costs following engagement with a virtual mental health system: a matched cohort study of healthcare claims data.

The COVID-19 pandemic has exacerbated the pressing need for mental health services. Digital mental health interventions could increase access to care and be an effective approach to reducing anxiety and depression at scale; however, research on their impact on healthcare expenditure is in the nascent stage and requires further investigation. The current study used claims data to examine the associations between use of an on-demand digital mental health platform and healthcare utilization costs compared to a matched control cohort. The study found that there were no significant differences between cohorts in total healthcare costs and pharmacy costs. There was a 16.8% reduction in outpatient costs (p=.08). On-demand digital mental health interventions can serve as a scalable approach to addressing the current mental health demands and potentially lower outpatient costs.

COVID-19 stressors and one-year changes in depression and anxiety in a longitudinal cohort of low-income adults in the United States.

Emerging data suggest that adults with low income are at highest risk for COVID-19-related stressors and mental health disorders. This study aimed to determine if COVID-19-related stressors were associated with worsening depression and anxiety in a cohort of low-income adults one year after the start of the pandemic. Participants included 253 Medicaid and commercial accountable care organization recipients from 5 community health centers around Boston, MA who enrolled December 2019-March 2020 in a larger longitudinal study of a Medicaid program. Participants completed surveys at baseline and one-year follow-up that measured depression (Patient Health Questionnaire-8 [PHQ-8]) and anxiety (Generalized Anxiety Disorder-7 [GAD-7]) symptoms. Follow-up surveys assessed COVID-19-related stressors experienced over the prior 12 months. A stressor score included COVID-19-related infectious, social, and economic stressors categorized into tertiles (low, 0-3; medium, 4-6; high, 7-19). Mean age (SD) was 45.2 (11.5) years; 71.2% were female, 42.3% Hispanic and 14.6% Black. At baseline, 126 (49.8%) had moderate or severe depression (PHQ-8 ≥ 10), and 109 (43.1%) had moderate or severe anxiety (GAD-7 ≥ 10). The mean (SD) number of COVID-19 stressors was 4.9 (3.1); the most frequent were food insecurity (52.2%) and job or income loss (43.9%). Compared to the low tertile, those in high and medium tertiles had significantly greater one-year increases in depression and anxiety symptoms. Low-income adults facing multiple COVID-19-related stressors, particularly health-related social needs, had worsening mental health symptoms over one year. Interventions are urgently needed to address the dual burden of health-related social needs and poor mental health exacerbated by COVID-19.