How AAAs can partner with health care for Health-Related Social Needs Assessments

Mon Ami partners with community based organizations (CBOs), including Area Agencies on Aging (AAAs), to enhance social care services through strategic collaboration with healthcare entities. A notable example is the Central Ohio Area Agency on Aging (COAAA) partnership with Molina Healthcare. 

As background, a 2024 Physician Fee Schedule ruling allows for reimbursement of services that address a person’s health-related social needs (HRSNs) and, importantly, also includes language explicitly allowing CBOs to receive reimbursement for these activities. This represents an important opportunity for partnership between Managed Care Organizations and CBOs to address an individuals’ Social Determinants of Health.  

The Central Ohio Area Agency on Aging (COAAA) is a key regional entity dedicated to improving the quality of life for older adults, individuals with disabilities, and their caregivers. Established with a mission to provide a comprehensive range of services, COAAA offers support that includes in-home care, nutrition programs, caregiver support, and access to various community resources. COAAA operates with a strong focus on advocacy, aiming to ensure that the needs of the aging population are met through effective policies and programs.

Molina Healthcare is a leading managed care organization, providing health insurance to individuals through government programs such as Medicaid and Medicare. 

In 2023, COAAA and Molina Healthcare formed a strategic partnership through the MolinaCares Accord platform to enhance community support for older adults and individuals with disabilities. This collaboration, bolstered by a generous grant from Molina Healthcare, aims to address critical social determinants of health (SDOH) such as nutrition, housing, and social isolation. COAAA's multidisciplinary team, including registered nurses, social workers, and community health professionals, works closely with individuals to assess their health related social needs. The partnership aims to remove barriers to high-quality care, enhancing the well-being of at-risk populations in central Ohio. 

Mon Ami provides a dedicated HIPAA-compliant solution for care coordination and case management to manage social determinants of health. Working with Mon Ami, COAAA set up the assessments and tools necessary to capture health-related social needs of Molina members, assign Z-codes used to document SDOH factors, and furthermore receive and share member information with its MCO partners. Importantly, COAAA maintains ownership of the data they create, while still able to share data through interoperability. 

By conducting risk assessments, COAAA has surfaced social needs around nutrition, social isolation, housing, and more among Medicaid members, showing that the majority of members presented with at least three (3) health risks. This data is now integrated into a member’s chart, allowing for more holistic provision of care. For COAAA, having a dedicated care management platform with embedded capabilities has meant more streamlined workflows and access to robust reporting and data to inform their collaboration with healthcare partners. The program has been furthermore recognized for its innovative approach by the John A. Hartford Foundation Business Innovation Award.