As part of the Affordable Care Act’s aim to promote high-value care, it is shifting incentives so that payment recognizes value, outcomes, and care experience, rather than payment being tied to the volume of services provided. This important move has prompted health systems, organizations, payers, and states to take on efforts to better integrate behavioral health and social service supports into medical care.

The Bridge Model is one approach to care that aims to bridge medical and social services, which traditionally have been fragmented and not efficient in working together to best meet the needs of their patients/clients. Bridge’s culturally-sensitive, team-based approach works to best support clients and caregivers in achieving what is important to and important for them as they transition home from the hospital. Broad research shows that individuals of low socioeconomic status are more likely to be readmitted to the hospital within 30 days of a hospital discharge, and our experience with the Bridge Model indicates that leveraging community-based social supports is a key aspect to preventing such readmissions.

While we’ve seen promising results in terms of the impact of the Bridge Model on preventing frequent hospitalizations, we are acutely aware of how much Bridge programs rely on publicly-funded services (which are on the chopping block in many states), on volunteer-based services, and on the ingenuity of social workers who work tirelessly to find resources to meet the needs of their clients.

The question then is, What if there aren’t any quality community-based services available? Many payers and health systems are realizing that it is worth it financially to invest in services and resources that can help prevent more expensive medical needs down the line – such as repairs to crumbling stairs, paying for a homemaker that can help grocery shop and cook healthy foods, or providing transportation to primary care appointments.

The New York Times recently highlighted a few such initiatives in its March 22, 2015 article “Health Care Systems Try to Cut Costs by Aiding the Poor and Troubled”. The article highlights a couple specific cases where health systems and payers engage social supports, and discusses the implications of them:

They raise a new question for the health care system: What is its role in tackling problems of poverty? And will addressing those problems save money?

“We had this forehead-smacking realization that poverty has all of these expensive consequences in health care,” said Ross Owen, a Hennepin County, MN health official. “We’d pay to amputate a diabetic’s foot, but not for a warm pair of winter boots.”

Now health systems around the nation are trying to buy the boots, metaphorically speaking.

With the ACA and state-based health reforms increasingly asking hospitals and payers to invest in “the boots”, care models such as the Bridge Model that emphasize inclusion of psychosocial factors, hospital-community partnerships, and team-based care will have an important role to play.