Pharm D Corner

Insights from doctors of pharmacy.

Beyond the pills: Accountable Health Communities highlight social comorbidities that affect our health

Mimi Chen, PharmD
Clinical Services Manager, MediMedia Managed Markets

Kayenta Health Center is a plain, white concrete building next to a grid of trailers that house the health care staff. The one-story hospital is on an isolated Native American reservation in Northern Arizona, an hour’s drive away from the Four Corners and more than two hours from the nearest major city. This was my home for five weeks as a pharmacy rotation student.

I distinctly recall a frail elderly Navajo woman in gaudy hand-me-downs that seemed a size too big. During my first medication counseling session with her, I finished our conversation by telling her to refrigerate the insulin and asked, “Any questions?” She paused, and then with a flummoxed look, she voiced her concern, speaking to the pharmacy technician who is also native to Kayenta. “I don’t have electricity at home.”

How many times had this woman been prescribed insulin without consideration for her living situation?

“Well then let’s improvise” I said, “and get you a cooler and some ice from the grocery store.”


Scientific studies will not delve into whether having a refrigerator may affect health outcomes in diabetes patients. But for this woman, it mattered. In this day and age of quick fixes, it is easy to overlook how housing instability, food insecurity, transportation limitations, and many other economic and social factors can influence people’s health.

Too often, we just go straight to writing a prescription for a new medication.

To its credit, CMS recognized these “social comorbidities” when it introduced the Accountable Health Communities (AHC) model earlier this year. AHCs tackle population health problems from a community perspective rather than from a purely medical one. Disadvantaged Americans can get help from numerous assistance programs, including WIC, SNAP, CHIP, TANF, and so on. But especially for beneficiaries who qualified for Medicaid because of a mental illness or disability, it is nearly impossible to navigate this maze of acronyms and the programs they stand for.

To address this problem, award recipients in the AHC model, referred to as “bridge organizations,” will identify CMS beneficiaries who lack basic social needs and connect them with the appropriate community assistance services. The primary evaluation of the AHC model will focus on reduction in total health care costs, emergency department visits, and inpatient hospital readmissions.

The CMS program is not an isolated effort. A variety of organizations are orchestrating innovative solutions to address health-related social determinants. For example, Hennepin Health, a Medicaid organization in Minnesota, has combined medical services and social services into one multidisciplinary team. The result has been an incremental rise in the percentage of patients receiving optimal care across all chronic disease states, and a high patient satisfaction rating of 87%.

On the flip side, some community service organizations are incorporating health care services into their work. Elijah’s Promise Soup Kitchen in New Brunswick, N.J., partners with a student-run health clinic that offers routine diabetes and blood pressure screenings. While offering medical students a hands-on clinical experience, it also allows them to understand the living condition of their patients as it relates to health outcomes.

However, it is still unclear how to most efficiently screen for these socioeconomic factors. There is also a dire need to increase awareness of and connect patients to the available community services. These are precisely the issues that CMS is beginning to tackle. As such, the AHC model is a positive step towards a more “patient-centered” health system to close the disparities and align community resources with their target population needs. In this time of digital revolution, it is also an opportunity for health information companies to develop technology that would efficiently connect beneficiaries to services.

My rotation ended before I could follow up with the elderly Navajo patient. But I have kept in touch with the pharmacy technician, who recently told me how much she appreciated that simple solution. I was moved by the positive effect on the patient’s life; however, the impact that she made on me was much greater, as it would affect the many lives of the patients I would encounter going forward, knowing that there could be changes made beyond their medications.

Mimi Chen, PharmD, is a Clinical Services Manager at MediMedia Managed Markets and a part-time community pharmacist.