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UTHealth School of Public Health Awarded $2.6 Million to Address Social Needs of Medicare and Medicaid Beneficiaries in Harris County


By UTHealth | June 21, 2017

Researchers at The University of Texas Health Science Center at Houston (UTHealth) School of Public Health have received a nearly $2.6 million grant for an innovative project that will address the social factors that affect the health of Medicare and Medicaid beneficiaries in Harris County.

The Accountable Health Communities grant was awarded by the Centers for Medicare & Medicaid Services.

“What we are trying to do is bridge the gap between health and barriers due to social needs that impact health outcomes,” said Linda Highfield, Ph.D., principal investigator for the project and assistant professor in the Department of Management, Policy and Community Health at UTHealth School of Public Health.

According to data from the Texas Department of Health and Human Services, Harris County has one of the highest uninsured rates in the nation at more than double the national average. The county also has a poverty rate of more than 17 percent and is home to nearly 500,000 Medicare beneficiaries and 600,000 Medicaid beneficiaries.

The five-year project is a collaborative effort involving UTHealth School of Public Health, McGovern Medical School at UTHealth, UT Physicians, Memorial Hermann–Texas Medical Center, Memorial Hermann Greater Heights Hospital, Memorial Hermann Southwest Hospital, Texas Children’s Hospital, Harris Health System and multiple community organizations.

The Accountable Health Communities project will work to evaluate the social needs of Medicaid and Medicare beneficiaries by utilizing an innovative screening tool that will be offered to patients when they seek medical care at any one of the partner clinical sites. Researchers will focus on identifying particular contributing factors that have a negative impact on health, such as food insecurity, housing instability, utilities, transportation or interpersonal violence.

The screening tool is an electronic questionnaire on a tablet that will survey the patient about their individual needs. The tablet will then provide a customized list of community resources to the beneficiaries who may be at high-risk for poor health outcomes.

A subset of the patients who are in need of services will be assigned to a Community Health Worker from the program who will connect them with local social service providers.

During the first phase of the project, starting in February of 2018, researchers have a goal of reaching 18,750 Medicaid and Medicare beneficiaries.  As the project progresses, researchers plan to reach 75,000 people a year in Harris County.

“Often, we are unaware of how people’s social needs affect their health, particularly if they are not disease-specific. However, an individual’s context and social needs can directly impact their health status and how they interact with the health care system. This project is looking at health care from a patient’s perspective,” Highfield said.

UTHealth co-investigators include Ryan Walsh, M.D., M.M.M., chief medical information officer of UTHealth and assistant professor at UTHealth School of Biomedical Informatics; Robert Morgan, Ph.D., professor and chair of the Department of Management, Policy and Community Health; Cecilia Ganduglia Cazaban, M.D., Dr.P.H., assistant professor in the Department of Management, Policy and Community Health; and Kevin Hwang, M.D., M.P.H., associate professor at McGovern Medical School at UTHealth.

Rosalia Guerrero-Luera, program manager for the Community Health Worker training program at the School of Public Health, will serve as project manager and support the research team. Technical support for the screening tool will be provided by the school’s Information Technology Department.




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