Infographic: State Team-Based Care Strategies for Medicaid-Eligible Women
For more information, please click the program titles and read NASHP’s State Medicaid Quality Measurement Activities for Women’s Health.
Acknowledgement: Thank you to the officials in Washington, DC, Montana, and Minnesota for reviewing their respective highlighted strategies. This infographic is a publication of the National Academy for State Health Policy (NASHP). This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services HHS under the Supporting Maternal and Child Health Innovation in States Grant No. U1XMC31658; $398,953. This information, content, and conclusions are those of the authors’ and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the US government.
States Increase Access to Oral Health Services and Support Overall Health
State officials continue to develop new approaches to increase access to oral health services, and many of their innovations were highlighted at National Academy for State Health Policy’s 2019 conference. There are ongoing initiatives, such as deploying community health workers in Minnesota, a New Hampshire Medicaid and Women, Infants, and Children Nutrition Program pay-for-prevention, bundled payment pilot for children’s preventive oral health services, and implementation of new Medicaid policies to expand access in Arizona and Utah.
These oral health policies underscore the critical relationship between increased access to oral health for overall health, a relationship that is highlighted in two new NASHP fact sheets that explore how states are expanding their oral health workforce: Minnesota Deploys Community Health Workers and Dental Therapists to Advance Equity and Arizona Uses Dental Hygienists to Improve Hospital Patient Safety.
For ventilator-assisted patients, good oral health supports patient safety. As an Arizona Department of Health Services representative discussed at NASHP’s conference, state legislation enacted in May 2019 changed scope-of-practice laws to allows dental hygienists working in hospital settings to practice under the supervision of a licensed physician.
A volunteer project enabled Arizona to test the use of dental hygienists to provide oral health care to ventilator-assisted patients — a strategy recommended by the US Centers for Disease Control and Prevention to reduce ventilator assisted pneumonia (VAP). VAP, which is usually caused by oral bacteria, was the leading cause of death from nosocomial infections in critically ill patients and significantly increased hospital costs. This project identified the scope-of-practice law, which required supervision by a dentist, as a key barrier to having dental hygienists in hospitals to improve oral health to support the overall health of ventilator-dependent patients. To learn more, read Arizona Uses Dental Hygienists to Improve Hospital Patient Safety.
Good oral health also supports overall health among adults with substance use disorder (SUD). As a representative from the Utah Department of Health’s Division of Medicaid and Health Financing highlighted at the conference, the state added dental benefits for targeted adult Medicaid beneficiaries with SUD in January 2019. The beneficiaries receive dental care at the University of Utah School of Dentistry and affiliated providers. The policy builds on the innovative Project FLOSS – Facilitating a Lifetime of Oral Health Sustainability for Substance Use Disorder Patients and Families. Project FLOSS demonstrated that providing comprehensive integrated dental and SUD care was associated with increased SUD treatment completion, employment, and drug abstinence, along with reduced homelessness among adults.
Emerging health professionals, such as community health workers (CHWs), promote overall health and health equity. Minnesota is one of just a few states that include a specific CHW role to promote oral health — helping to link oral health and overall health. In 2005, Minnesota became the first state to implement a for-credit, transferrable-credit CHW certificate program through its state college system and private higher education institutions. CHWs work under the supervision of eligible Medicaid providers in the state, including dentists. By providing culturally competent, high-quality access to services and increasing the health knowledge of the individuals they serve, CHWs can help reduce disparities. To learn more about the role of CHWs and dental therapists, read Minnesota Deploys Community Health Workers and Dental Therapists to Advance Equity.
In 2020, NASHP will continue to track state policy changes and efforts to increase access to pediatric and adult oral health services as part of states’ commitment to promote overall health.
The DentaQuest Partnership for Oral Health Advancement supported the conference session and these fact sheets.
Expanding the Oral Health Workforce to Promote Overall Health: Minnesota Deploys Community Health Workers and Dental Therapists to Advance Equity
Oral health access and quality varies across populations, with disparities related to income, age, sex, race, ethnicity, and medical status persisting despite its value to general health.[1] Minnesota is working to increase access and advance oral health equity through the adoption of emerging health professionals, including community health workers (CHWs) and dental therapists (DTs) and advanced dental therapists (ADTs).[2]
Eight states and tribal organizations in five states allow DTs to provide preventive and restorative dental care.[3] Forty-seven states and Washington, DC have programs designed to integrate CHWs into evolving health care systems, but only a few state programs allow CHWs to play a role in expanding oral health.[4]
Minnesota initiated an expansion of its oral health workforce because more than half of its counties are considered Dental Health Professional Shortage Areas (DHSPAs),[5] which poses a major barrier for rural and under-resourced residents to receive oral health care. Recent data from a Minnesota Department of Health (MDH) survey indicates that the overall dentist to population ratio is one dentist for every 1,641 Minnesotans.[6] This ratio increases for rural residents, with:
- One dentist per 2,153 micropolitan or large rural city residents;
- One dentist per 2,272 small town or small rural city residents; and
- One dentist per 3,938 rural or geographically isolated residents.
Minnesota’s 2013-2018 Oral Health Plan details strategies to expand the oral health workforce to reduce these disparities. The following explores how Minnesota’s programs and policies are using CHWs and DTs/ADTs to address oral health needs.
Community Health Workers
The Minnesota Department of Human Services (DHS) defines CHWs as community-based workers who provide diagnosis-related patient education, health promotion, advocacy, and disease management for a range of health issues, including oral health. States have embraced the CHW model as a mechanism to engage more vulnerable populations in care.[7] CHWs can work in homes, schools, and in community-based organizations. To help build trust and relationships, CHWs typically come from the communities in which they serve. By providing culturally competent, high-quality access to services and increasing the health knowledge of the individuals they serve, CHWs can help reduce health disparities.[8]
The Minnesota legislature established the Healthcare Education-Industry Partnership (HEIP) in 1998 to address health disparities. In the early 2000s, HEIP worked with the Minnesota Community Health Worker Project, a group of 21 health care industry, university, and non-profit organizations, to develop a sustainable CHW profession. Through this work group, in 2005, Minnesota became the first state to implement a for-credit, transferrable-credit CHW certificate program through its state college system and private higher education institutions.
More than 650 CHWs been trained through Minnesota’s certificate program to date, and about 70 percent are racial and ethnic minorities.[9] The three largest racial and ethnic minority populations Minnesota’s CHWs work with are Latino, Somali/East African, and Hmong populations. Medicaid does not directly reimburse CHW for oral health services, so CHWs work under the supervision of eligible providers, such as dentists or physicians, to provide oral health services.[10] Minnesota’s Medicaid program covers care coordination and patient education services related to oral health and dental care from a CHW if the CHW received a certificate from the licensed CHW certificate program, or has at least five years of supervised experience with an enrolled dentist, physician, or other eligible provider.[11]
The state was awarded a three-year, $45 million State Innovation Model (SIM) grant in 2013 to expand and improve accountable care models in the state.[12] In Maplewood, a community dental clinic expanded to four clinics across the state using CHW interns. In Mankato, a federally qualified health center used SIM funds to integrate CHWs into a mobile dental unit serving rural areas, which led to a large increase in service utilization. For more information about how CHWs resources are used across the country, explore NASHP’s interactive map of State Community Health Worker Models.
Dental Therapists and Advanced Dental Therapists
In 2009, Minnesota’s legislature authorized the licensing of DTs and ADTs with the requirement that they primarily serve low-income, and under/uninsured patients.[13]
- DTs are licensed oral health practitioners and members of an oral health care team who provide evaluative, preventive, restorative, and minor surgical dental care within their scope of practice.[14] DTs are mid–level practitioners licensed by the Board of Dentistry, and work under the supervision of a dentist.
- ADTs provide the same services that a DT does, plus oral evaluation and assessment, treatment plan formulation, and non–surgical extraction of certain diseased teeth. ADTs are certified by the Board of Dentistry and can practice under the supervision of a licensed dentist, but the dentist does not need to be on-site during procedures and does not need to see the patient prior to them receiving care from an ADT.
Research shows that DTs improve underserved patients’ access to oral health care, including Medicaid enrollees, partly due to reduced waiting times and travel distances.[15] Minnesota has two dental therapy programs that accept and train 10 students per year. In 2018, 92 dental therapists, including ADTs, were licensed to practice in Minnesota.[16]
To ensure Minnesota has appropriate dental workforce coverage for rural areas, Minnesota’s Office of Rural Health and Primary Care implemented a state loan forgiveness program. The program is offered to final-year DTs and ADTs as well as licensed DTs and ADTs who plan to practice in a designated rural area for at least three years. These DTs and ADTs are eligible for $10,000 in annual loan repayments.
Next Steps and Reflections
Ensuring access to oral health care requires sufficient provider participation and provider reimbursement. The Minnesota Rural Health Advisory Committee’s[17] Oral Landscape for Rural Residents report[18] highlighted reimbursement rate challenges specifically for pediatric dental services. As a result, MDH pledged to work with DHS and legislators to promote a reimbursement system that covers the cost of providing oral health services and encourages providers to accept patients participating in public programs. MDH also plans to share workforce data with legislators to:
- Highlight programs that succeed in expanding the workforce in rural Minnesota;
- Facilitate work with stakeholders and within provider communities to encourage practices in order to extend the reach of the existing workforce to meet oral health needs.[19]
State officials across agencies recognize the importance of oral health for overall health and work collaboratively to expand the oral health workforce to ensure access for vulnerable populations and advance equity.
Notes
[1] National Institutes of Health. National Institute of Dental and Craniofacial Research. 2000 Surgeon General’s Report on Oral Health in America. July 2000. https://www.nidcr.nih.gov/research/data-statistics/surgeon-general
[2] Minnesota Department of Health. Office of Rural health and Primary Care. Community Health Worker Toolkit. 2016. https://www.health.state.mn.us/facilities/ruralhealth/emerging/chw/docs/2016chwtool.pdf
[3] American Dental Hygienists’’ Association, “Expanding Access to Care Through Dental Therapy,” July 2019. https://www.adha.org/resources-docs/Expanding_Access_to_Dental_Therapy.pdf
[4] National Academy for State Health Policy, “State Community Health Worker Models.” https://www.oldsite.nashp.org/state-community-health-worker-models/
[5] Minnesota Department of Health. Minnesota Public Health Data Access. Dental Workforce Shortage Areas. January 2018. https://data.web.health.state.mn.us/hpsa-access
[6] Minnesota Department of Health. Oral Health in Minnesota. https://www.health.state.mn.us/people/oralhealth/data/oralhealthmn.html
[7] Clary, Amy. “Community Health Workers in the Wake of Health Care Reform: Considerations for State and Federal Policymakers,” National Academy for State Health Policy. November 2015. https://www.oldsite.nashp.org/wp-content/uploads/2015/12/CHW1.pdf
[8] Minnesota Department of Health. Community Health Worker Toolkit, 2016. https://www.health.state.mn.us/facilities/ruralhealth/emerging/chw/docs/2016chwtool.pdf
[9] Minnesota Department of Health. Community Health Worker Toolkit, 2016. https://www.health.state.mn.us/facilities/ruralhealth/emerging/chw/docs/2016chwtool.pdf
[10] Community Health Worker Toolkit, 2016. https://www.health.state.mn.us/facilities/ruralhealth/emerging/chw/docs/2016chwtool.pdf
[11] Minnesota Legislature. Office of the Revisor of Statutes. Section 256B.0625 Covered Services. Subd. 49. Community Health Workers. https://www.revisor.mn.gov/statutes/2010/cite/256B.0625/subd/256B.0625.49#stat.256B.0625.49
[12] State Health Access Data Assistance Center, “Evaluation of the Minnesota Accountable Health Model,” September 2017. https://www.leg.state.mn.us/docs/2018/other/180336.pdf
[13] Minnesota Department of Health. Dental Therapists and Advanced Dental Therapists. Updated in 2017. https://www.health.state.mn.us/facilities/ruralhealth/emerging/dt/index.html
[14] Minnesota Legislature. Office of the Revisor of Statutes. 2019 Minnesota Statute. Section 150A.105 Dental Therapist. 2019, https://www.revisor.mn.gov/statutes/cite/150A.105
[15] Minnesota Department of Health. (2014, February). Early Impacts of Dental Therapists in Minnesota. https://www.health.state.mn.us/data/workforce/oral/docs/dtlegisrpt.pdf
[16] Minnesota Department of Health. Office of Rural Health and Primary Care. Minnesota’s Dental Therapist Workforce. September 2019. https://www.health.state.mn.us/data/workforce/oral/docs/2019dt.pdf
[17] The workgroup represented a variety of oral health perspectives and roles, including oral health professionals, dental professional associations, oral health educators, safety-net providers, and other oral health stakeholders.
[18] Minnesota Department of Health. Office of Rural Health and Primary Care. Strengthening the Oral Health System in Rural Minnesota. August 2018. https://www.health.state.mn.us/facilities/ruralhealth/rhac/docs/2018ruraloral.pdf
[19] Ibid.
Acknowledgements:
The authors would like to thank the officials with the Minnesota Department of Human Services and Minnesota Department of Health who shared their time and insights. Thanks also to Malka Berro, Trish Riley, and Jill Rosenthal for their assistance and contributions. Finally, our sincere thanks to Trenae Simpson, M. Parrish Ravelli, and the DentaQuest Partnership for Advancing Oral Health for funding this project.
Minnesota and Indiana Governors Work to Improve Social Equity and Health in Every Zip Code
In their 2019 state of the state speeches, 13 governors addressed social equity, acknowledging that reducing inequities and improving opportunities for all residents improves lives and health outcomes. Two of them — Indiana and Minnesota – offer examples of how states are orchestrating their legislative and administrative efforts to reduce health disparities and promote social equity.
Background
Of the many factors that influence health, 80 percent occur outside of the health care system, such as access to safe and affordable housing, high-quality education, and employment opportunities. Across the nation, health disparities persist where racial and ethnic discrimination, gender inequities, class distinctions, and other barriers systemically keep certain people from the opportunities and resources needed to live long and healthy lives.
These health disparities can be observed and tracked by state, county, zip code, or neighborhood. Indiana and Minnesota state policymakers are using budget appropriations, executive orders, and legislation to improve social equity.
Indiana
Gov. Eric Holcomb and a group of Indiana state leaders are tackling disparities in infant mortality under the umbrella of health equity. Their goal is to lower the state’s rate of infant mortality across all zip codes by improving services for expecting mothers.
“Now we’re seeking to implement two more programs that aim directly at reducing infant mortality…. These are the kinds of efforts it will take to get more babies to celebrate their first birthdays, regardless of their zip codes.” – Indiana Gov. Eric Holcomb
In May, Gov. Holcomb signed a bill to address infant mortality and establish a perinatal navigator program. The program engages pregnant women in evidence-based, early prenatal care to improve outcomes regardless of where a woman lives by providing referrals for wraparound services and community-based, home-visiting programs. There is an evidence base to support the positive impact on birth outcomes of community-based programs like these that address social determinants of health. The new law also establishes a program to provide more nurse partners and community health workers to coach, care for, and educate young women during pregnancy.
Across the United States, African Americans experience a higher infant mortality rate than any other racial group — and this is true in Indiana as well. From 2013 to 2015, Indiana’s infant mortality rate averaged 7.13 per 1,000 live births, compared to the 2015 national average of 5.90 per 1,000 live births. The non-Hispanic black population infant mortality rate in Indiana was much higher, at 13.26 per 1,000 live births. Indiana’s plan to boost resources for pregnant women and to engage women sooner in supportive care is designed to make pregnancy outcomes — and overall health outcomes — more equitable for all.
Minnesota
In Minnesota, Gov. Tim Walz and state leaders are using a variety of levers to address the structural components of inequity. The initiatives proposed in the budget or enacted through executive orders are designed to reduce disparities in educational achievement and hiring experienced by racial minorities in Minnesota. Though not directly tied to health, these disparities can lead to income inequality and other stressors that are strongly associated with poor health outcomes — so Minnesota’s upstream approach has the potential to improve health across the state.
“Every student in Minnesota deserves the opportunity to learn in the best schools in the country with caring, qualified teachers. But as I travel around the state, I see how the quality of a student’s education is too often dependent on their race or zip code. …Disparities in our educational system based on geography, race, or economic status hold back not only our students, but our entire state from reaching its full potential. We must make Minnesota the Education State for all children — black, white, brown, and indigenous.” — Minnesota Gov. Tim Walz
Minnesota’s state budget, approved in late May, included a 2 percent increase in per-pupil funding to public schools, which is part of Gov. Walz’s plan to reduce disparities in educational achievement by improving school resources across the state. He also proposed a Community Solutions Fund in his budget that would provide local groups with grants to help them address children’s health care issues in a flexible way.
Gov. Walz also issued an executive order at the beginning of his term creating the Diversity, Inclusion and Equity Council. Headed by Chris Taylor, the state’s new Chief Inclusion Officer, the council will focus in part on diversifying the state workforce as another strategy to address historic structural inequities. The council’s long-term approach to address disparities is designed to level Minnesota’s economic and social playing fields and improve social equity and health outcomes for all.
The approaches taken by Minnesota’s and Indiana’s governors demonstrate how state leaders can push for social equity with targeted or broad systemic changes to improve overall social conditions. As more policymakers adopt an upstream approach to health and address inequities, they can reduce economic, social, and discrimination-based obstacles to generate better health outcomes for all.
Ten States Selected to Attend Palliative Care Summit in Chicago
NASHP is pleased to announce the 10 states selected to attend the State Policymakers Palliative Care Summit, supported by a grant from The John A. Hartford Foundation. Policymakers, including legislators as well as Medicaid and public health officials from Arizona, Colorado, Hawaii, Kentucky, Massachusetts, Minnesota, Ohio, Oklahoma, Pennsylvania, and Texas, will participate in the day-long summit where they will learn from national and state experts about strategies to improve access to and quality of palliative care. For more information about palliative care, explore NASHP’s Palliative Care Resource Hub and sign up for its palliative care listserv.
Governing Accountable Health Entities: Examples from 12 States
More than a dozen states are developing accountable health models to improve population health and control costs by addressing community needs, such as transportation, recreation, and housing. These entities’ mission — to build healthy communities through cross-sector partnerships — is supported by innovative and evolving governance structures. This NASHP chart and a companion blog highlight how states are structuring these entities to keep them accountable and reflective of their communities.
Print this chart.
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| California Accountable Communities for Health Initiative (CACHI) | “An accountable communities for health (ACH) must establish a sound governance structure that ensures effective decision-making; accountability to the community; representation of stakeholders’ interests; proper fiduciary, fiscal, and social responsibilities; and control over funding and staff.” (ACH Legal & Practical Recommendations, p. 4) An ACH should have a set of rules (bylaws or agreement) to hold stakeholders accountable to their obligations, defined fiduciary duties for the Governing Body, established controls over activities and finances, and a conflict of interest policy and procedure.” (p. 4) |
The ACH collaborative must include: “-Health plans, hospitals, private providers or medical groups and community clinics serving the geographic area. -Government health and human services agency/public health department -Grassroots, community and social services organizations that include authentic and diverse representation of residents, particularly from underserved communities.” “It is desirable that every ACH include broad representation of several of the following types of entities: -County and/or city government leadership, including elected officials -Behavioral health providers – Housing agencies -Food systems -Employers and other business representatives -Labor organizations -Faith-based organizations -Schools and educational institutions -Parks and recreational organizations and agencies -Transportation and land use planning agencies -Dental providers -Local advocacy, grassroots organizations or policy-focused organizations.”(RFP, p. 7) |
CACHI’s Year 1 request for proposals awarded points for, “Meaningful resident engagement and a process for ongoing engagement throughout the funding period.” (RFP, p. 14) | Recommended key milestone: “By the end of Year 1: Develop a governance plan that includes the following: -A list of community sectors to be represented on the Governing Body of the Wellness Fund. -An outline of key components of bylaws to establish the number of directors, meetings, voting procedures, a community investment committee, and conflict of interest and anti-nepotism policies. -A document outlining how accountability to the community will be achieved and maintained (e.g., by reserving board and committee slots for community residents and providing annual reports on activities and spending).” (ACH Legal & Practical Recommendations, p. 35-36) |
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| Colorado Regional Accountable Entities | “The contractor shall have a governing body responsible for oversight of the Contractor’s activities in relation to this Contract.” (RFP 5.3.5) |
“The contractor shall select members of the governing body in such a way as to minimize any potential or perceived conflicts of interest.” (5.3.5.1) | “The regional accountable entities (RAE) will develop mechanisms to engage community partners within the RAE’s region for population health and nonmedical community services.” (3.3.10) The RAE will “promote physical and behavioral health ….[and] the population’s health and functioning, coordinate care across disparate providers, interface with long-term services and supports providers, and collaborate with social, educational, justice, recreational and housing agencies to foster healthy communities ….” (3.3.3) |
The contractor shall publicly list information, including, but not limited to, the names of the members of the governing body and their affiliations, on the contractor’s governing body on the contractor’s website.” (RFP, 5.3.6) | “The program will focus on greater coordination with the Colorado Departments of Human Services, Public Health and Environment, Education, and Corrections, as well as initiatives such as Comprehensive Primary Care Plus (CPC+), State Innovation Model (SIM), Hospital Transformation Program, and the Colorado Opportunity Project. The RAE will play key regional roles in these initiatives as they are well aligned with the Accountable Care Collaborative’s goals.” (3.3.11) |
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| Connecticut Health Enhancement Communities (HECs) | “Health Enhancement Communities (HEC) will have a defined structure, with a formal governance structure and community organizing groups. The formal governance structure will have clearly defined decision-making roles, authorities, and processes. The community organizing groups will have ownership and decision-making authority over the things that matter most to them and will lead the identification and implementation of interventions in their communities.” HEC Design Principles (See p. 52-54 of HEC model design draft proposal, Oct. 22, 2018, for chart of other governance requirements.) |
“-In addition to community organizing groups, HECs will need to identify multiple methods for gaining meaningful involvement, including in decision-making, as HECs form and operate -HECs will need to include multiple community organizations that directly address root causes of poor health in their communities.” (HEC model design draft proposal p. 52) |
“Given their unique and essential perspectives and insights about their communities, HECs’ success depends on the ongoing involvement of community members and community members making decisions about things that matter most to them. In addition to community members being involved in HEC formation and operation, the HEC structure should also support community organizers and locally owned and directed community organizing groups within communities….” (HEC model design draft proposal p. 9-10) | Minimum governance structure elements required by the state and determined by HECs: “-Partnership agreements -Bylaws -Backbone organization -Formal contracts for services.” (HEC model design draft proposal p. 52-53) |
State Innovation Model |
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| Delaware Healthy Neighborhoods | Neighborhood task forces: “Create and propose data driven, evidence-based initiatives, request funds…measure outcomes… engage in quality improvement. Local councils “serve as a ‘board’ of the Healthy Neighborhood (e.g. decision making about resource allocation)… [and] approve Task Forces’ requests for resources.” (HMA, Healthy Neighborhoods Model, Dec. 2017, p. 7) The role of the fiscal agent is to: -“Distribute funding to entities implementing Task Force Initiatives (once ‘readiness process’ has been completed) -Collect data/outcomes from each Task Force related to funded initiatives and utilize this practice of continuous analysis as a tool for ongoing learning -Focus on sustainability of the SIM Grant funding (e.g., establishing and managing a community trust) -Serve as a ‘Backbone Organization’ across all Local Councils.”(HMA, p. 4) |
Local neighborhood task forces contain: “-Local community stakeholders and leaders that are focused on a priority area -Two co-chairs.” Local councils are made up of: “-At least one representative from each task force -Local leaders with expertise in priority areas -Cross-sector entities and organizations recruited via the Social Network Analysis to ensure representation of all critical entities -Delivery systems as well as community-based organizations -Community advocates from neighborhoods -Community stakeholders.” (HMA, p. 7) “Voting procedures are established in the bylaws of the Local Council.” (HMA p. 18)Local councils are advised by a statewide consortium with: “-Local council co-chairs -Statewide leaders focused on user-friendly community-level data -Statewide leaders focused on sustainability of healthy neighborhoods -Statewide leaders focused on policy -Advocacy organizations from neighborhoods -The statewide fiscal agent.” (HMA p. 8) |
“Readiness assessment will assess: -Did the task force use data about community needs to develop the initiative? -Did the task force include representatives from diverse entities who weighed in on the creation of the plan? -Similarly, do you have community buy-in?” (p. HMA 15-16) |
State Innovation Model |
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| Massachusetts Accountable Care Organizations (ACOs) | Massachusetts Health Policy Commission (HPC)’s ACO Certification Program assessment criteria includes a “Patient-centered, accountable governance structure.” (ACO Policy Brief, April 2018, p. 3) |
“The ACO provides for meaningful participation in the composition and control of the Governing Body for its participants or their representatives.” ACOs must attest that “ACO Participants have at least 75% control of the Governing Body (Proposed 2019 ACO Certification Standards, p. 7). – [ACOs must have] “at least one patient or consumer advocate within the governance structure.” (Proposed 2019 ACO Certification Standards, p. 7-8) |
“The ACO governance structure is designed to serve the needs of its patient population, including by having … a patient and family advisory committee.” (Proposed 2019 ACO Certification Standards, p. 7-8) | The HPC requires ACOs to submit an “Organizational chart(s) of the Governance Structure(s) of the Applicant (and Component ACOs as applicable), including Governing Body, executive committees, and executive management, and indicating the location of a patient or consumer representative role within each Governance Structure.” (Proposed 2019 ACO Certification Standards, p. 5-6) ACOs are required to submit a Full Participation Plan that includes “The providers and organizations with which the ACO is partnering or plans to partner, the governance structure … [and] a population and community needs assessment.” (p. 14) |
MassHealth Medicaid Section 1115 Demonstration |
| “The ACO Governing Body regularly assesses the access to and quality of care provided by the ACO, in measure domains of access, efficiency, process, outcomes, patient safety, and patient experiences of care, for the ACO overall and for key subpopulations (i.e. medically or socially high needs individuals, vulnerable populations), including measuring any racial or ethnic disparities in care.” (Proposed 2019 ACO Certification Standards, p. 8) | ACOs are required to submit a Full Participation Plan that includes “The providers and organizations with which the ACO is partnering or plans to partner, the governance structure … [and] a population and community needs assessment.” (DSRIP protocol, p. 14) |
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| Michigan Community Health Innovation Regions (CHIRs) | “Each of the five regions is supported by a backbone organization that serves as a fiduciary and acts as a neutral convener for the CHIR’s governing body.” “CHIR partners are organized by a neutral backbone organization that [serves as a fiduciary and] facilitates the development and implementation of key strategies, creating the necessary capacity to sustain progress on stated objectives. CHIR steering committees provide a clear leadership structure and promote shared accountability among partners for aligning their resources to address priority community health needs.” (SIM, “About CHIRS”) |
“CHIR governance facilitates effective collaboration of providers, health plans, community based organizations and individuals to pursue community‐centered solutions to upstream factors of poor health outcomes and health disparities.” (NASHP slides, Aug. 2018) | State Innovation Model |
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| Minnesota Accountable Communities for Health (ACHs) | “The lead organization is responsible for convening a multi-sectoral governing body with representation from partner organizations and the community. ACH projects are exploring and testing a variety of governance approaches such as charters, formal business agreements between partners and use of technical subcommittees …. ACH leadership team structure and makeup differs across ACHs. Some ACHs created an entirely new governance structure while others use existing committees, task forces, or advisory bodies (such as Statewide Health Improvement Program – SHIP – committees) to organize their work.” (ACH: Perspectives on Grant Projects and Future Considerations, Oct. 2016, p. 12). “Besides leadership and governance, the ACH must have a ‘backbone’ or lead organization to serve as convener and integrator.” (p. 35) |
“Each ACH has a lead organization (e.g., private foundation, non-profit social service agency, local public health agency or health care system) that serves as fiscal agent and resources manager. The lead organization is responsible for convening a multi-sectoral governing body with representation from partner organizations and the community.” (ACH: Perspectives on Grant Projects and Future Considerations, p. 12) “All health plans and systems serving the population should participate in the ACH. Local public health must be an active partner, and local political leaders, government officials and other leaders should be invited to participate. Most importantly, the governing body should ensure that persons experiencing health disparities are represented in ACH partnerships, mission and vision.” (ACH: Perspectives on Grant Projects and Future Considerations, p. 35) |
“Each ACH grant project features … community-led leadership.” (Minnesota Accountable Communities for Health) | Required components of each ACH grant project are: “-Community-led leadership -Care coordination between multi-sectoral partners -Population-based prevention -Measurement and evaluation -Partnership with an Accountable Care Organization -Participation in an ACH learning community -Sustainability planning -Health equity focus.” (Minnesota Accountable Communities for Health) |
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| New York Performing Provider Systems (PPSs) | “The Performing Provider System will need to demonstrate that it has a governance strategy that ensures that participating providers work together as a “system” and not as a series of loosely aligned providers nominally committed to the same goal.” (DSRIP Program Funding and Mechanics Protocol, p. 14) | “Please explain how the selected members provide sufficient representation with respect to all of the providers and community organizations included within the PPS network. Please outline where coalition partners have been included in the organizational structure, and the PPS strategy to contract with community based organizations.” (DSRIP PPS Organizational Application, p. 35) |
“Describe how the PPS governing body will engage stakeholders on key and critical topics pertaining to the PPS over the life of the DSRIP program.” (DSRIP PPS Organizational Application, p. 34-36) | Medicaid Section 1115 Demonstration Delivery System Reform Incentive Payment program | |
| “Describe the decision making/voting process that will be implemented and adhered to by the governing team. Explain how conflicts and/or issues will be resolved by the governing team.” (DSRIP PPS Organizational Application, p. 35.) | State Health Innovation Plan (through the State Innovation Model) | ||||
| State Health Improvement Plan (the Prevention Agenda). |
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| Oregon Coordinated Care Organizations (CCOs) | “Coordinated care organizations may be local, community-based organizations or statewide organizations with community-based participation in governance or any combination of the two.” (2017 ORS 414.625) “Each coordinated care organization’s governing body establishes standards for publicizing the activities of the coordinated care organization and the organization’s community advisory councils, as necessary, to keep the community informed.” (ORS 414.625) |
“Each coordinated care organization has a governing body of which a majority of the members are persons that share in the financial risk of the organization and that includes: (a) A representative of a dental care organization selected by the coordinated care organization; (b) The major components of the health care delivery system; (c) At least two health care providers in active practice, including: (i) A physician licensed under ORS chapter 677 or a nurse practitioner certified under ORS 678.375 (Nurse practitioners), whose area of practice is primary care; and (ii) A mental health or chemical dependency treatment provider; (d) At least two members from the community at large, to ensure that the organization’s decision-making is consistent with the values of the members and the community; and (e) At least one member of the community advisory council.” (2017 ORS 414.625) |
Required to serve on the governing body are: “At least two members from the community at large, to ensure that the organization’s decision-making is consistent with the values of the members and the community; and At least one member of the community advisory council.” (2017 ORS 414.625)Community advisory councils: “A coordinated care organization must have a community advisory council to ensure that the health care needs of the consumers and the community are being addressed. The council must: (a) Include representatives of the community and of each county government served by the coordinated care organization, but consumer representatives must constitute a majority of the membership; and (b) Have its membership selected by a committee composed of equal numbers of county representatives from each county served by the coordinated care organization and members of the governing body of the coordinated care organization.” (2017 ORS 414.627) |
Medicaid Section 1115 Demonstration |
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| Rhode Island Accountable Entities (AEs) | “The intent of these requirements include: 1) To ensure multi-disciplinary providers are actively engaged in a shared enterprise and have a stake in both financial opportunities and decision-making of the organization; (2) to ensure that assets and resources intended to support RI Medicaid are appropriately allocated, protected, and retained in Rhode Island; (3) to ensure that the mission and goals of the new entity align with the goals of EOHHS and the needs of the Medicaid population; (4) to ensure a structured means of accountability to the population served.” (AE Certification Standards, 2017, p. 16) |
“There shall be an established means for shared governance that provides all AE Partner Providers with an appropriate, meaningful proportionate control over the AE’s decision-making process.” (AE Roadmap, April 2017, p. 42) “Board or Governing Committee Membership. The majority of voting members of the Board or the Governing Committee shall be provider representatives from participating Partner or Affiliate provider organizations, provided that at least three members shall be LTSS providers and one member shall be a behavioral health provider. Minimal representation requirements for each population certified to serve -Children: pediatric representative member of Consumer Advisory Committee, community-based organization (CBO) provider of age-appropriate supports -Adults: representative member of Consumer Advisory Committee, CBO provider of age-appropriate social supports (AE Certification Standards, 2017, p. 45) |
Draft certification standards include a requirement for AEs to have a “Community Advisory Committee consisting of at least ten persons who are attributed Medicaid beneficiaries who are representative of the populations served by the AE.” (AE Roadmap, 2.1.8) | Medicaid Section 1115 Demonstration | |
| State Innovation Model (SIM) |
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| Vermont Accountable Communities for Health (ACHs) | “An accountable community for health is managed through a governance structure that articulates the process for decision-making and outlines the roles and responsibilities of the integrator organization, the steering committee (or other decision-making body), and other collaborative structures or partners.” From Vermont Accountable Communities for Health Peer Learning Lab Report, March 2017 |
“The governance structure should include a diverse representation of stakeholders, including decision-makers, experts, community members, and leaders from the variety of community organizations that impact health in the region.” (Vermont ACH Peer Learning Lab Report, p. 18). | “The ACH Peer Learning Lab sought to build on this framework and test model implementation while increasing community capacity and readiness across the nine Core Elements of the ACH model.” (Vermont ACH Peer Learning Lab Report, p. 6 ) |
Governance is one of the nine core elements of the ACH model. (Vermont ACH Peer Learning Lab Report, p. 18) |
| State | Description, Goals, and Functions of Governing Body | Representation in Governing Body | Community Engagement | Governance Accountability, Incentives, or Milestones | Connection to Other State Initiatives |
| Washington Accountable Communities of Health (ACHs) | Accountable communities of health must: -Maintain a governance structure that includes balanced cross-sector collaboration and decision-making, including the necessary documented procedures and agreements, e.g. bylaws and a memorandum of understanding. -Ensure that no one sector or organization can control decision-making. -Revisit the process at least annually to determine effectiveness considering the regional landscape and specific governance structure.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, P. 5)“Minimum expectation: ACHs must develop and maintain a communications framework to keep partners informed and involved in between meetings and events.”(State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 8). |
“Washington’s tribes and urban Indian health organizations (UIHOs) are among the partners ACHs should reach out to for participation in ACH activities, including governance and decision making… Tribal governments are not stakeholders. The state maintains relations with the tribes on a government-to-government basis.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 7) | “ACHs require governance structures tailored by community leaders to most effectively implement the goals of Healthier Washington at the local level.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 5). “Because of the unique regional demographics, existing resources, and potential initiatives already under way, the specific community engagement strategies will not be prescribed by the state.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 8). |
“Minimum expectation: ACHs must implement a cascading engagement approach tailored to the local environment that brings the voice of consumers and individual community members to ACH development and decision making, in addition to the balanced multi-sector decision making structure.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 8) “ACHs are strongly encouraged, under the SIM contract, to maintain open public governing body meetings.” (State Innovation Model Contractual Guidelines for Accountable Communities of Health, p. 8) |
State Innovation Model |
How States Address Social Determinants of Health in their Medicaid Contracts and Contract Guidance Documents
To encourage investments in population health, states are increasingly using levers available in their managed care and value-based contracts to address social determinants of health, such as housing and employment. With support from the Robert Wood Johnson Foundation, the National Academy for State Health Policy examined Medicaid contracts and contract guidance documents in 11 states to highlight how each state’s contract requirements sought to enhance population health. This new chart compares the social determinants each state targeted, and how states monitored outcomes and funded these efforts.
View or download: How States Address Social Determinants of Health in Their Medicaid Contracts and Contract Guidance Documents
For more information, contact Jill Rosenthal or Amy Clary.
How Six States Use Medicaid Managed Care to Serve Children with Special Health Care Needs
Shutterstock.com
Medicaid managed care provides a unique opportunity for states to strengthen the structure and delivery of care for children and youth with special health care needs (CYSHCN). The National Academy for State Health Policy (NASHP), studied how six states (Arizona, Colorado, Minnesota, Ohio, Texas, and Virginia) designed their managed care systems to serve CYSHCN and examined some of their best practices and strategies to meet the unique needs of these children in three reports:
- How States Structure Medicaid Managed Care to Meet the Unique Needs of Children and Youth with Special Health Care Needs and an accompanying chart that provides an Overview of Selected State Medicaid Managed Care Programs
- Structuring Care Coordination Services for Children and Youth with Special Health Care Needs in Medicaid Managed Care: Lessons from Six States
- State Strategies to Enhance Medicaid and Title V Partnerships to Improve Care for Children with Special Health Care Needs in Medicaid Managed Care
These studies reveal that while there is variation among states in the design, scope of services, and targeted populations, there are strategies that states can employ in Medicaid managed care to ensure delivery of quality care for CYSHCN, including:
- Assessing the needs of CYSHCN to better coordinate care;
- Establishing network requirements for specialty providers;
- Promoting continuity of care during transitions; and
- Creating quality measures around processes and outcomes.
These three studies build on NASHP’s 50-state scan of Medicaid managed care systems serving CYSHCN and states’ use of Medicaid quality metrics for CYSHCN.
These resources were developed with support from the Lucile Packard Foundation for Children’s Health and the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services under grant number UC4MC28037 Alliance for Innovation on Maternal and Child Health.
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
