Q&A: A Deep Dive into New York’s Drug User Health Hubs with New York’s Allan Clear
The COVID-19 pandemic poses unique risks to people with opioid use disorder (OUD). Overdose risk increases when using individuals are in isolation and injection drug users are at higher risk of COVID-19 mortality due to increased rates of other infectious diseases and negative health effects from substance use.
State-supported comprehensive harm reduction programs that often provide sterile syringes, naloxone to reverse opioid overdoses, and education and counseling have shown encouraging results and remain critical during the current crisis. As policymakers face tough budget decisions in the coming months, understanding the value of harm reduction services will be increasingly important.
The National Academy of State Health Policy (NASHP) recently spoke to Allan Clear, director of the New York State Department of Health’s AIDS Institute’s Office of Drug User Health to identify the effectiveness of these programs. The institute’s Office of Drug User Health operates the state’s Syringe Exchange Program, Expanded Syringe Access Program, Opioid Overdose Prevention Program, Increasing Access to Buprenorphine Program, and Drug User Health Hubs. Clear has worked with people with substance use disorders (SUD) for decades and ran one of New York’s first syringe exchanges.
Describe the history of harm reduction in New York.
We had been doing underground needle exchange in New York City. The state Department of Health had been monitoring what we were doing and recognized that syringe exchange was of value and important in terms of the HIV epidemic. When the Foundation for AIDS Research said it was going to fund programs in New York City, that’s when the AIDS Institute stepped in, developed regulations, and amended the public health law on syringes, which allowed us to move forward legally and with the blessing of the government.
You don’t see it in documents, but New York state has invested heavily in harm reduction over the years, so our overriding philosophy in the AIDS Institute and Office of Drug User Health is a harm reduction approach.
Why is there an emphasis on people who inject drugs as a distinct service population?
I personally don’t think harm reduction would be necessary if we treated people who use drugs in the way we treat people with ‘medical’ problems. We have a health care system which we call “drug treatment,” which has been developed completely outside of the health care system, which I think is fairly unusual. If you have a pain in your neck or a pain in your stomach, you go to your doctor. If you have a substance use issue, you have to completely navigate an unknown and foreign system to find help. And that help is not in any form of outreach – it’s just waiting for you to find it. And then it’s a very imprecise and inaccurate response to your medical problem. The drug treatment system has never really gotten behind efforts that embrace people who use drugs, as opposed to people who desire to stop using drugs, and people sort of dip in and dip out of the treatment system. And I commend [our] agency for saying, “we do drug user health.”
Describe the inception of the drug user health hub program.
The best health care delivery system for people who use drugs would be the existing health care system. Ideally, we would destigmatize drug use to the extent that it becomes a normal thing for people who use drugs to get a compassionate response and quality health care when they enter the health care system. However, at this moment in time, we don’t have that, so we have to develop a system that exists outside of the mainstream medical system. This is why in New York, we have 24 syringe exchange programs (SEPs), and 12 of them are designated as drug user health hubs.
What is the process for becoming a drug user health hub?
[There is no formal certification process. Selected programs are given additional funding to enhance their regular programming in order to incorporate low-threshold medical care – an approach that offers services without attempting to control a patient’s intake of drugs and provides counselling only if requested.] The office approached a SEP in Albany, that already had a Law Enforcement-Assisted Diversion (LEAD) program, so, they added on extra case management staff to work with the pre-arrest diversion from the Albany police department. The office also approached a SEP in Buffalo, which had been extremely hard hit by overdoses. They used the money to build up capacity to respond to overdoses internally and to conduct outreach and anti-stigma work within the community, as the Buffalo police department was not carrying naloxone at the time. In Ithaca, they did a great deal of work around exploring drug policy reform and decided to do low-threshold buprenorphine program at their SEP. Over time, we’ve added another nine programs.
What are some of the most important services provided by a drug user health hub?
There are also so many restrictions and problems for doctors to prescribe buprenorphine that there’s a big shortage of providers who are willing to do it. We sort of saw buprenorphine as a frontline medication that prevents death from heroin or opioid overdose, and what we have been promoting is that we provide the medication and then find out what the person wants.
[Clear and his colleagues discovered that once people are properly treated and given assistance with resume drafting and interview techniques to help them return to the workforce, they were more amenable to addressing their secondary health needs, including hepatitis C. Describing the individuals that benefit from the services the hubs provide, Clear said, “people would come back and would be interested in other health care – they want other elements of their care addressed. They now have found a venue where they are welcome and where they get the care that they need.”]
How do the efforts of the Office of Drug User Health play into addressing infectious disease?
[Using the opioid overdose reversal drug naloxone as an example, SUD and infectious disease are intertwined.] Naloxone is not really about HIV – it’s obviously about keeping people alive who consume opioids. Back in the late 80s and early 90s, people who inject drugs drove the epidemic here, and now we’re down to something like less than 2 percent a year of new infections among people who inject drugs. The other element in there now that we talk about a lot is invasive infections, so MRSA, staph infections, endocarditis, all of which are on the increase among people who use drugs. We’re doing a lot of work around supporting staff in emergency departments (EDs) to recognize signs of SUD, conduct screening in the ED to see if someone does have an OUD, or if someone shows up with a staph infection to investigate their injection practices.
How would you apply what you’ve seen over the years to the work that needs to be done systemwide?
I’ve been around since the start of the AIDS epidemic and have seen the response and know how to address serious health epidemics for people who use drugs, and here we are – two and a half decades later – still trying to integrate health services …for people who use drugs into a health system that is not receptive to them. It makes me think, “Why didn’t we learn our lesson? Emerging from the AIDS epidemic, why didn’t we make those changes that were sustainable?” I’m hoping that we can, certainly with our office and the relationships we have built with other entities. We should be able to do something that is lasting and transformative.
New York Recommends Pediatric Preventive Care Improvements in its First 1,000 Days on Medicaid Report
By age three, a child’s brain has grown to 80 percent of its adult size and experiences during the first 1,000 days are critical to healthy brain development and social, emotional, cognitive, language, and physical development. Preventive measures taken in the first few years of life can have a significant and lasting impact on a child’s future health outcomes and overall success. New York is honing strategies to support healthy development during the first 1,000 days through primary care and trauma prevention strategies.
In October 2019, New York released recommendations from its Final Report of the First 1,000 Days Preventive Pediatric Care Clinical Advisory Group as part of the First 1,000 Days on Medicaid redesign initiative, which was launched in July 2017. It recognizes the critical role that Medicaid can play in the early life of children to help set them up for future success. The initiative also aims to work collaboratively with education programs and other sectors to deliver better results for children in New York.
Later in 2017, a group of stakeholders from different sectors and agencies, including education, child welfare, community-based organizations, public health, and mental health, convened to produce a plan for 10 proposed activities to be part of this initiative. Their first goal was to create a Preventive Pediatric Care Clinical Advisory Group that would develop a framework model for how to organize pediatric care in order to implement the Bright Futures guidelines. The framework model would identify barriers, possible incentives, and new system approaches to deliver the most effective care possible during well-child visits.
The advisory group included members from several child- and family-serving sectors that frequently partner with pediatric primary care, such as education, Early Intervention, and child welfare, and the group also sought feedback and participation from family representatives and community groups. The report, produced in October for the New York Medicaid program, details the group’s Model of Pediatric Population Health, which aims to build on the patient-centered medical home model with higher standards of care and care coordination. The focus of the model is on practice transformation to address the social determinants of health related to poverty, racism, and other environmental influences, and it integrates behavioral health care with traditional clinical care. The model lays out three tiers for integrating behavioral health:
- Tier 1: Services received by all children:
- Screening: Age-appropriate screenings for child development, maternal depression, and adverse childhood experiences (ACEs), social-emotional development, social determinants of health, and interpersonal violence
- Culturally sensitive anticipatory guidance focused on social-emotional/family health (e.g., Reach Out and Read, Vroom, lactation counseling, parent access for questions)
- Information about community resources (e.g., Head Start)
- Tier 2: Services received when a child or parent has an identified need: (Examples include developmental delay, housing or concrete services need, trauma, or maternal anxiety)
- Short-term counseling by early childhood mental health-trained professionals
- Care coordination by staff knowledgeable about early childhood services to facilitate connection with community resources
- Follow up and escalation to Tier 3 if needed
- Care delivered in a collaborative care model by the primary care provider, with support from mental health professionals either in the practice or remotely via tele-health
- Tier 3: Services received when a more complex need is identified for a child or parent
- Therapeutic intervention (e.g., dyadic therapy, parental mental health and substance use treatment) in the practice
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- Referral to community-based mental health services when needed
- Case management (with early childhood skills) for all needs, including navigation across services
The report recognizes that there will be an increased need for behavioral health staff if the three-tier model is to be implemented successfully. The group envisions that half of the Tier 1 and Tier 2 services could be reimbursed under Medicaid based on diagnoses and fee-for-service payments, but that a capitated payment model might be more effective. For Tier 3 services, the report recommends a parallel to the value-based payment model used to fund collaborative care for adults through Medicaid. Capitated payments through value-based contracts between Medicaid managed care organizations and pediatric practices have been suggested by stakeholders as a potential path for a child-focused, population-based arrangement.
The goal of this model is to achieve health equity for all children and families by addressing systemic disparities, fostering trust between families and medical providers, promoting community linkages, and providing two-generational, trauma-informed, culturally competent, and integrated primary and behavioral health care.
The advisory group also produced a list of recommendations about committing to the Pediatric Population Health model through activities like investment in its core programs, including sustaining the HealthySteps model and sites funded by the NYS Office of Mental Health HealthySteps pilot, and the documentation of progress and outcomes for children as different aspects of the model are piloted. The other planned activities included in the First 1,000 Days on Medicaid initiative include a focus on early literacy, home visiting, development of data systems for cross-sector referrals, and a peer family navigators pilot program.
New York is not the only state focusing on the first few years of a child’s life as a critical period for improving health outcomes across the lifespan. Rhode Island’s First 1,000 Days of RIte Care, the state Medicaid program, aims to improve rates of developmental screening and coordination between pediatric care with family home visiting and Early Intervention. California’s Medicaid program, MediCal, is collaborating with the state’s Office of the Surgeon General to address ACEs with trauma screenings and provider training on trauma-informed care. As states continue to look for ways to improve health at all ages, early childhood is a period where increased coordination across sectors and agencies can lead to preventive strategies that have a lasting impact.
This blog is supported by the David and Lucille Packard Foundation. To learn more about state efforts to promote healthy child development, please visit NASHP’s Healthy Child Development State Resource Center.
Behavioral Health Workforce Innovations: How Massachusetts and New York Engage Community Health Workers and Peers to Address Racial and Ethnic Disparities
Racial and ethnic inequities in access and quality of health care affect outcomes and increase the cost of care, especially among racial and ethnic minorities with behavioral health conditions. New York and Massachusetts are using innovative regulatory levers, such as revising training and certification requirements and reforming their payment and delivery systems, to improve behavioral health care for their racial and ethnic minority populations.
Background
Racial and ethnic inequities in health status and quality of care affect individuals’ health outcomes and increase the cost of care. This is especially pronounced for racial and ethnic minorities with behavioral health conditions.[1] Racial and ethnic minorities are less likely to receive diagnoses and treatment for mental illnesses, have less access to mental health services, and often receive poorer quality of mental health care.[2]
There are a variety of ways states are addressing these issues, such as broadening access to and building capacity of, their behavioral health workforce. Cultural and linguistic competency is an important strategy for improving the quality of care provided to people of all backgrounds and there are training tools available to enhance this skill.[3]
In addition to building the capacity of trained and licensed health care providers, evidence suggests individuals benefit from relationships with people who have similar lived experiences and are members of their community, such as community health workers (CHWs) and peer supports. These professionals include, but are not limited to, promotores, peer support specialists, and natural helpers.[4]
CHWs may be uniquely positioned to build trust and address barriers traditionally underserved communities face to seeking care.[5] Training CHWs to support the delivery of evidence-based practices may help to address mental health disparities.[6] CHWs can reduce the stigma associated with receiving mental health care and provide collaborative, patient-centered approaches to care, including understanding and incorporating patient preferences.
As states transform their health systems, they have opportunities to integrate innovative workforce approaches to meet the needs and understand the lived experiences of individuals with behavioral health needs, particularly among racial and ethnic minority populations. Many state programs are enlisting CHWs to address challenging aspects of their health improvement initiatives, such as facilitating care coordination, enhancing access to community-based services, and addressing social determinants of health.[7] Massachusetts and New York are incorporating CHWs and credentialed family peer advocates respectively into their redesigned payment and delivery systems in ways that can address these disparities. They are using a range of strategies and working across state agencies and with private to ensure that this new workforce is able to address patient needs.
The National Academy for State Health Policy (NASHP) interviewed officials from Massachusetts and New York to learn how they regulatory levers, such as training and certification requirements, along with payment and delivery reform, to improve behavioral health care for racial and ethnic minority populations. They also shared their models at the 2019 NASHP annual health policy conference.
How Massachusetts Builds Community Health Worker Capacity
The Massachusetts Delivery System Reform Incentive Payment (DSRIP) Program, under the authority of its 1115 Demonstration waiver,[8] provides $1.8 billion over five years (through June 30, 2022) to support MassHealth (Massachusetts Medicaid) providers as they transition to value-based payment. Entities that have signed contracts to be MassHealth accountable care organizations (ACOs) or Community Partners (behavioral health or long-term support and services) are eligible to participate in DSRIP. DSRIP supports the development of infrastructure and the implementation of care coordination activities for ACOs and Community Partners throughout the state, helps providers transition to new care delivery models, improves enrollees’ care and experience, and strengthens provider capacity.[9]
In addition to funding ACOs and Community Partners directly, there is a dedicated funding stream to support s, which allows the state to scale up statewide infrastructure and workforce capacity to better prepare the workforce for a newly emerging health care environment. Investing in training CHWs, recovery coaches, and peer specialists, along with their supervisors is among the workforce development and training priorities.[10] MassHealth chose this area of focus because ACOs and Community Partners recognized that CHWs and peer specialists have a unique ability to engage and help improve the health of MassHealth enrollees who are most likely to be disconnected from health care, and they expect to increase the size of this workforce. Although MassHealth does not reimburse CHWs, ACOs can spend DSRIP dollars in a variety of ways and many have chosen to hire CHWs as part of their efforts to improve health outcomes and decrease total cost of care.
Cultural competency is woven into the 10 recognized core competencies of CHWs.[11] The Massachusetts Board of Certification of CHWs administers a voluntary CHW certification program designed to help integrate CHWs into the health care and public health systems. The board develops standards for the education and training of CHWs and CHW trainers.
According to a 2016 survey, mental/behavioral health is the second-most frequently cited issue that CHWs report addressing, and the area that CHWs who work within clinical organizations expressed the most interest in receiving training.[12] The Massachusetts Department of Public Health currently funds curriculum development of specialized training for CHWs in behavioral health and substance addiction. In addition to expanding the capacity of existing training programs to accommodate new needs, MassHealth supported the design and implementation of a new training curriculum for CHW supervisors, as well as the design of a nine-month learning community to provide peer support, mentorship, and professional development for CHWs and peer specialists and to promote primary care/behavioral health integration. MassHealth plans to share data and knowledge gained from these programs with ACO and Community Partner leaders to better equip them to create workplaces that support CHWs and peer specialists.
Levers Massachusetts Uses to Support CHW Capacity to Address Health Disparities
State and public health agency partners:
- MassHealth (Medicaid program)
- Department of Health
- Office of Community Health Workers, Bureau of Community Health and Prevention
- Board of Certification of CHWs, Bureau of Health Professions Licensure
- Boston Public Health Commission, Cambridge Public Health (CHW core competency training programs)
Legislation: Chapter 58, Acts of 2006 Section 110[13] and Chapter 224, Acts of 2012.[14] Chapter 322, Acts of 2010[15] to establish a board within the Department of Public Health to certify CHWs.
Regulation and guidance: Core Competencies for Community Health Workers
Federal authority: Massachusetts’ Delivery System Reform Incentive Payment (DSRIP) Program, under the authority of its 1115 demonstration waiver.
How New York Expands Family Peer Support for Child Health
New York is in the process of transitioning its Medicaid-funded behavioral health services into Medicaid managed care and is using this opportunity to build on its experience using family peer supports. New York has a long history of including family peers in its state programs, engaging families in accessing services, and in policy development. The state has provided peer support services as an integral component of children’s behavioral health system for many years. Family peers have:
- Engaged families and addressed concerns about the mental health system;
- Explained how services can help their children;
- Alleviated stigma; and
- Addressed cultural barriers to services.
New York’s Children and Family Treatment and Support Services (CFTSS) program was developed under a State Plan Amendment (SPA)[i] as part of the Children’s Medicaid Redesign. The program is available to children and youth up to and including age 20 who are Medicaid-eligible under the Medicaid EPSDT benefit. Family peer services, previously only accessible to a subset of children under a Home and Community Based Services (HCBS) waiver, will be more universally available to all children who meet medical necessity criteria. The expanded access to the new CFTSS, including family peer support services as a reimbursable service, became available in January 2019.[ii] Provider agencies that employ peer advocates bill Medicaid using a specified set of rate codes.
According to the state plan, CFTSS, including family peer supports, can be provided by those with a state-recognized Family Peer Advocates (FPA) credential[iii] for children with mental health needs and Certified Peer Recovery Specialist certification with a family parenthetic (CRPA-F) for children with substance use needs. Families Together in New York State (FTNYS) administers the two levels of the FPA credential, which includes parent empowerment training. FTNYS also provides training for certification on the Family Needs and Strengths[iv] assessment and awareness tool to help FPAs ensure their work is family-driven and youth-guided. The Community Technical Assistance Center (CTAC),[v] in partnership with the state and FTNYS, offers Family Peer Support Services training including how to provide the services within a Medicaid managed care environment.
Eligibility for the FPA credential includes, among other criteria, demonstrating “lived experience” as a parent or primary caregiver who has navigated multiple child-serving systems on behalf of their child(ren) with social, emotional, developmental, health and/or behavioral health care needs and adherence to cultural competency guidelines. Cultural awareness and competence are among the requirements to complete the credential. A component of the curriculum incorporates the impact of structural and cultural factors that may shape families’ tendencies to care for their health in certain ways.[vi] It is intended to facilitate understanding of how structural factors determine beliefs, attitudes, values, and behaviors.[vii]
Formal and informal services and supports are provided through a structured, strength-based relationship between an FPA and the parent or caregiver, based on goals and objectives that a licensed practitioner recommends in the child´s treatment plan.[viii] All SPA services can be delivered in the community where the child/youth lives, attends school, and/or engages in services.
Levers New York Uses to Help Family Peer Advocates Address Health Disparities
State agency partners:
- Department of Health (Medicaid program)
- Office of Mental Health
- Office of Alcoholism and Substance Abuse Services
- Office of Children and Family Services
- Office for People with Developmental Disabilities
Legislation and guidance: Children and Family Treatment and Support Services
Federal authority: New York SPA and 1115 Waiver
Lessons and Considerations
Massachusetts and New York offer examples of ways that states can work to develop and deploy unique workforces to meet the behavioral health needs of racial and ethnic minority populations. Other states may consider the following early lessons:
Incorporate peer supports and CHWs during transitions to new payment and delivery approaches. Both Massachusetts and New York are redesigning their delivery systems to improve their quality of care and control Medicaid costs. As they do, they are expanding and adapting this workforce with the recognition that CHWs and peer supports may be uniquely positioned to address barriers to care and address mental health disparities. They are making these workforce investments through the federal authority of 1115 waivers and state plan amendments.
Partner across state agencies to maximize state resources and opportunities to engage CHWs and peer supports most effectively. Medicaid agencies can be critical to transforming payment and delivery systems. Departments of health, mental health, and other state agencies with responsibilities and expertise can support efforts through training, certification, and unique approaches to behavioral health and health equity. Massachusetts is drawing on its national leadership in CHW training and credentialing, and New York is building on its strong history of employing family peer supports.
Provide capacity-building support to employ and supervise the workforce. Massachusetts and New York offer training for supervisors and organizations that employ CHWs and peer supports. Massachusetts provides technical support to employers and sister agencies, such as the departments of Mental Health and Corrections and MassHealth, so they are prepared to meet CHW workforce needs. Knowing that managed care organizations want to ensure that the family peer support providers with whom they contract are effective in the delivery of services that they provide to families, New York provides toolkits to help organizations support and integrate peers and CHWs and online self-assessments to evaluate organizational readiness.
Embrace the cultural shift needed to employ CHWs and peer supports as equal partners within treatment teams. Massachusetts and New York recognize that providers must collaborate on care teams and with communities, and must value the lived experiences of CHWs and peer supports. Their criteria for CHWs and peer supports, including cultural competency, reflect these values. Massachusetts requires ACOs to partner with community partners in order to qualify for DSRIP funding. New York includes family peer support among an array of professionals serving children.
Recognize the unique needs of racial and ethnic minority populations with behavioral health needs. Engaging CHWs and peer supports can build trust, reduce stigma, and address barriers to care. Massachusetts and New York are expanding the reach of this workforce in innovative ways that can address care inequities. They are using a range of patient-centered approaches to facilitate care coordination, enhance access to community-based services, and address social determinants of health to meet patient .
As states transform their health systems, they have opportunities to integrate innovative workforce approaches that acknowledge the lived experiences of individuals with behavioral health needs in order to better meet their needs. CHWs and family peer advocates hold promise for improving health outcomes and reducing costs, particularly for racial and ethnic minority populations. States can use their purchasing and regulatory levers to advance innovative strategies and improve behavioral health.
Notes
[1] Artiga, Samantha, Julia Foutz, Elizabeth Cornachione, and Rachel Garfield. “Key Facts on Health and Health Care by Race and Ethnicity” (Kaiser Family Foundation, June 7, 2016), https://www.kff.org/report-section/key-facts-on-health-and-health-care-by-race-and-ethnicity-section-2-health-access-and-utilization/.
[2] “Minority Mental Health Awareness Month – July” (United States Department of Health and Human Services, Office of Minority Health, July 1, 2019), https://www.minorityhealth.hhs.gov/omh/content.aspx?ID=9447.
[3] The HHS OMH has developed a free and accredited e-learning program: Improving Cultural Competency for Behavioral Health Professionals .
[4] Taylor, Beck, Jonathan Mathers, and Jayne Perry. “Who Are Community Health Workers and What Do They Do? Development of an Empirically Derived Reported Taxonomy,” Journal of Public Health 40, no. 1 (March 2018): 199–209, https://doi.org/10.1093/pubmed/fdx033.
[5] Katigbak, Carina, Nancy Van Devanter, Nadia Islam, and Chau Trinh-Shevrin. “Partners in Health: A Conceptual Framework for the Role of Community Health Workers in Facilitating Patients’ Adoption of Healthy Behaviors,” American Journal of Public Health 105, no. 5 (May 2015): 872–80, https://doi.org/10.2105/AJPH.2014.302411.
[6] Barnett, Miya L., Araceli Gonzalez, Jeanne Miranda, Denise A. Chavira, and Anna S. Lau. “Mobilizing Community Health Workers to Address Mental Health Disparities for Underserved Populations: A Systematic Review,” Administration and Policy in Mental Health 45, no. 2 (March 2018): 195–211, https://doi.org/10.1007/s10488-017-0815-0.
[7] “State Community Health Worker Models,” National Academy for State Health Policy, accessed October 24, 2019, https://www.oldsite.nashp.org/state-community-health-worker-models/.
[8] Centers for Medicare and Medicaid Services, “MassHealth Medicaid Section 1115 Demonstration,” June 26, 2019, https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ma/ma-masshealth-ca.pdf.
[9] “State Delivery System and Payment Reform Map,” National Academy for State Health Policy, accessed October 24, 2019, https://www.oldsite.nashp.org/state-delivery-system-payment-reform-map/#toggle-id-3.
[10] Although the Massachusetts focus in this case study is on CHWs, the state is also investing in Certified Peer Specialists and Recovery Coaches. For a comparison of roles, see Commonwealth of Massachusetts Peer Support Worker Comparison Chart: Adult Services Department of Public Health Bureau of Substance Addiction Services (DPH/BSAS), February 27, 2019, https://www.mass.gov/files/documents/2019/03/20/Peer%20Support%20Worker%20Comparison%20Chart%203.14.pdf.
[11] “Board of Certification of Community Health Workers,” Commonwealth of Massachusetts, accessed October 31, 2019, https://www.mass.gov/orgs/board-of-certification-of-community-health-workers.
[12] Pokhrel, D, Community Health Workers, Health Inequity, and the Massachusetts Landscape: Results from Massachusetts Statewide Community Health Worker Workforce Surveillance Survey. Fifth Annual Massachusetts Department of Public Health Epidemiology Conference, Boston MA, November, 2018.
[13] Chapter 58, Acts of 2006 Section 110, (MA 2006), https://malegislature.gov/Laws/SessionLaws/Acts/2006/Chapter58.
[14] Chapter 224, Acts of 2012, (MA 2012), https://malegislature.gov/Laws/SessionLaws/Acts/2012/Chapter224.
[15] Chapter 322, Acts of 2010, (MA 2010), https://malegislature.gov/Laws/SessionLaws/Acts/2010/Chapter322.
[16] “State Plan Amendment #19-0003,” Centers for Medicare and Medicaid Services, February 7, 2019, https://www.health.ny.gov/regulations/state_plans/status/non-inst/approved/docs/app_2019-02-07_spa_19-03.pdf
[17] New York State Department of Health, “New York State Medicaid Update” 35, no. 6 (May 2019), https://www.health.ny.gov/health_care/medicaid/program/update/2019/2019-05.htm#behavioral.
[18] “Family Peer Advocate Credential (FPA),” Families Together in New York State, 2018, https://www.ftnys.org/training-credentialing/family-peer-advocate-credential/.
[19] “Family Needs & Strengths (FANS),” Families Together in New York State, 2018, https://www.ftnys.org/training-credentialing/family-needs-strengths-fans/.
[20] “Community Technical Assistance Center of New York,” accessed October 28, 2019, https://www.ctacny.org.
[21] “Center for Research on Cultural & Structural Equity,” accessed October 28, 2019, http://ccase.org.
[22] Lekas, Helen-Maria, Crystal Fuller Lewis, and Joanne Trinkle. “Integrating the Social and Cultural Determinants of Health into Peer Advocates Training.” Behavioral Health News, Summer 2019.
[23] “SPA Services Chart,” New York State Department of Health, November 30, 2015, https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/spa_distinct_chart.htm.
Acknowledgements: The author wishes to thank the state officials and stakeholders in Massachusetts (Masachusetts Department of Public Health, Commonwealth of Massachusetts Executive Office of Health and Human Services) and New York (New York State Office of Mental Health, New York State Department of Health, Families Together in New York State) who graciously shared their experiences or reviewed a draft of this publication. Trish Riley, Malka Berro, and Ariella Levisohn of NASHP helped inform its development. Finally, the author wishes to thank Dr. Margarita Alegria and her colleagues at the Disparities Research Unit/Department of Medicine/Massachusetts General Hospital for their guidance and support.
Research reported in this publication was supported by the National Institute on Minority Health and Health Disparities (NIMHD) of the National Institutes of Health under Award Number
R01MD009719. The content is solely the responsibility of the author and does not represent the official views of the National Institutes of Health.
Webinar for State Officials Only: Balancing Value and Affordability – Lessons from New York’s Medicaid Drug Cap and the Role of the Institute for Clinical and Economic Review
Tuesday, April 9, 2019
3:30 to 4:30 p.m. (EST)
In its first year of implementation, New York’s Medicaid Drug Cap received national attention for its unique approach to the rising cost of prescription drugs. The cap allows the New York Health Commissioner to negotiate a supplemental rebate with manufacturers if spending on a drug exceeds the cap. Entering its second year of implementation, what have state officials learned? How have assessments from the Institute for Clinical and Economic Review (ICER) informed New York’s process? Join NASHP for a state officials-only webinar to hear updates about New York’s Medicaid Drug Cap and learn more about ICER’s approach of bringing a focus on value to the current debate on high-priced prescription drugs. This webinar provides an opportunity for state officials to ask questions and explore more about what ICER is – and isn’t- and about how New York’s experience might inform other state action. This webinar is for state officials only, and will not be recorded.
The moderator is NASHP Executive Director Trish Riley.
Speakers are:
- Amir Bassiri, MA, Senior Policy Advisor for Health, Office of Governor Andrew M. Cuomo
- Steven D. Pearson, MD, MSc, Founder and President, Institute for Clinical and Economic Review (ICER)
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 |
#NASHPCONF18: As the HIV Population Ages, States Redesign their Long-Term Services Programs
People living with HIV (PLWH) are living longer due to advances in antiretroviral therapies and disease management. In 2016, 47 percent of PLWH in the United States were over age 50. This population often needs long-term services and supports at an earlier age due to increased risk of dementia, chronic illness, and the social isolation still associated with HIV infection. This aging population’s unique health care service and support needs are ushering in a new wave of state initiatives that work both within and outside traditional systems.
At the National Academy of State Health Policy’s annual conference earlier this year, state leaders met during a daylong preconference, Covering the Waterfront: Innovative State HIV Policy Approaches, from Prevention to Aging in Place, to share the strategies and challenges they face as they work to support PLWH across their lifespans.
New York and South Carolina have longstanding Medicaid that provide home- and community-based services (HCBS) to an aging PLWH population. Policymakers from those states described how these programs address the needs of their older :
South Carolina, whose HIV/AIDs 1915(c) waiver dates back to 1988, has made changes to its waiver benefits to better support an older population, including enhanced prescription drug coverage and self-directed, in-home services. Waiver benefits also include and home modifications, which state officials noted was key to keeping aging PLWH living independently for as long as possible. While South Carolina adapted its HIV/AIDS waiver to meet these needs, state officials noted that fewer PLWH are accessing waiver services in recent years because they no longer meet institutional level-of-care criteria. Attendees noted that states may need to consider other strategies to address the needs of PLWH who still need long-term care in their homes or communities, but no longer qualify for waiver programs. Policymakers suggested that over time older adults with HIV may be best served through other, non-HIV-specific HCBS waivers.
New York has operated its AIDS Adult Day Health Care Program (ADHCP) under its Medicaid state plan since 2007. ADHCPs are long-term care programs that provide eligible PLWH and people at risk for HIV with services and supports in a community setting. In addition to core services, such as nursing visits, mental health treatment, and support for daily living activities, clients can also participate in group meals, yoga classes, and socialization services. State policymakers view these investments as effective tools to reduce the isolation commonly experienced by PLWH, encourage engagement in treatment, and ultimately reduce the cost of care for PLWH who can be successfully supported in their homes and communities for longer periods of time.
While PLWH are living longer and often able to age in place in their communities, many will eventually need care from long-term care facilities. Officials expressed concern that these facilities may be ill-equipped to handle this population — a 2015 scan of state long-term care facility regulations found that very few states require these facilities to train their staff in how to care for PLWH. State policymakers discussed the need to enhance provider and staff training and address the persistent stigma associated with HIV infection often found among long-term care facility staff as key priorities for future work.
For more information about how states are working to improve the lives of PLWH, including older adults, explore NASHP’s Toolkit: State Strategies to Improve Health Outcomes for People Living with HIV.
Additional resources from the Health Resources and Services Administration’s HIV/AIDS Bureau:
HRSA Care Action: The Graying of HIV
Aging with HIV: Care Challenges
Engaging and Retaining Older Adults in HIV Care
States Jumpstart Efforts to Integrate Health and Housing Policies
As part of the National Academy for State Health Policy’s (NASHP) health and housing institute, officials from five states (IL, LA, NY, OR, and TX) met with other policymakers at #NASHPCONF18 to share how they work across agency siloes to improve health and housing for vulnerable populations, including those experiencing homelessness, struggling with behavioral health or substance use disorders, or transitioning out of institutions.
While the responsibilities of each sector often overlap, the ability to develop and maintain clear cross-agency communication allows each sector to play to its strengths and maximize resources and staff capacity.
States are working to partner across agencies to strengthen services that can help vulnerable populations become and remain successful tenants, such as helping with completing leasing forms, budgeting, interacting with landlords, or navigating personal crises that could jeopardize their living arrangements. States are also exploring ways to weave health and housing priorities into the very fabric of state health transformation initiatives, such as requiring or encouraging accountable health entities or Medicaid managed care plans to provide housing-related services and supports. States are using their policy levers to spur development of more affordable housing initiatives through public-private partnerships or increasing state fees to support affordable housing programs.
State health and housing policymakers, including those participating in the Health Resources and Services Administration-supported NASHP institute, shared their progress toward health and housing goals, discussed cross-sector data strategies, and explored federal policy priorities during #NASHPCONF18.
Cross-Sector Collaboration
The state teams participating in the discussion themselves exemplified cross-sector collaboration, with representatives from:
- Affordable housing
- Aging and adult services
- Developmental disabilities
- Health/public health
- Homes and community renewal
- Housing and community services
- Housing development
- Human services
- Medicaid
- Mental health
With both housing and health sectors represented, state teams were able to candidly discuss the responsibilities of each sector. On the housing side, state officials and partners explained they generally work to maximize available housing units, manage waiting lists, work with landlords, and administer subsidy programs. State health officials said they often oversee the housing- and health-related services that help keep people stably housed. While the responsibilities of each sector often overlap, the ability to develop and maintain clear cross-agency communication allows each sector to play to its strengths and maximize resources and staff capacity.
Harnessing the Power of Shared Data and Goals
State teams visited Ability Housing’s Village on Wiley in Jacksonville, FL, during #NASHPCONF18.
The five state health and housing teams share some common goals, such as capitalizing on insights and efficiencies gained from shared or integrated data to improve health through health and housing initiatives. For example, states are working to match Medicaid claims data with data from state Homeless Management Information Systems (HMIS) to map changes in emergency department use after previously homeless people are housed, in order to make the business case for investing in housing initiatives. States are also working to match HMIS and Medicaid data to identify and help the highest utilizers of emergency departments. A number of states are working to compile and integrate data from Medicaid, public health, justice, and homelessness systems to create a more complete picture of the social conditions and unmet needs that affect the health of vulnerable groups.
While states share many health and housing goals, individual states may focus on different populations. For instance, some states focus on housing people transitioning from long-term care or other institutional settings, such as through the Money Follows the Person program, while others prioritize housing people experiencing homelessness. States may also concentrate on the housing and service needs of people with behavioral health needs or substance use disorders, rural residents, or families with children. Despite the different populations of interest, some common state goals include:
- Make more effective use of data by:
- Creating and implementing agreements to share data across mental health, intellectual/developmental disability, Medicaid, and homeless systems;
- Developing data-matching systems to help with hot-spotting and managing wait lists, such as developing a vulnerability score that prioritizes people on housing waiting lists based on their use of shelters, jails, and emergency services;
- Using data from managed care organizations to track the interaction between Medicaid, health care, and housing programs; and
- Analyzing data across systems to demonstrate the return on investment (ROI) of health and housing programs.
- Explore capital investment strategies for healthy affordable housing acquisitions and/or development;
- Develop pilot programs to leverage health systems as housing referral sources;
- Facilitate meaningful partnerships between accountable care and housing entities in local communities to support investment in housing-related services and supports; and
- Test the impact of integrated housing and tenancy support services on emergency department usage.
Over the next two years, the five state teams in the health and housing institute will continue to work toward stably housing vulnerable people and providing the services they need to live healthy lives in their communities. While individual state goals differ, they often build on progress made during past technical assistance opportunities, such as the Centers for Medicare & Medicaid Services Innovation Accelerator Program. As the health and housing institute advances, states’ successes and lessons learned will be featured at future NASHP conferences and at its health and housing resources page at NASHP.org.
The health and housing institute is supported through NASHP’s Cooperative Agreement with the Health Resources and Services Administration (HRSA), grant #UD3OA22891, National Organizations of State and Local Officials. This information or content and conclusions are those of the author 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.
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.
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. 
