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Lessons from Rhode Island: How to Effectively Blend, Braid, and Use Block Grant Funds to Improve Public Health
When Rhode Island health policymakers read the U.S. Centers for Disease Control and Prevention’s Healthy People 2010 report, they realized their children’s generation could face a shorter life expectancy than their own unless they changed their approach to public health. In response, Department of Health officials doubled down on their commitment to address health disparities and improve the social factors that directly affect health, such as housing and nutrition.
At the same time, they understood they needed a new financial approach to support their growing focus on improving health and health equity and reducing obstacles such as poverty, discrimination, poor education, and unsafe environments. Their solution: braided funding from a number of sources to help realign staff, break down organizational silos, and promote cross-sector collaboration.
The department first tested its innovative, collaborative approach through integrated projects, such as bringing together staff from diabetes, obesity, and maternal and child health programs and recruiting community partners to work on a shared initiative. When those initial projects proved successful, they took stock of their funding sources and looked for opportunities to divest from disease-specific funding sources and invest instead in more community-focused funding.
Ana Novais, executive director of health in Rhode Island’s Department of Health
“Where is the funding for doing this kind of work?” observed Ana Novais, executive director of health in Rhode Island’s Department of Health. “There is no health equity funding being given to us, but nearly every proposal or grant we receive mentions health disparities.”
Rhode Island ultimately designed a method for “braiding” together funds from several sources to support its work to improve health equity. Officials wove together federal funds from the Maternal and Child Health Bureau of the Health Resources and Services Administration, the Substance Abuse and Mental Health Services Administration, the Preventive Health and Health Services Block, and two different chronic disease grants from the U.S. Centers for Disease Control and Prevention. They combined these federal funding streams with state funds, designed their work plan to meet both the department’s health equity goals as well as the various federal grants’ requirements, and then requested proposals from community organizations to improve health equity.
Novais explained the proposal asked communities to define themselves as health equity zones and submit proposals to prevent chronic diseases, improve birth outcomes, and improve the social and environmental conditions of neighborhoods across the state. See NASHP’s In the Zone for more about Rhode Island’s work to advance health equity and community health.
Novais recently shared her expertise and experience when she chaired a session on braiding and blending funds for improved population health at the annual 2017 NASHP state health policy conference held in late October. The session, presented in partnership with the de Beaumont Foundation, also featured state officials from Louisiana, Vermont, and South Carolina. Each state uses innovative braiding or blending models to address non-clinical health needs that affect public health through programs such as supportive housing and nurse home visiting for low-income, first-time mothers.
These innovative strategies may become even more important — and more widespread — in the wake of federal proposals to create block grants and cut state public health funding. A number of state health policymakers expressed concern that the flexibility provided by block grants may not adequately compensate for cuts to already lean public health budgets. To help state health policymakers prepare for and respond to such proposed changes, NASHP, the de Beaumont Foundation, and the Association of State and Territorial Health officials recently convened a group of state health policymakers from 11 states to strategically address opportunities and challenges that may result from potential changes to the federal funding landscape.
A new NASHP report, Blending, Braiding, and Block-Granting Funds for Public Health and Prevention: Implications for States, charts a way forward for states interested in maximizing their abilities to coordinate work and resources across programs. It distils ideas from the recent meeting of state leaders and explores state responses to possible federal funding scenarios. The report also:
- Surveys historic and existing sources of block grants and disease- or condition-specific federal funding;
- Examines how states currently use those funds; and
- Poses key questions for officials to ponder in the months ahead.
In this time of rapid policy changes, it is important to learn from states working to align their funding sources to advance their population health and prevention goals. “This paper is an important and much-needed resource for state officials seeking to improve health and health equity by investing in building stronger, healthier, and more resilient communities during this time of change,” said Novais.
Presented in partnership with the de Beaumont Foundation.
Learn How States Can Blend, Braid, and Use Block Grant Funds to Promote Public Health
As federal officials hint at overwhelming changes in how state health programs will be funded in the future, policymakers are strategizing how to reconfigure their programs to take advantage of the promised brave new world of flexibility and realigned funding. The National Academy for State Health Policy (NASHP), the de Beaumont Foundation, and the Association of State and Territorial Health Officials recently convened a small group of state health policymakers from 11 states to strategically address opportunities and challenges that may result from changes to the federal funding landscape.
The meeting produced a new paper, Blending, Braiding, and Block-Granting Funds for Public Health and Prevention: Implications for States, that charts a way forward for states interested in coordinating work and resources across programs.
“This paper is an important and much needed resource for state officials seeking to improve health and health equity by investing in building stronger, healthier, and more resilient communities during this time of change,” said Ana Novais, executive director of health at the Rhode Island Department of Health. To learn more about Rhode Island’s innovative financing to advance health and health equity, read this blog.
The 2017 annual NASHP state health policy conference also addressed braiding and blending funds for improved population health. The session, presented in partnership with the de Beaumont Foundation, featured officials from Rhode Island, Louisiana, Vermont, and South Carolina. Each state uses innovative braiding or blending models to address population health and non-clinical health needs through programs such as supportive housing and nurse home visiting for low-income first-time mothers. Read more.
Presented in partnership with the de Beaumont Foundation
South Carolina – Medical Homes
In early 2011, the Centers for Medicare & Medicaid Services (CMS) approved South Carolina’s request to expand its Healthy Connections Choices program to require that most beneficiaries enroll in managed care. Healthy Connections Choices enrollees have the option to join a managed care plan or a primary care case management program known as the Medical Homes Network Program. In the Medical Homes Network Program, South Carolina Department of Health and Human Services (SCDHHS) (the South Carolina Medicaid agency) contracts with Care Coordination Service Organizations (CSOs) to provide medical home services to Medicaid beneficiaries. The CSOs individually contract with primary care physicians to create the medical home network. Palmetto Physician Connections and South Carolina Solutions are the current CSOs.
The goals of the Medical Homes Network Program include:
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Providing accessible, comprehensive, family centered, coordinated care (including 24/7 telephonic patient access);
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Providers that manage the patient’s health care, perform primary and preventive care services, arrange for any additional needed care, and focus on the physician-patient relationship; and
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Patient education regarding preventive and primary health care, utilization of the medical home and appropriate use of the emergency room.
More information, including specific provider requirements, can be found in the network contract and policy and procedure guide, as well as the provider manual for Palmetto Physician Connections.
Federal Support: South Carolina has received a duals demonstration grant from CMS to “coordinate care across primary, acute, behavioral health and long-term supports and services for dual eligible individuals.”
Last Updated: January 2014
Federal Support: South Carolina has received a duals demonstration grant from CMS to “coordinate care across primary, acute, behavioral health and long-term supports and services for dual eligible individuals.”
Last Updated: January 2014
| Aligning Reimbursement & Purchasing |
Care Coordination Service Organizations (CSO), administrative entities that contract with primary care physicians in a Medical Home Network, receive two payments for their services:
Networks that do not achieve savings risk a penalty that would require the network to return a portion (or all) of their prospective care coordination fees.
It is up to each CSO to determine specific care coordination fees and shared savings payments made to the participating primary care providers in their network. Care coordination fees to providers are paid out of the network’s $10 PMPM payment.
Participating providers continue to receive fee for service reimbursement from South Carolina Medicaid; the Medical Home Networks do not pay any claims.
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| Supporting Practices |
Under the Medical Homes Network Program, the South Carolina Department of Health and Human Services contracts with Care Coordination Service Organizations to provide care coordination, disease management and data management support.
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| Measuring Results |
The South Carolina Department of Health and Human Services requires participating medical home networks to work with the department to establish outcome measures relevant to the program.
Furthermore, an external quality review organization conducts an annual quality assurance evaluation for each medical home network. This process includes:
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South Carolina
In South Carolina:
- As of July 1, 2011, there were 862,145 beneficiaries enrolled in the state’s Medicaid program. 428,765 beneficiaries are enrolled in four Medicaid-only managed care organizations (MCOs), while 142,296 beneficiaries are enrolled in a primary care case management program (PCCM) known as the Medical Homes Network. All Medicaid beneficiaries are also enrolled in a transportation-only Prepaid Ambulatory Health Plan.
- Physical health services are provided to children primarily through managed care organizations, though disabled or foster care children may be enrolled in the state’s PCCM program. Limited behavioral health services are available through MCOs, and most behavioral are paid for a fee-for-service basis. Oral health benefits are administered by DentaQuest.
As of 2013, 695,485 individuals were eligible for South Carolina’s Early Periodic Screening, Diagnostic and Treatment Benefit (EPSDT). According to 416 data from 2013, the state achieved an EPSDT screening ratio of 80% and a participant ratio of 61%. 333,902 children received dental services of any kind, with 319,129 receiving preventive dental services.
Last updated September 2014
| Medical Necessity |
Medicaid policy manuals in South Carolina define medical necessity as:
“Medical Necessity (the provision of which may be limited by specific manual provisions, bulletins, and other directives) is directed toward the maintenance, improvement, or protection of health or toward the diagnosis and treatment of illness or disability.”
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| Initiatives to Improve Access |
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| Reporting & Data Collection | South Carolina’s Quality Through Technology and Innovation in Pediatrics (QTIP) initiative (funded through a CHIPRA quality grant) is supporting work to collect CHIPRA quality indicator data from 18 pediatric practice. |
| Behavioral Health |
South Carolina Medicaid allows providers to bill for developmental screenings at select well-child visits (9 months, 18 months, 24 months, and 48 months). Providers must use a standardized screening tool; the state suggests: the
The state allows Child Service Professionals—required to have training in children’s behavioral health but not specific certification is required—to provide rehabilitative behavioral health services to children. Medicaid covers Behavioral Modification for children in the community, as well as Skills Training and Development Services for Children.
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| Support to Providers and Families |
Support to Providers
The state offers provider bulletins to keep providers abreast of policy changes in a number of areas including EPSDT. The Medicaid manual for physicians contains detailed information about the EPSDT benefit and its requirements.
Providers from the 18 pediatric primary care practices participating in the Quality Through Technology and Innovation in Pediatrics (QTIP) initiative participate in learning collaboratives that share information on quality improvement, health information technology, quality reporting, and enhanced primary care.
Support to Families
Member education about the EPSDT benefit is primarily the responsibility of Medicaid managed care plans. Materials for families on the state’s website are focused on helping families determine eligibility and enroll in Medicaid.
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| Care Coordination |
Medicaid managed care contracts in South Carolina require plans to participate in care coordination activities, including:
Beneficiaries enrolled in the state’s Medical Home Network primary care case management program. The state provides a list of patient-centered medical home practices in the state.
Through the Quality Through Technology and Innovation in Pediatrics (QTIP) initiative (funded through a CHIPRA quality grant), South Carolina Medicaid is helping 18 pediatric primary care practices transform to become patient-centered medical homes. The project provides a Patient Centered Medical Home Toolkit to help guide practices through the medical home certification process. |
| Oral Health |
South Carolina Medicaid covers application of topical fluoride varnish by primary care providers during well-child visits for children up to age 3. Physician applying fluoride varnish must also offer relevant oral health anticipatory guidance. The state also offers a Medicaid dental provider manual that includes information on dental benefits for children. |
State Experience with ACA Open Enrollment: Early Successes and Lessons
Individuals and families began to explore options and enroll in coverage through the Affordable Care Act (ACA) on October 1, 2013. States now have nine weeks of experience with open enrollment under their belts and can share early lessons learned in what worked and what did not, and managing the rough spots. During this Maximizing Enrollment and State Refor(u)m-sponsored webinar, a NASHP expert will describe some of the early experiences shared by state officials at the 2013 NASHP Annual State Health Policy Conference and other NASHP convenings held in October. Officials from states with different marketplace and Medicaid models will reflect on open enrollment in their states so far, highlighting their successes and challenges to date, their experiences with outreach and messaging, and how their operations and systems are performing. Panelists will describe their approaches in these key areas and identify priority areas for states as they look to January 1, 2014 when health insurance coverage under ACA takes effect.
Participants:
- Moderator: Catherine Hess, Co-Director, Maximizing Enrollment; Managing Director for Coverage and Access, National Academy for State Health Policy
- Speaker: Joanne Jee, Program Director, National Academy for State Health Policy
- Speaker: Michael Koetting, Deputy Director for Planning and Reform Implementation, Illinois Department of Healthcare and Family Services
- Speaker: Richard Onizuka, Chief Executive Officer, Washington Health Benefit Exchange
- Speaker: John Supra, Deputy Director for Information Management and Chief Information Officer, South Carolina’s Department of Health and Human Services
| Click to download presentation slides (PDF) | 7 MB |
New State Refor(u)m Webinar: Beyond the Expansion Decision: Tackling the Other Medicaid Changes in the ACA
State decisions about whether or not to do the Medicaid expansion have begun to unfold, but Medicaid has many other critical changes on its plate. States have complex eligibility and enrollment, financing, benefit design and consumer assistance requirements to untangle, and 2014 is approaching quickly.
This State Refor(u)m webinar will provide a brief overview of these reforms and why they are important. We will then ask our state panelists to address questions like:
- What progress have they made so-far in simplifying and automating enrollment and renewals? What are some of the toughest remaining issues?
- How are they coordinating state or federally facilitated health insurance exchanges to prevent coverage gaps?
- Do they plan to roll out a Medicaid benchmark plan and what will it look like?
- How do they plan to provide consumer assistance?
Moderator:
Matt Salo, Executive Director, National Association of Medicaid Directors
Overview:
Alice Weiss, Program Director, National Academy for State Health Policy
Kaitlin Sheedy, Policy Analyst, National Academy for State Health Policy
Speakers:
Beth Osthimer, Director, Medicaid and Health Reform, Division of Coverage and Enrollment, Office of Health Insurance Programs, NY State Health Department
Linda Skinner, Director of Health Care Innovation Infrastructure Management Arizona Governor’s Office
John Supra, Deputy Director for Information Management and Chief Information Officer, South Carolina Department of Health and Human Services
South Carolina
NASHP’s Accountable Care Activity map is a work in progress; state activity pages will be launched in waves throughout Fall 2012.
At this time, we have no information on accountable care activity that meets the following criteria: (1) Medicaid or CHIP agency participation (not necessarily leadership); (2) explicitly intended to advance accountable or integrated care models; and (3) evidence of commitment, such as workgroups, legislation, executive orders, or dedicated staff.
If you have information about accountable care activity in your state, please email skinsler@oldsite.nashp.org.
Last updated: October 2012
Improving the Quality of Care and Coordination of Services for Young Children—ABCD, CHIPRA and Beyond!
Early identification of delays and linkage to appropriate services can improve coordination among pediatric primary health care providers and providers of mental health, early intervention, child welfare, and early care and education services and influence the course of young children’s healthy development. States are using a variety of mechanisms to develop and test interventions to improve linkages between primary care and other child and family service providers. This webinar will highlight how Illinois, Oregon, South Carolina, and Vermont are using ABCD III (Assuring Better Child Health and Development) and/or CHIPRA quality grants to build on and align current efforts, such as medical home initiatives, health information technology or exchange, performance measurement, and health reform, to transform the delivery of care to children covered by Medicaid and CHIP. This event is sponsored by The Commonwealth Fund and builds upon a session held during the NASHP Annual Conference in October 2010.
Panelist Discussion
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State Uses of Hospital Discharge Databases to Reduce Racial and Ethnic Disparities
This report summarizes how leading states that participate in the Healthcare Cost and Utilization Project (HCUP) and their clients use hospital discharge data on patient race/ethnicity to inform state health care disparities reduction activities. The report features California, Florida, Massachusetts, Rhode Island, and Wisconsin HCUP Partners, but also notes activity in Connecticut, Georgia, New Jersey, and South Carolina. Partner States’ experiences demonstrate that patient race/ethnicity data are an important tool for informing state initiatives and producing policy- and practice-relevant publications to support health equity.
| State Use of Hospital Discharge Databases to Reduce Racial & Ethnic Disparities.pdf | 204.8 KB |
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. 
