CalAIM: Leveraging Medicaid Managed Care for Housing and Homelessness Supports
/in Policy, Population Health California Featured News Home, Reports Housing and Health, Medicaid Managed Care, Medicaid Managed Care, Population Health /by Allie AtkesonHealth and Housing: Introduction to Cross-Sector Collaboration
/in Social Determinants of Health Featured News Home, Reports Health Equity, Housing and Health, Social Determinants of Health /by Allie Atkeson and Sandra WilknissAmerican Rescue Plan Act Gives States Opportunity to Invest in Transition Services and Housing
/in COVID-19 Relief and Recovery Resource Center Featured News Home, Maps COVID-19, Housing and Health, Relief and Recovery /by Mia AntezzoData Sharing Resources for Health and Housing Partnerships
/in Population Health Housing and Health /by Allie AtkesonSix States Selected for NASHP’s Second Health and Housing Institute
/in Policy Blogs, Featured News Home Housing and Health /by Allie AtkesonWith historic federal investments in housing and health, states are well poised to shift investments from episodic emergency and institutional care to more sustainable community and supportive housing solutions. Housing stability is an essential social determinant of health and necessary for maintaining positive health outcomes. The impact of COVID-19 on people in institutional settings and populations experiencing homelessness further compels state officials to consider the need for equitable and targeted supportive housing programs. States can leverage federal funding for capital and rental assistance and have a variety of levers including federal Medicaid authorities and Medicaid managed care contracting to address housing-related services.
The National Academy for State Health Policy (NASHP), with support from the Health Resources and Services Administration (HRSA), will convene six states for a two-year Institute beginning in June 2021. NASHP will work with state Medicaid and housing agencies and other state policymakers from six states to address challenges related to sustainable financing of health and housing programs, including ensuring equitable access to housing-related services, demonstrating return on investment (ROI), collecting and sharing data among agencies and providers, determining effective governance structures for cross-sector housing and health initiatives, and measuring program outcomes.
States selected to participate in the Institute include:
- Arizona
- Colorado
- Kansas
- North Dakota
- Pennsylvania
- Virginia
The Institute will draw on lessons learned from NASHP’s first Institute; from November 2018 to November 2020, NASHP convened multi-agency teams in Illinois, Louisiana, New York, Oregon, and Texas. Detailed information on these states’ priorities and outcomes can be found in the final report, Five States Break Down Interagency Silos to Strengthen their Health and Housing Initiatives.
To learn more about NASHP’s work on health and housing, visit our resource center for states.
Acknowledgement: This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number U2MOA394670100, 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.
New Federal Resources Can Support States’ Affordable and Supportive Housing Programs
/in COVID-19 Relief and Recovery Resource Center Blogs, Featured News Home Chronic and Complex Populations, Chronic Disease Prevention and Management, Health Equity, Housing and Health, Medicaid Managed Care, Physical and Behavioral Health Integration, Population Health, Relief and Recovery, Social Determinants of Health /by Allie AtkesonAcross the nation, COVID-19 has exacerbated the dual challenges of housing affordability and homelessness. As states address these issues, there are new federal resources available through the American Rescue Plan Act (ARPA) and proposed American Jobs Plan that states can deploy efficiently and equitably.
The economic impact from COVID-19 has left 30 to 40 million Americans at risk of eviction with a disproportionate impact on low-income communities of color. To avoid homelessness, many individuals and families have sought housing with friends and family, leading to crowding and increased coronavirus transmission. The pandemic has also greatly impacted individuals currently experiencing homelessness and living in congregate shelters. In New York City, the age-adjusted mortality rate from COVID-19 among sheltered people experiencing homelessness was 50 percent higher than the rest of the population’s cumulative rate as of February 2021.
For more information about NASHP’s health and housing institute opportunity, please view the request for applications due Friday, April 30, 2021.
The National Academy for State Health Policy (NASHP) is launching its Second Health and Housing Institute. The goal of the institute is to help states break down inter-agency silos and strengthen services and supports to help low-income and vulnerable populations become and remain successfully housed. Permanent supportive housing programs require affordable housing and housing-related services financed by Medicaid. Importantly, the new institute will focus on state deployment and execution of newly available federal resources.
With the passage of ARPA and the proposed American Jobs Plan, the following are new programs, policy, and funding opportunities:
Eviction Prevention and Affordable Housing:
- In late March, the Centers for Disease Control and Prevention (CDC) Director Rochelle Walensky extended the temporary halt in residential evictions until June 30, 2021. Under the eviction moratorium, individuals must declare their inability to pay rent due to the loss of income or employment to avoid eviction.
- ARPA allocated $21.5 billion for the Emergency Rental Assistance Program (ERAP). ERAP funds will be released by early May 2021 to support eligible households in which one or more individuals are experiencing unemployment or housing instability. Financial assistance is limited to 18 months.
- $100 million in grants to organizations approved by the Department of Housing and Urban Development (HUD) that provide housing counseling services to households experiencing housing instability. Housing counseling includes information on renting, mortgage defaults, foreclosures, and credit issues.
- $5 billion allocated in ARPA for emergency housing vouchers. Vouchers serve as emergency rental assistance and voucher renewals for people experiencing homelessness, at risk of homelessness, experiencing housing instability, or fleeing intimate partner violence.
Supportive Housing and Homelessness Assistance:
- $5 billion in federal funding to states for the Homelessness Assistance and Supportive Services Program. This funding will be distributed to states to acquire and develop properties for supportive housing programs, tenant-based rental assistance, and supportive services, including housing counseling and homeless prevention services. Funding can also be used for the supportive housing workforce and service providers.
Home- and Community-Based Services:
- President Biden’s proposed American Jobs Plan includes $400 billion to strengthen home- and community-based services for seniors and people with disabilities. This funding will also raise wages for home health care workers and support the Money Follows the Person program to provide services for individuals in communities rather than nursing homes. Both home-and community-based services and the Money Follows the Person program are essential components of supportive housing.
These newly available resources provide states with opportunities to support, expand, and develop programs for those experiencing homelessness, housing instability, and populations that benefit from supportive housing. States will play an important role in determining how resources are distributed equitably to communities that have historically been denied federal housing resources and those most in need. In addition, some funding will go directly to local governments, public housing authorities and HUD-approved nonprofits. States can work collaboratively with these partners on shared agendas around housing stability and homelessness to strengthen health outcomes.
Acknowledgement: This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number U2MOA394670100, 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. The author would also like to thank the Corporation for Supportive Housing for their analysis of the American Rescue Plan Act.
Rhode Island’s Accountable Entities Emphasize Children’s Health and Social Needs
/in Policy Rhode Island Blogs, Featured News Home Chronic and Complex Populations, Eligibility and Enrollment, Eligibility and Enrollment, Health Coverage and Access, Health Equity, Housing and Health, Integrated Care for Children, Maternal, Child, and Adolescent Health, Physical and Behavioral Health Integration, Population Health, Social Determinants of Health /by Elinor HigginsIn the midst of the pandemic, many states are continuing to advance their health system transformation efforts. Rhode Island’s Medicaid Accountable Entities (AE) Program, for example, is shifting to a pay-for-performance model for several screening measures. Under this model, there is an additional financial incentive to screen children and their families for health and social needs, which have taken on new importance due to the added stressors of COVID-19.
Rhode Island’s AE program, now entering its fourth year, makes provider organizations (AEs) accountable for health outcomes of their members as well as the total cost of care of their populations. Using contractual levers in the agreements between AEs and managed care organizations (MCOs), the state requires AEs to integrate strategies to address social needs and social determinants of health (SDOH). The strategies must include assessment of social needs, referral to community resources, and utilizing community partnerships and engagement to address the identified needs.
Read NASHP’s 2018 profile of Rhode Island’s Accountable Entities Program here.
The state developed SDOH screening requirements for the AEs. Screening tools must be approved by the Rhode Island Executive Office of Health and Human Services (EOHHS), and they must include information on the following domains: housing insecurity, food insecurity, transportation, interpersonal violence, and utility assistance.
Screening for a child’s needs can offer insights about what kinds of services, referrals, or wrap-around care are needed to ensure healthy development. Because the ongoing pandemic has required children and families to stay home and spend additional time together, a safe and supportive home environment is especially crucial for children’s health and well-being. The SDOH screening domains that are required by EOHHS overlap with adverse childhood experiences (ACEs), such as poverty, food and/or housing insecurity, neglect, and mental illness — all of which contribute to poor health outcomes for children.
Rhode Island’s AE program takes into account the benefit of a two-generation (2Gen) approach to these issues. Under a 2Gen framework, services are provided to both children and the adults in their lives simultaneously to help families live healthy and productive lives. When screening children under age 12, Rhode Island’s SDOH screening measure can be applied to an entire household instead of to only the individual child. This can provide a better understanding of how to target interventions for the whole family going forward.
This year, a key change is happening within the AE program that may increase the number of children and families served by the program. The state is shifting to pay-for-performance (P4P) for the SDOH screening requirement. Beginning in Project Year 4 (PY4), there is a financial incentive for the AEs to increase their SDOH screening rates among their attributed populations. AEs needed time to develop their screening tools and build capacity around screening for SDOH before shifting the AE incentive metric to P4P. Other measures, including documented developmental screening for children younger than age 3, will also transition to P4P in PY4.
Though the SDOH screening requirements are specific to Medicaid AEs in Rhode Island, state officials expect the screening requirements to have a ripple effect. In primary care settings, for example, if a provider is administering the SDOH to AE-attributed patients, officials expect they are likely integrating the screening into their workflows and administering it to all of their patients. This has proven to be the case with other well-child practices. For example, the AE Coastal Medical, has implemented universal screenings across all of its practices to assess and identify needs around depression, anxiety, and SDOH.
Screening is only the first step in improving health-related social needs for children and families. One of the goals of the AE program is to use screening results and the improved understanding of its members’ circumstances to improve their overall health. Rhode Island is leveraging its Quality Report System (QRS), a tool for data collection, to calculate performance on the quality measure. This tool enables providers to drill down to the patient level to identify patients still in need of screening.
An upcoming strategy to help AEs coordinate better with community partners is the procurement of a community referral system that would help connect individuals to necessary resources. Such a referral network could be linked with the QRS in the future, making data collection, analysis, and referral a centralized process. Ultimately, this initiative may drive a broader conversation about how the state collects screening data across both public and private payers, and how this data can be used to improve the health outcomes of Rhode Island residents.
States Address Racial and Ethnic Disparities in their COVID-19 Responses and Beyond
/in COVID-19 State Action Center Blogs, Featured News Home COVID-19, Equity, Health Equity, Housing and Health, Population Health, Relief and Recovery, Social Determinants of Health /by Allie Atkeson and Rebecca CooperMore than a year into the pandemic, COVID-19 is proving to be a complicated syndemic with political, economic, and social factors influencing who is most at risk of infection and death. With communities impacted by structural racism facing higher COVID-19 infection and mortality rates, state responses and recovery plans are focusing on equity.
The latest update to the National Academy for State Health Policy’s (NASHP) interactive map and chart, How States Collect Data, Report, and Act on COVID-19 Racial and Ethnic Disparities, highlights the cross-sector actions states are taking to reduce COVID-19 inequities. Many are:
- Developing strategies to create resilient public health systems capable of weathering future challenges; and
- Developing longitudinal, agency-level changes, such as instituting racial equity impact assessments to determine the impact of state policies on various racial and ethnic groups.
Discover how states are reporting race and ethnicity in their COVID-19 cases and how they’re addressing equity here.
States Emphasize Equity in COVID-19 Response
Washington, DC has prioritized equity in its coronavirus response and vaccine distribution strategies. The Reopen DC Taskforce designated a subcommittee to focus on vulnerable populations to address the inequities of the pandemic including the disproportionate impact on African American individuals in case counts and deaths. The subcommittee has assembled several recommendations addressing social and economic determinants of health for Mayor Muriel Bowser to consider as she works to create an equitable reopening plan based on science and tailored to community needs. The District is focusing on prevention, health outcomes, and access to resources by collecting and publishing race/ethnicity data to guide their initiative to reopen the District. The District is also exploring philanthropic partnerships to help provide health and economic support to communities of color. The committee’s recommendations focus on:
Council Office of Racial Equity’s (CORE) Framework for Equity:
- Focus on racial equity;
- Put people first;
- Invest in community infrastructure;
- Build an equitable economy; and
- Protect and expand community voices and power.
- Employment and income;
- Education;
- Food environment;
- Health and medical care;
- Housing;
- Transportation;
- Outdoor environment; and
- Community safety.
The committee recommends sustaining investments in the expansion of supportive and affordable housing for domestic violence victims and incarcerated individuals re-entering their communities, as well as non-congregate housing for people experiencing homelessness.
The committee also recommends incentivizing employers who accommodate extended work-from-home requests from employees and working with pharmacies and other medical corporations to prevent treatment shortages in underserved areas.
The DC Council has also passed legislation to create the Council Office of Racial Equity (CORE). CORE recently released a report in March examining racial equity in the District’s vaccination rates and practices, and proposing best practices to ensure the District can ensure a racially equitable process moving forward. For example, to ensure equitable vaccine distribution, the District prioritizes doses for individuals living in high-need zip codes and has restricted registration on certain days to allow only those individuals to sign up on the vaccine portal or call the vaccine hotline. CORE is currently working on another report that focuses on a racially equitable economic recovery.
In Illinois, the Department of Public Health established a COVID-19 Health Equity Task Force to work across the department and with other relevant state and local entities to assess health concerns of minority communities and create and maintain culturally sensitive programs. The task force launched a COVID-19 text messaging system that includes a Spanish-speaking option. The department also supported the City of Chicago, in partnership with the city’s chief equity officer, to create the Racial Equity Rapid Response Team (RERRT) to address the disproportionate effects of the pandemic on communities of color. The city experienced a significant improvement in vaccine administration to communities of color by February 2021 as a result of RERRT’s oversight and involvement.
Georgia’s Department of Public Health created a COVID-19 Health Equity Council to ensure equity in COVID-19 vaccination education and distribution efforts in communities most affected by COVID-19. Members of the council represent community-based organizations, news stations, chambers of commerce, and universities. The council will work with Georgia’s 18 public health districts to address COVID-19 concerns.
State Actions to Address Equity Beyond the Pandemic
States are making financial and cross-agency leadership commitments to ensure equity is the focus of their work moving forward. Washington, DC, Illinois, Indiana, and Washington State have recently hired or are in the process of hiring cabinet-level positions to oversee inter-agency diversity, equity, and inclusion (DEI) initiatives. States are also implementing cross-sector equity plans and making significant investments in identified program and policy areas.
Washington’s state legislature passed HB 1783 in 2020 to create the Office of Equity. Lawmakers explained, “the legislature finds that a more inclusive Washington is possible if agencies identify and implement effective strategies to eliminate systemic inequities.” In February 2021, Gov. Jay Inslee named a director of the program to be in office by March 8. The office will be staffed by eight people and is tasked to develop and implement a five-year equity plan for the state. Staff will work with other state agencies to help create and implement DEI plans.
In his $365 million equity policy package, Gov. Inslee earmarked $2.5 million from the state’s general fund for the office. Other state equity priorities include:
- $10 million for the Washington COVID-19 Immigrant Relief Fund;
- Funding for the Office of Minority and Women’s Business Enterprises to launch the Washington State Toolkit for Equity in Public Spending to increase the number of minority and women contractors;
- Funding for the Department of Financial Institutions to address racial wealth inequities by working with financial institutions, federal, state, and local governments, and community partners;
- $79 million to support residential broadband connection for families and $6 million for a Digital Navigator Program that enables navigators to provide one-on-one support for students, English language learners, older adults, and individuals searching for work; and
- $8.4 million for students who experienced foster care or homelessness, including $3 million for pre-apprenticeship training.
In Florida, bills introduced in the House of Representatives and State Senate (HB 183 and SB 404) require each county health department to designate a minority health liaison. The liaison will collaborate with the state Office of Minority Health and Health Equity on implementation of programs, policies, and practices. Examples of these activities include:
- Data analysis for disparities in health status, health care quality, and access to care for racial and ethnic minority populations;
- Demonstration projects to increase health equity;
- Community health workers working to improve cultural competency and individual and community self-sufficiency;
- Analysis of a community’s risk for involvement in the adult and juvenile legal system and foster care system, or risk of homelessness. Available support programs and diversion programs addressing these areas will also be examined; and
- Developing and executing programming for individuals with limited English proficiency to help them better access health care services.
Racial equity impact assessments are another strategy to address equity beyond the pandemic. These assessments help determine the impact of a policy or budget item on racial and ethnic groups. Seven states (CO, CT, FL, IA, MD, NJ, and OR) require racial impact statements. The following states recently took action to establish racial impact assessments:
- Maine’s legislature passed LD 2, a bill that requires the inclusion of racial impact statements in the legislative process. The bill allows legislative committees to request state agencies to provide analysis of the impact of pending legislation on historically disadvantaged racial populations.
- The Virginia General Assembly passed HB 1990, a bill that allows the chairs of the House Committee for Courts of Justice and Senate Committee on the Judiciary to request racial and impact statements from the Joint Legislative Audit Review Commission. Committee chairs may not request more than three racial and ethnic impact statements during a single session.
- The Washington, DC Council passed L23-0181, the Racial Equity Achieves Results (REACH) Act. Among other activities to ensure racial equity in the District, the legislation creates a racial impact assessment requirement for council legislation. The District’s Council Office of Racial Equity (CORE) is charged with evaluating legislation prior to committee markup for its potential impact on racial equity.
States are taking important steps to immediately address the impact of COVID-19 on racial and ethnicity disparities and incorporating health equity approaches into their systems moving forward. In their 2021 state of the state addresses, 21 governors highlighted strategies to address racial and ethnic disparities. Several governors specifically discussed racism and racial injustices, citing how communities of color were disproportionately impacted by COVID-19 and articulating their commitment to improvement. The recent passage of the American Rescue Plan will provide significant financial support to states for their recovery efforts. States have the opportunity to center equity in their dispersal of funds and address the health, social, and economic impact of COVID-19.
To read more about state initiatives to address health equity, explore NASHP’s toolkit, Resources for States to Address Health Equity and Disparities.
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.
How States Can Leverage Hospital Community Benefit Policy to Advance Health Equity
/in Policy Reports Community Benefit, Health Equity, Health System Costs, Hospital/Health System Oversight, Housing and Health, Making the Case for Action, Population Health, Social Determinants of Health /by Allie Atkeson and Elinor HigginsFor decades, nonprofit hospitals have received large tax exemptions for investments in their communities. Currently, federal requirements do not define minimum spending by hospitals on community benefit programs nor are hospitals required to link community benefit dollars to identified health needs. With limited federal guidance, states are leading the way and establishing impactful community benefit policies. This slide deck outlines the levers states are using to hold nonprofit hospitals accountable for their investments in community health improvement. For more information, read NASHP’s blog, Now Is the Time for States to Hold Hospitals Accountable for their Community Benefit Expenditures.
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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. 























































































































































