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
States Drive Innovations in Quality Measurement and Improvement for Children with Special Health Care Needs
Children and youth with special health care needs (CYSHCN) are a diverse population whose health care needs and costs often exceed those of most children. Improving care for this population is critical, yet challenging, due to the complexity of conditions of some children, and the multitude of systems (e.g., health, education, social services) and supports that children typically use.
With Medicaid and CHIP programs financing health care services for 44 percent of all CYSHCN in the United States, state Medicaid agencies are increasingly targeting CYSHCN as part of their health system transformation efforts to improve health care quality and outcomes. A recent NASHP 50-state scan of state Medicaid managed care programs found that 37 states and Washington, DC, now enroll some or all populations of CYSHCN in risk-based Medicaid managed care. As state payment and delivery system reform efforts advance, tailoring quality measurement and improvement strategies to CYSHCN is a growing priority for many states to improve care for this vulnerable population.
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Despite this growing interest, states face numerous barriers in implementing quality improvement strategies for CYSHCN. For example, many Medicaid agencies lack the resources and capacity to develop robust quality improvement initiatives for this population of children. Many existing quality measures have limitations in their applicability across all CYSHCN populations, and may not fully assess the overall quality of care. Surveys that can be used to measure family experience with care are often challenging and burdensome to administer. Quality improvement is a lengthy and iterative process and requires substantial time and resources for non-complex patient populations. These challenges are more pronounced when developing quality improvement initiatives that meet the unique needs of CYSHCN.
Some state Medicaid agencies, however, are leading the way by designing innovative programs and exploring new ways to align and embed quality measurement for CYSHCN in within broader state initiatives.
- Michigan: Michigan’s Children’s Special Health Care Services (CSHCS) program serves children with special needs. Michigan Medicaid utilizes the Consumer Assessment of Healthcare Providers and Systems 5.0 Child Medicaid Health Plan Survey with the Children with Chronic Conditions measurement set to assess the experience of care and quality of care for children enrolled in the CSHCS program. The survey results are used to guide improvements in the CSHCS program, and they are factored into incentive payments for the state’s managed care organizations (MCOs).
- New York: As part of New York’s overall Medicaid Redesign Team initiatives, the state is changing how children, including CYSHCN, are served in the state’s Medicaid program. One new program that is specifically driving quality measurement and improvement for CYSHCN is Health Homes Serving Children (HHSC). Through this program, participating Health Homes use a care management model to support to Medicaid-enrolled children with complex physical and/or behavioral health conditions. Health Homes report on the “Health Homes Measures Subset,” which is a list of performance measures designed to assess members’ well-being and the impact of care management activities. Some of these measures include adolescent well-care visits, time from health home referral to outreach, and follow-up after hospitalization for mental illness. The HHSC program also develops and maintains a Quality Management Program that monitors, evaluates, and ultimately improves the quality of care for members. The current quality measurement activities are laying the groundwork for New York to eventually integrate Health Homes into its statewide transition to value-based payments, with the goal of holding Health Homes accountable for the quality of care rendered and the outcomes of their members.
- Texas: Texas Medicaid serves children and youth with disabilities and complex conditions in a specialized managed care program called STAR Kids, which uses several strategies to measure and improve the quality of care for enrollees. Prior to the launch of STAR Kids, a study established baseline data for utilization, access, and consumer satisfaction. Now that the program is in its first year, Texas Medicaid will conduct a post-implementation survey of the children enrolled in STAR Kids to assess its performance, compare the performance of MCOs, and determine which measures to integrate into future quality improvement activities. Texas Medicaid also plans to implement additional quality improvement activities for STAR Kids over the next several years, including releasing MCO report cards that can help STAR Kids enrollees and their families select a health plan, and linking financial incentives and disincentives to MCO performance.
To learn more about these and other innovative Medicaid quality measurement strategies targeted to CYSHCN, read NASHP’s new issue brief, State Strategies for Medicaid Quality Improvement for Children and Youth with Special Health Care Needs. The brief includes a table highlighting selected Medicaid quality measurement sets and tools for children, and three case studies featuring ongoing work Michigan, New York, and Texas.
For more information about NASHP’s work on Medicaid Quality Measurement and CYSHCN, contact Becky Normile at bnormile@oldsite.nashp.org.
Lessons from Project LAUNCH: Promoting Healthy Child Development through Behavioral Health Integration and Mental Health Consultation Where Children Live, Learn, and Grow
The first few years of life are critical to a child’s development, setting the foundation for success in school and overall health and well-being later in life. Recent research proves that providing early, skilled behavioral and mental health interventions in venues where young children and their families live and play is highly effective at improving wellness and reading scores, and in decreasing grade retention in early elementary school.
Project LAUNCH (Linking Actions for Unmet Needs in Children’s Health), an initiative of the Substance Abuse and Mental Health Services Administration (SAMHSA), has helped state and local partners to promote the wellness of children from birth to age eight and to support pediatricians, child care providers, teachers and home visitors to identify and address behavioral issues before problems become severe.
To accomplish this, states and local programs funded by Project LAUNCH are implementing a range of strategies, including early childhood mental health consultation and integration of behavioral health services into pediatric primary care settings. The National Academy for State Health Policy (NASHP) explored these Project LAUNCH strategies and the impact they have had on children, families, and providers in two new issues briefs – The Use of Mental Health Consultation in Home Visiting and Early Care and Education Settings and The Integration of Behavioral Health into Pediatric Primary Care Settings – with support from SAMHSA under a sub-contract with NORC at the University of Chicago. The reports offer valuable insights into the challenges and successes of the Project LAUNCH grantees that states can use to strengthen their own child-serving systems.
Providing Mental Health Consultation Where Children Play and Learn
The places where young children and their families live, play, and learn provide important opportunities and venues to promote healthy social-emotional development and to intervene early when problems arise. Too often, child care providers, preschool teachers, home visiting program staff, and others who work with young children and their families are not trained to foster social-emotional development and may be ill-equipped to manage behavioral health issues when they arise. Early childhood mental health consultation (ECMHC) fosters a team approach by pairing a mental health consultant with professionals in child-serving settings to strengthen their knowledge of and build their capacity to support the social-emotional and behavioral health of children. Typical ECMHC supports include teaching behavior management strategies, creating behavior support plans for individual children in collaboration with families and child care staff, and facilitating linkages to mental health professionals.
State and local Project LAUNCH grantees were able to demonstrate that ECMHC had a positive impact on children and their families, and the providers who serve them. They found that:
- ECMHC services sharply reduced the number of children held back in the second grade and improved second grade reading scores.
- ECMHC services helped early childhood education and home visiting staff better identify children with social-emotional and behavioral challenges and provide support to these children and their families.
- The longer child care and home visiting providers were supported by ECMHC, the greater the gains for both children and programs.
Integrating Behavioral Health into Pediatric Primary Care Settings
Researchers found that the primary health care office was another key venue for supporting children’s social-emotional and behavioral health. Primary care providers have regular contact with young children and families and are often trusted by the family, making them well-positioned to proactively support social-emotional development and detect the early onset of behavioral health issues. However, primary care providers often:
- Lack training in the use of standardized screening tools;
- Have too little time to conduct additional screenings during appointments; and
- Are not always able to receive reimbursement for the full spectrum of behavioral health services required to meet a child’s needs.
Additionally, the physical and behavioral health systems in the United States have traditionally been highly fragmented, forcing families to navigate multiple systems in order to obtain appropriate care.
Behavioral health integration in pediatric primary care settings refers to a model of care where a practice team of primary care and behavioral health clinicians work in concert to provide a systematic, cost-effective, coordinated, and patient- and family-centered approach to care. While behavioral health integration can take a variety of forms, it ultimately is designed to equip primary care providers with the knowledge and skills needed to:
- Support children’s social, emotional, and behavioral health;
- Detect issues and intervene early; and
- Enhance coordination and collaboration among providers.
Project LAUNCH grantees implemented a variety of strategies to achieve greater integration of behavioral health services into pediatric primary care settings. The key integration strategies included:
- Training primary care providers in the routine use of developmental and social-emotional screenings;
- Establishing enhanced referral and care coordination systems;
- Providing parenting education and support groups within primary care settings; and
- Embedding an infant and early childhood mental health specialist in primary care settings.
Evaluations of the Project LAUNCH grantees found these efforts increased early screenings and referrals; boosted patient, family, and provider satisfaction levels; and improved children’s social-emotional functioning.
The work of the Project LAUNCH grantees clearly reinforces the role ECMHC and behavioral health integration can play in promoting healthy child development, supporting the whole family, and improving long-term outcomes. Implementing ECMHC across child-serving settings and integrating behavioral health services into primary care practices were significant undertakings by the Project LAUNCH grantees, and they faced numerous challenges in launching and expanding these initiatives.
For example, grantees had to obtain buy-in and commitments from providers, and cultivate acceptance and engagement among families. These initiatives also required a significant amount of resources, including time, funding, and staff capacity, and many grantees continue to grapple with how to sustain and expand them. However, the grantees demonstrated the positive impact that comprehensive, integrated, and coordinated systems can have on children, their families, and providers, and they offer valuable lessons for other states.
States Share Innovative Approaches to Improve Population Health through Accountable Health Models
More than 200 state health officials crowded into a National Academy for State Health Policy’s (NASHP) annual conference session recently to learn about strategies to improve population health and reduce costs while simultaneously transforming their state’s health care finance and delivery models.
An Accountable Community for Health (ACH) is:
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They came to hear representatives from California, Michigan, Oregon, and Washington State discuss their approaches to building population health priorities into their health system transformations through “accountable health” organizations. These entities invest in population health improvement through Accountable Communities for Health (ACHs) and care delivery structures that are accountable for population health, such as Accountable Care Organizations and Coordinated Care Organizations (CCO).
During the standing-room-only session, the four state presenters described their unique models, including financing and measurement strategies and relationships to broader health system transformation. Officials shared examples of how these new delivery models invest in social determinants of health to increase health and well-being and control costs. Examples include:
- Several of California’s Accountable Communities for Health have chosen to focus on reducing violence and trauma as a priority. One conference participant observed, “It doesn’t matter how many times people who are victims of domestic violence see a doctor, it won’t improve their health until the violence stops.”
- Michigan’s Community Health Innovation Regions identified the intersection of housing, homelessness, and health as a priority area. Its goal is to strengthen collaboration between health and housing agencies and develop solutions for Medicaid beneficiaries whose housing needs put their health at risk.
- Oregon CCOs’ global budgets give them flexibility to provide non-medical services that result in better health and lower costs, such as supporting home improvements and rental assistance, embedding mental health professionals in school systems, and promoting gym memberships.
- Washington state’s Accountable Communities of Health are addressing the opioid use public health crisis.
During the conference, NASHP also facilitated a half-day convening of state policymakers from 10 states, across departments and agencies, to advance state accountable health models. During the session, state officials discussed models, shared strategies, and identified multi-sectoral funding to support their focus on population health, health disparities, and social determinants of health. This cross-sector convening included officials from Medicaid and public health agencies and state health transformation offices, along with some key partners.
NASHP will continue to convene meetings, analyze, and report on the evolution of these state models, and build on previous analysis of State Levers to Advance Accountable Communities for Health, to help states advance these transformational efforts. Stay tuned for an upcoming cross-state comparison chart and accompanying issue brief that share lessons and themes related to accountable health models gathered during the NASHP annual conference.
For more information about NASHP’s work on state accountable health models, e-mail NASHP Senior Program Director Jill Rosenthal at jrosenthal@oldsite.nashp.org.
NASHP Identifies State Strategies to Address Mental Health and Education Inequities
State policymakers increasingly recognize the need to address the social determinants of health — housing, employment, education, and income — to reduce health care costs and improve population health. Educational attainment, for example, provides dividends for overall health. People with higher levels of education generally live longer and experience healthier lives.
The quality of education a student receives impacts educational attainment and overall health. Evidence shows the overrepresentation of certain groups of students in separate classrooms or other settings of poorer quality overwhelmingly affects students of color. Teachers have identified students of color as having disabilities at higher rates than white students, with research documenting racial bias as influencing their decisions to remove students from the classroom. Students removed from mainstream education settings are less likely to make progress, build skills, and/or return to general educational settings. Black and Latino students are more likely to be affected by disproportionality.[1]
| Disproportionality occurs when any racial or ethnic group’s numbers in special education classes or programs are statistically higher than other students. |
States are uniquely positioned to promote the mental health and educational achievement of all children by addressing the mechanisms that underlie racial and ethnic differences in mental disorder onset and persistence, and the causes and consequences of disproportionality in out-of-regular classroom settings, such as resource rooms, separate schools, or separate facilities. Using the resources of a variety of agencies, including public health, Medicaid, mental health, and education, can address disproportionality. Drawing from interviews with state officials conducted in conjunction with Massachusetts General Hospital’s Disparities Research Unit, the National Academy for State Health Policy (NASHP) identified state policy levers and programs, including mental health consultation, data sharing, convening authority, systemic interventions and supports, that states can use to eliminate mental health disparities.
State Levers to Address Disproportionality in Educational Settings
- Mental health consultation programs: Minnesota, Delaware, Colorado, Ohio and Connecticut utilize mental health consultation programs that can support efforts to address disproportionality. Mental health consultation varies across states, but commonly mental health providers support child care professionals and teachers, including Head Start, Part C Early Intervention Program, and child care workers, to improve their ability to identify and ameliorate mental health issues in children. States are also investing in training resources to improve the skills of early childhood mental health clinicians. Mental health consultants are typically funded by Medicaid agencies, education agencies, state general revenue or federal funds, or grants, and may receive cultural awareness training designed to improve their skills while reducing implicit cultural and racial bias. With leadership from the Substance Abuse and Mental Health Services Administration and other federal health and education agencies, states increasingly expect mental health consultants to carry out their consultative and clinical services in ways that help teachers provide supportive learning environments for all children.
- Data usage: State departments of education are required to monitor, report, and address disproportionality based on race and ethnicity as required by the US Department of Education’s Equity in Individual with Disabilities Education Act final regulation effective July, 1, 2018. Some state officials mentioned having a longitudinal data system to track disproportionality would be helpful, and would provide an opportunity for state health and education agencies to collaborate.
- Advisory groups: Colorado, Minnesota, and Delaware benefit from advisory groups that facilitate interagency collaboration that can address disproportionality. In Minnesota, an interagency task force including the Medicaid agency (Department of Human Services), Department of Health, and Department of Education promotes coordinated efforts to achieve equitable, universal early childhood screening and referrals. Minnesota’s task force laid the foundation to include mental health consultation services within its school-linked grants under its early childhood mental health infrastructure grants. Delaware, Connecticut, and Colorado were able to generate statewide attention to disproportionality by addressing school suspensions and expulsions. Connecticut became the first state to prohibit expulsions in publically-funded preschools and has recently instituted policies to ensure accountability.
- Ohio’s Cultural and Linguistic Competency Plan: Ohio’s Department of Mental Health and Addiction Services instituted a statewide Cultural and Linguistic Competency Plan to promote health equity and eliminate disparities. Ohio provides cultural competence and linguistic trainings to state employees that reference the Culturally and Linguistically Appropriate Services Standards. Additionally, the plan highlights incentives for providing culturally-competent services. Culturally-competent services can result in lowered health care costs stemming from a reduced number of medical errors, unnecessary or avoidable treatments, and lower numbers of missed medical visits. They also can support new business and revenue-generating opportunities, improved performance on quality measures, and alignment with Medicare and Medicaid, which have placed priorities on cultural and linguistic competency. The state also developed a business case for achieving health equity cited in its Cultural and Linguistic Competency Plan.
Mental health inequities can result from disproportionality and are systemic. Addressing this issue involves:
- Unraveling policies and practices that negatively impact students of color of all ages; and
- Implementing systemic interventions and supports to identifying and assisting individual children with specific needs.
As demonstrated by numerous states, state health officials can use several mental health policy levers and strategies to improve students’ overall health and success in school.
Notes
This blog was supported by the Massachusetts General Hospital Disparities Research Unit.
1. Green, J.G., McLaughlin, K.A., Alegria, M., Bettini, E., Gruber, M.J., Kwong, L., Sampson, N., Zaslavsky, A.M., Xuan, Z., & Kessler, R.C. (unpublished manuscript). Ethnic/racial inequities in educational placement for youth with psychiatric disorders.
Community Health Worker Resources for States
As states transform their health systems, many are turning to community health workers (CHWs) to improve health outcomes and access to care, address social determinants of health, and help control costs of care. While state definitions vary, CHWs are typically frontline workers who are trusted members of and/or have a unique and intimate understanding of the communities they serve. NASHP has produced a number of resources, below, to support state efforts to incorporate CHWs into their health and health equity improvement work. If you would like to suggest a resource or share your state’s efforts, please contact Elinor Higgins.
Resources
- Innovative Community Health Worker Strategies: Medicaid Payment Models for Community Health Worker Home Visits, December 2017. This case study examines Medicaid payment models from Minnesota, New York, Utah, and Washington for CHWs providing in-home services that address healthy home environments.
- Innovative Community Health Worker Strategies: My Health GPS in Washington, DC, Seeks to Achieve Sustainable Funding and Whole-Person Care, November 2017. This case study explores the financing and roles of CHWs in My Health GPS, the District of Columbia’s health home program.
- Community Health Workers: Policy Opportunities for Population Health and Patient-Centered Health Care, October 2017. This NASHP conference session highlighted state strategies and experiences in CHW financing, training, and oversight. Speakers from Oregon, Texas, and Wisconsin discussed the national CHW landscape and policy opportunities that could be explored to advance the CHW workforce in states. Please click on the speakers’ names to access their conference slides.
- State Community Health Worker Models Map, last updated August 2017. This map highlights state-level activities and policies to integrate CHWs into evolving health care systems in key areas such as financing, education and training, certification, and state definitions, roles and scope of practice. The map includes enacted state CHW legislation and provides links to state CHW associations, state agencies, and other leading organizations working on CHW policy in states. An instructional video, designed with support from the National Center for Healthy Housing (NCHH) and the W.K. Kellogg Foundation, is available to facilitate use of the map.
- Community Health Workers in the Wake of Health Care Reform: Considerations for State and Federal Policymakers, December 2015. This brief captures key themes that emerged during an October 2015 meeting of state and federal leaders to identify areas in which state and federal policy can align around the use of CHWs in transforming health systems to achieve better care, lower costs, and improved population health.
These resources were produced and updated with support from the Robert Wood Johnson Foundation, The W.K. Kellogg Foundation, the National Center for Healthy Housing, and The Commonwealth Fund.
State Health Policymakers Look to Washington and Each Other to Fight the Opioid Epidemic
In the last two weeks, there has been a flurry of federal and state activity focused on the nation’s opioid epidemic that currently kills more Americans than guns or car accidents.
- In Washington, the President’s Commission on Combating Drug Addiction and the Opioid Crisis released its final report featuring 56 recommendations to stem opioid and substance abuse and improve treatment, followed by a State Medicaid Director Letter from the Centers for Medicare & Medicaid Services (CMS), outlining expanded flexibility for states seeking Section 1115 Waivers to address the problem.
- At the annual National Academy for State Health Policy (NASHP) conference, it was standing room only at a day-long session entitled State Innovations and Interventions in America’s Opioid Crisis. State health officials from across the country shared their new approaches, which ranged from treatment improvements, innovative use of data, and coalition-building between public safety, businesses, and communities to stem the epidemic that claimed more than 64,000 lives in 2016.
| For more details about how states are combatting the opioid crisis, explore NASHP’s State Innovations and Interventions in America’s Opioid Crisis Preconference resource book. |
While it’s unclear whether the Trump Administration will adopt all of the commission’s recommendations, which include additional block grant funding and federal incentives for evidence-based programs, the state Medicaid directors’ letter offered guidance for state officials interested in using Section 1115 Waivers to create innovative or experimental programs that meet the goals of Medicaid. In this case, states could use Section 1115 Waivers to expand or create new prevention and treatment initiatives in order to provide a fuller continuum of services to address opioid use disorders within their states.
Section 1115 of the Social Security Act permits CMS to waive certain federal Medicaid requirements so states have more flexibility to innovate and test new models of care, including providing services and expanding Medicaid in ways not typically permitted under current Medicaid rules. States must show that their initiatives still align with the purposes of the Medicaid program, and their waiver applications can be far-reaching or narrowly tailored, and usually require discussion and negotiation with federal partners.
The recent Medicaid letter reiterates the ability of CMS to waive the restrictive “Institutions for Mental Disease” or IMD exclusion, which would enable state Medicaid programs to receive federal financial participation (FFP) support for those facilities that treat opioid use disorders. The guidance notes that IMD costs do not include room and board unless those settings qualify as inpatient facilities.
Additionally, while states may submit an implementation plan after they apply for the waiver, IMD costs will only be paid prospectively once the plan has been approved. Moreover, interested states will need to demonstrate their ability to make improvements on a number of additional goals and milestones, and, as with other 1115 Waivers, the cost of the waiver initiative must be budget-neutral, and incur no costs beyond what the federal government would otherwise have paid.
States may access technical support and resources from the Innovation Accelerator Program to develop their 1115 Waivers. The administration recently approved its first substance use disorder-focused waiver application from West Virginia, which provides additional insight for states looking to go in this direction.
West Virginia’s 1115 Waiver enables the state to expand its substance use disorder (SUD) treatment to include methadone treatment services, peer recovery support services, withdrawal management services, and short-term residential services to all Medicaid enrollees.
“In implementing the SUD demonstration, West Virginia is delivering SUD services through comprehensive managed care plans for managed care enrollees and introducing new policy, provider and managed care requirements to improve quality of the care delivered to West Virginia Medicaid beneficiaries and to ensure that SUD treatment services are delivered consistent with national treatment guidelines established in the American Society of Addiction Medicine Criteria,” CMS officials wrote in their letter announcing the waiver.
“In addition, West Virginia is taking steps to improve the quality and access to care for West Virginia Medicaid beneficiaries with SUD, such as introducing new care coordination features and collecting and reporting quality and performance measures,” they noted. While obtaining financial support for services in IMD may help support a full continuum of services for SUDs, states are also moving forward with innovative community-based approaches, using other funding and policy levers. Examples from the NASHP preconference include:
- The Drug Free Moms and Babies Program in West Virginia, spearheaded by that state’s Office of Maternal and Child Health. The program is decreasing the presence of illicit substances at delivery through screening and comprehensive care, including long-term follow-up.
- Connecticut’s multi-pronged approach incorporates increased use of medication-assisted treatment in corrections settings, a statewide access line with transportation, and targeted supports in emergency departments to initiate treatment, including recovery coaches.
- Ohio’s Episodes of Care payment model measures share data on opioid prescribing in connection with dental extraction, a common pathway for opioid access.
Federal focus on the opioid crisis is expected to produce tangible supports for state policymakers who are on the frontlines of the opioid epidemic. In the meantime, policymakers attending the NASHP conference concurred that they will continue to serve as the leaders, innovators, and problem-solvers in their battles against this devastating epidemic.
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. 
