NASHP’s Health and Housing Institute Celebrates First Anniversary
This month, the five member states of the National Academy for State Health Policy’s (NASHP) Health and Housing Institute are marking their first anniversary of breaking down agency silos and advancing reforms 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.
Illinois, Louisiana, New York, Oregon, and Texas have each made significant strides in their housing reforms by:
- Making effective use of data;
- Sharing data across agencies and programs;
- Exploring financing for permanent supportive housing;
- Increasing housing options for Medicaid beneficiaries; and
- Developing sustainable cross-agency financing.
Group learning conference calls have supported state team participants in engaging with experts on a variety of topics, including pay-for-success and return on investment in supportive housing, Medicaid waiver authorities, federal housing policy, and more. NASHP also has provided individual technical assistance to states and has published some of the resulting research, including Tenancy Supports in Three States’ Medicaid Waivers, State Housing and Services Options in 1915(c) Waivers for People with Developmental Disabilities, and Reasonable Accommodation Appeals Resources.
The Health and Housing Institute states have been using this assistance to develop and implement Medicaid waivers and contract opportunities. Some of their recent successes include:
- Leveraging Medicaid dollars for housing transition and tenancy-sustaining services;
- Working toward data sharing between managed care organizations and Homeless Management Information Systems (HMIS);
- Addressing social determinants of health through value-based payment systems or managed care/coordinated care settings;
- Utilizing supports under Money Follows the Person to test the impact of tenancy support services available through Medicaid targeted case management and mental health rehabilitation services; and
- Developing pilot programs to work with health systems to advance supportive housing. Some of these include programs highlighting behavioral health transformation, which assists people with behavioral health conditions to find sustainable housing.
States will continue their work with the institute during the next two years. The newly developed resources resulting from their initiatives to improve health and housing for vulnerable populations will be featured on NASHP’s Housing and Health Resources for States, and presented at the #NASHPCONF19 annual health policy conference, scheduled for Aug. 21-23, 2019, in Chicago, by NASHP’s Health and Housing Institute state participants.
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.
The State of States’ Health Policies: What Governors Highlighted in their 2019 Addresses
State of the state and inaugural speeches give governors the opportunity to highlight their recent policy successes and outline key plans and priorities for the coming year. These speeches are strong indicators of governors’ policy goals and often include proposals and funding recommendations for their legislatures.
As a result of 2018 gubernatorial races in 36 states, there are 20 new governors and seven governorships (IL, KS, ME, MI, NV, NM, and WI) shifted from Republican to Democratic control. There are currently 27 Republican and 23 Democratic governors. As of mid-February, 48 governors had outlined policy priorities through their inaugural and/or state of the state speeches or budget addresses.*
View a chart comparing the health topics each governor addressed.
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Key Health Themes
Forty-five governors addressed health care in their speeches this year, and while many themes were similar to years past, a notable exception was the issue of health care costs and affordability, which emerged as a much more significant concern for governors this year. Twenty-four governors spoke of the need for affordable health coverage and others also addressed Medicaid costs and pharmaceutical pricing.
Behavioral Health Issues
Health issues related to mental health and substance use disorders (SUD) were the most commonly cited by governors. Thirty-seven mentioned these issues — the same number of governors who commented on behavioral health in 2018. Governors frequently highlighted strategies they had implemented or that they planned to implement to increase access to behavioral health services or restructure care systems. For example, New Hampshire’s governor commented on recent initiatives to establish mobile crisis teams and community wrap-around services and plans to continue to improve the quality of the state’s mental health system with an upcoming 10-year mental health plan.
Gov. Michelle Lujan Grisham plans to rebuild New Mexico’s behavioral health system and develop strategies to reduce cost, increase patient access, and focus on improved patient care, better health outcomes, and stronger relationships between patients and providers. In North Dakota, the governor is proposing to invest more than $19 million across a continuum of care services to address the state’s behavioral health issues. In Texas, the governor declared that mental health reform would be an emergency item for the 2019 legislative session.
Fourteen governors (AZ, CO, GA, IN, IA, KY, NH, RI, SC, TX, UT, WA, WI, and WY) referenced plans to increase access to mental health services in schools, with some citing the need to provide these additional services to help prevent school shootings. Iowa’s governor also emphasized behavioral health services for children, citing the recent creation of a children’s mental health board that focused on developing a cohesive children’s mental health system. She noted plans to build on the board’s recommendations, and requested that legislators provide additional funding for home- and community-based mental health services for children.
Twenty-six governors specifically mentioned current and future strategies to address the opioid epidemic — a slight decrease from 30 mentions in 2018 — but this demonstrates that the issue remains a top priority for many states. Ten governors also spoke about the issue of behavioral health within the context of better addressing the needs of justice-involved individuals as they transition back into communities and/or providing mental health and SUD treatment services rather than incarceration when appropriate.
Medicaid Program Reforms and Costs and Medicaid Expansion
In total, 23 governors mentioned Medicaid and/or Medicaid expansion in their speeches, which is similar to last year when 19 governors addressed these topics. Ten governors provided general remarks about their states’ Medicaid programs, highlighting recent program improvements, the growth of overall program costs, or plans to implement reforms to ensure the program’s sustainability. New York’s governor expressed concerns about upcoming Medicaid Disproportionate Share Hospital (DSH) cuts, and that previous proposals by federal policymakers to cut Medicaid funding have created uncertainty.
Fourteen governors specifically mentioned Medicaid expansion in their speeches. Some governors commented positively on expansion or the potential for it, with Maine’s newly-elected governor announcing plans to begin implementing the 2017 voter-approved expansion measure, which had been stalled by the former governor. Nebraska’s governor announced he would move forward with filing a state plan in accordance with the expansion ballot measure that state voters approved in 2018. Utah’s governor noted that while Medicaid expansion is needed, the 2018 voter-approved expansion should be implemented in a fiscally sustainable way, with “common sense adjustments.” Montana’s governor outlined in detail the positive economic effects and increased coverage rates that have resulted from implementing expansion and its importance in helping to sustain small businesses and rural hospitals. He indicated that he would not support adding measures to the state’s expansion model that could potentially reduce enrollment and be costly to administer, and recommended that legislators make expansion permanent. In contrast, New Hampshire’s governor urged the legislature to support the upcoming implementation of federally-approved work requirements for the expansion population, responding to some calls to repeal them.
Addressing Increasing Health Care Costs
In addition to mentioning Medicaid-related health care costs, 24 governors also addressed increasing health care costs more broadly, often mentioning that health care coverage needs to be more affordable for individuals and families. This is a notable increase from 2018, when only 11 governors mentioned the impact of rising health care costs. Colorado’s new governor is taking the bold approach of establishing a specific office to focus on reducing patient costs, improving price transparency, lowering prescription drug costs, and improving the affordability of health insurance. Montana’s governor highlighted the state’s reference-based pricing model for state employee health plans, which has made medical costs more consistent and comparable across facilities and in just two years has resulted in a $13 million reduction in state health plan costs. He also encouraged passage of legislation designed to address surprise medical bills.
Governors in Colorado, Montana, and Rhode Island have signaled plans to establish reinsurance programs in their states to address rising premium costs. Gov. Mark Gordon commented that there is an opportunity to “craft a Wyoming solution for health care” and develop state-led solutions to reduce costs.
Prescription Drug Costs
The rising costs of prescription drugs emerged as a new theme in this year’s speeches, earning mentions from seven governors. This is notable, given last year the issue was not addressed by any governor. Colorado’s governor advocated having residents pay a “fair price” for prescription drugs, and promised to work with the legislature to develop a wholesale importation program. Nevada’s governor plans to create the Patient Protection Commission that will identify options for protecting state residents from exorbitant prescription drug prices. The most comprehensive proposal was came from California’s governor who signed an executive order to establish the nation’s largest single-purchaser system for prescription drugs to leverage the state’s purchasing power as a way to lower drug costs.
Health Care Coverage
Eleven governors commented on potential changes that may occur to the Affordable Care Act (ACA) and health coverage in general. Many indicated they would take action to safeguard ACA coverage gains and insurance protection provisions. Nevada’s governor expressed support for defending the ACA and blocking any efforts to scale back protections for preexisting conditions, and Gov. Andrew Cuomo said New York should codify the ACA and incorporate preexisting condition protections into state law. Governors in Oregon and Rhode Island similarly pledged to protect coverage of preexisting conditions, and Wisconsin’s governor issued an executive order creating a Healthy Communities Initiative to promote affordable and accessible health care and another to ensure preexisting conditions were covered.
In his speech, Washington Gov. Jay Inslee promised to “fight for a public health option to ensure health care for all,” in reference to his recent proposal to offer a public plan through the state’s marketplace to make an affordable coverage option available across all regions of the state.
In California, Gov. Gavin Newsom proposes to provide Medi-Cal coverage to undocumented young adults up to age 26, and also seeks federal changes to allow states to implement even more comprehensive coverage reforms and move toward a single-payer model. He is also planning to increase the amount of subsidies available for marketplace coverage and would allow higher-income families to access ACA subsidies. To help cover the costs of this expanded financial assistance, Newsom’s budget proposes to implement a state-level individual mandate. Other states are also considering individual mandates — although not mentioned in recent state of the state speeches, the governor of Rhode Island’s budget proposal recommends implementing such a measure, and Nevada’s governor has indicated earlier that his proposed Patient Protection Commission would examine the issue.
Health Care Workforce
Fourteen governors addressed health care workforce issues, primarily identifying strategies to address provider shortages. This is similar to 2018, when twelve governors mentioned health care workforce issues. This year, governors in Missouri and South Carolina commented about current and planned investments in telehealth to increase access to providers in rural areas. Governors in Mississippi, Nebraska and Oklahoma expressed plans to either create or expand existing scholarship programs to help increase the number of physicians in rural areas. New Hampshire’s governor proposed a $24 million investment to increase the state’s nursing and health care workforce. Other governors in Iowa and Washington highlighted strategies to enhance the capacity of the behavioral health workforce.
Miscellaneous Health Issues
Most governors mentioned other health-related topics in their speeches, either as recent accomplishments or as future plans. These included support for seniors, disabled individuals, and/or children in foster care; women’s health issues; and efforts to address broader social and/or environmental issues that directly affect health. Delaware, New York, and Vermont governors expressed concerns about the use of tobacco products by youth. Other governors drew direct connections between homelessness and health, with Hawaii’s governor highlighting that a hospital in his state had become the first in the nation to place medically fragile, homeless patients into housing to promote recovery. Governors in Maine and New Mexico commented on plans to revive their states’ children’s cabinets to support the health and safety of vulnerable children. Rhode Island’s governor characterized gun violence as “one of the most disturbing and preventable public health crises of this generation” and New Mexico’s governor is requesting that the state’s Department of Health study gun violence to help inform gun violence prevention reforms. Other governors (CA, HI, ME, MI, NM, NY, UT, VT, WA, and WI) commented on environmental issues affecting health, with a few noting the connection between climate change and health, and others committing to improve air or water quality to reduce the negative health effects of pollution. California’s governor also established a state surgeon general position to help address health disparities (see this NASHP blog for more information).
Culture of Health
Eight governors mentioned the importance of building healthy communities, commenting that promoting population health helped create healthy economies. In a future analysis of the governors’ speeches, the National Academy for State Health Policy (NASHP) will provide a more detailed look at how states are specifically addressing and/or tackling some of the social determinants of health — defined as the social and economic factors that directly affect health.
NASHP will track these proposals as they move toward implementation by state legislatures. Clearly, health policy is in play in the states and NASHP will continue to report on state initiatives on a range of health issues in the coming year.
*For some states, information from both a governor’s inaugural address and a state of the state or budget address is included in this review. For other states, information from only one speech is incorporated, due to one of the following reasons: the inaugural address has occurred but the state of the state speech has not yet occurred; the inaugural address served as the governor’s primary policy speech and no state of the state address is planned; or the governor did not have an inauguration and only had a state of the state address. As of mid-February, 2019, Louisiana and North Carolina governors had not made speeches.
Q&A: How Connecticut Matched Its Medicaid and Homelessness Data to Improve Health through Housing
Brian Roccapriore (L) and Steve DiLella
States working to improve the health of people experiencing homelessness can match their Medicaid data with Homeless Management Information Systems (HMIS) data to track which populations are using housing services and which have the greatest unmet need. HMIS are databases that housing service providers and Continua of Care (CoCs) community and state agencies use to collect and aggregate demographic and service-use information for individuals and families experiencing and at risk of homelessness. Recently, the National Academy for State Health Policy’s Health and Housing Institute interviewed Connecticut Coalition to End Homelessness’ Director of HMIS and Strategic Analysis Brian Roccapriore and Connecticut Department of Housing’s Director of Individual and Family Support Programs Steve DiLella for their insights into the successes and challenges of HMIS-Medicaid data sharing in their state.
What is the history of Connecticut’s HMIS-Medicaid data sharing?
There is a long history in Connecticut of providing permanent supportive housing to homeless populations. Ten years ago, the Corporation for Supportive Housing helped with data matching for the most vulnerable people in the state. The first match between HMIS and state Medicaid data was for a re-entry program for the criminal justice population. They used that data-matching model to identify housing needs and ultimately to decrease costs for high-cost Medicaid users. This cost savings resulted from a substantial reduction in the utilization of health care and shelter systems. The Connecticut Coalition to End Homelessness received a federal Social Innovation Fund grant to house the 160,000 highest-cost Medicaid beneficiaries who use housing services. Once this grant was in place, the state experienced a decrease in high-cost medical services use, such as emergency departments, ambulances, behavioral health care, and hospitals, but also an increase in outpatient and medication usage. The state is currently trying to address some of this increase through a proposed Medicaid 1915(i) plan option.
Connecticut previously had 13 homeless CoCs, which used three different HMIS software systems and six to seven iterations of this software. About four years ago, the CoCs merged their systems into one platform that allows for a single release of information. This process proved challenging for the state, and officials faced a variety of issues. The most important part of addressing these setbacks was getting collective buy-in from providers to move to an open system. There was a great deal of conversation with the state attorney general’s office and the state’s hospital coalition over a year about what the release of information should look like — specifically, how restrictive it should be in terms of what to share and with whom. [The state’s current release of information authorization form can be viewed here.] The current release of information form now allows the state, with a client’s consent, to match data for housing and health opportunities.
Who approves data-matching requests, and who does the actual match?
In Connecticut, HMIS and Medicaid provided their data to a third party, New York University (NYU). NYU completed the actual matching process, and then the matched names went back to the state’s HMIS.
HMIS is guided by a steering committee with representatives from Coordinated Access Networks – referral systems that link people to housing services from all regions of the state. Whenever there is a request to obtain data from the HMIS, the committee must approve it.
Did you have to go through a process of defining appropriate data to be included in the data-use agreements?
There was a discovery period to see what was in each specific data warehouse and what was needed to match it. In Connecticut, each warehouse is unique in how it collects data and the data might not match well. We needed to be sure the data was similar enough to match and that it was collected in a uniform way. We had to look at data dictionaries to find common elements and had to define the requests to specify what specific data was needed, such as enrollment and length-of-stay data for emergency shelters, or transitional shelters, and Medicaid claims data.
How important are agency leadership and buy-in?
It’s important. Connecticut has a broad interagency council to increase supportive housing and we had buy-in from the Department of Social Services. This data sharing became a natural fit with the support of our leadership.
Did you seek input from the US Department of Housing and Urban Development (HUD)?
HUD officials recently said that some HMIS releases are too restrictive in the amount of information they can share.
We received HUD technical assistance on the initial release of information. The trend nationally is toward a more open-sharing model. People often default to “we cannot share information” in fear of violating the Health Insurance Portability and Accountability Act (HIPAA), when the true concern should be ensuring informed consent. In fact, the HIPAA Privacy Rule supports the secure sharing of information for a range of purposes, including improving patient and public health and health care quality.
What roadblocks did you encounter?
Most roadblocks we faced were from individual providers, who are protective of the people they serve. It was also hard to find time in the schedules of officials from the attorney general’s office and the Connecticut hospital association to discuss the work. It is important to start this process as early as possible.
Any additional advice you would like to share with states?
Start early, as this process moves slowly. Washington State has a warehouse of data that could be useful to look at. Allegheny County in Pennsylvania also has an impressive data warehouse. It’s important to ensure that there is someone to drive the process.
Strategic use of data can help states maximize and streamline their efforts to improve the health of state residents by addressing social and living conditions. Connecticut’s data-sharing work is an important example to other states similarly seeking to leverage data to improve health through housing.
This work is supported through NASHP’s Cooperative Agreement with the Health Resources and Services Administration (HRSA), grant #UD3OA22891.
NASHP’s Housing and Health Resources for States
Safe and stable housing is necessary for people to become and stay healthy. States and the federal government have both invested in programs that help low-income and vulnerable populations find housing and access health care and supportive services. However, those programs often remain siloed with health and housing sectors often working independently toward similar goals.
California Creates a State Surgeon General Position
California Gov. Gavin Newsom unveiled several health care initiatives in his inaugural address last week, including a well-publicized plan to lower drug costs using public purchasing power. But a less-publicized action – establishing a state surgeon general post – to help tackle the social determinants of health and health equity, presents a significant opportunity for a state as diverse as California.
Read NASHP’s 2016 report: Advancing Health Care Transformation through a State Surgeon General Model: Opportunities and Challenges
The idea is not a new one. In 1996, Pennsylvania established and still maintains a physician general position. In the decade that followed, Michigan, Florida, and Arkansas governors also appointed state surgeons general, though Michigan eliminated the position in 2010.
In their early iterations, surgeons general were tasked with a variety of jobs that differed by state, but included:
- Showcasing the importance of health and wellness;
- Addressing health care safety;
- Providing a cross-agency focus on health;
- Serving as the state’s chief advocate and strategist for public health; and
- Strengthening the state’s public health infrastructure.
The states usually house the surgeon general in their departments of public health, including Florida where the surgeon general also serves as the health department’s director. The Arkansas surgeon general holds a joint appointment with the University of Arkansas’ School of Medicine.
California’s proposal emerges at a time when health disparities are increasing and there is a growing consensus that health can only be fully achieved when we address economic and life circumstances — such as housing, education, and jobs — that can contribute to poor health. Gov. Newsom has charged his new surgeon general to address these social determinants of health.
The task of running a state health department is growing increasingly complex and divergent, and some states are turning to non-physicians to take on that administrative role. The appointment of a state surgeon general could provide additional physician input to help health department leaders meet the challenges of improving the health of a state’s population. This approach can help state agencies collaborate to address disparities and social determinants of health. (Read NASHP’s new Toolkit: Upstream Health Priorities for New Governors.)
We will soon report on the health care initiatives that governors across the country address in their 2019 inaugural state-of-the-state addresses.
Many will be following the Golden State’s actions to learn more about the role and responsibilities of its new surgeon general. We want to see how this latest iteration of the position helps advance the governor’s comprehensive approach to improving health for all residents through cross-sector reforms.
Below is a chart from our report, Advancing Health Care Transformation through a State Surgeon General Model: Opportunities and Challenges, which details the roles and responsibilities of surgeons general in Arkansas, Florida, Michigan, and Pennsylvania.
For New Governors: Snapshot of Major Federal Opioid Funding by State
There has been significant federal investment made in recent years to address the opioid crisis in every state. This chart summarizes the key federal funding that has flowed to each state’s government agencies and other stakeholders to address the opioid crisis. Data featured in these charts represent grants from multiple federal agencies provided through specific initiatives aimed at supporting state efforts to prevent and treat addiction by addressing behavioral and mental health workforce shortages, promoting evidence-based research, making justice system innovations, and more.
The funding summary chart below shows the total federal grant amounts each state received in FY 2018. To see a more detailed breakdown of the targeted federal initiatives in recent years, click the tabs along the top of the chart. Individual agency funding charts feature grants awarded since FY 2017.
How Supported Employment Can Address Mental Health Inequities in Minority Populations: Five States’ Experiences
Supported employment is used to help people with severe mental illness and other disabilities obtain and retain jobs. As states increasingly promote employment among public assistance recipients, could this model be expanded to new populations, including those with more common mental disorders or racial or ethnic groups who face health disparities? In this report, NASHP and Massachusetts General Hospital’s Disparities Research Unit examined how five states (CT, OK, TN, UT, and WA) are using their supported employment programs to tackle these issues.
Read or download: How Supported Employment Can Address Mental Health Inequities in Racial and Ethnic Minority Populations: Five States’ Experiences
Contact Malka Berro with any questions or to share your state’s supported employment efforts.
Q&A: How Rhode Island Tackles Social Determinants of Health through its Accountable Entity Model
Across the country, states are launching new payment models that reward quality, promote care integration, improve access, and address the social determinants of health (SDOH) in an effort to improve population health. One of these ground-breaking initiatives is Rhode Island’s Accountable Entity (AE) Program, created to improve the health of Rhode Islanders enrolled in Medicaid managed care plans.
Rhode Island’s program is designed to encourage Medicaid managed care organizations (MCOs) and providers to deliver more cost-effective care through value-based payments, improve coordinated care delivery, and focus on population health in ways that go beyond traditional clinical care. Rhode Island Health System Transformation Project Director Lauretta Converse and AE Program Director Deborah Correia Morales, members of National Academy for State Health Policy’s (NASHP) State Accountable Health Models workgroup, recently shared how their program is addressing SDOH during the first year of AE implementation.
Could you describe Rhode Island’s accountable entity program and how it fits into your managed care model?
State officials developed the AE program through an amendment to the state’s 1115 Medicaid Demonstration Waiver as a way to move the existing Medicaid MCO model away from fee-for-service and towards value-based care to expand its ability to improve health outcomes and decrease costs. The AEs are provider organizations that once certified by the Executive Office of Health and Human Services (EOHHS ) are eligible to contract with one of the state’s MCOs. Specific contractual requirements set forth by the EOHHS provide guidelines for how MCOs and AEs should proceed in coordinating teams of providers with the goal of aligning financial incentives, improve their capacity to manage complex conditions, and better address social needs. The AEs, through increased delivery system integration and improved information exchange, will enhance the capacity of the MCOs and providers to support and serve high-risk populations. AE participation is voluntary, but once MCOs enter into an AE contract, they are eligible to receive incentive funding from a pool of total incentive dollars. During project Year 1, 15 percent of those dollars is allocated to the MCO incentive pool while 85 percent is allocated to the AE incentive pool.
EOHHS is the certifier not the contractor. The Rhode Island EOHHS certifies AEs, but contracts are developed between the AEs and the MCOs.
How are you incorporating SDOH into the AE model?
AEs are accountable for care coordination for their attributed populations and are required to adopt a defined population health approach. Rather than having individual providers treat patients’ individual health issues one at a time, AEs coordinate a team of providers who take on increasing financial risk for treating the whole person. A central element of the AE model is the required integration of strategies to address SDOH. The strategies must include assessment of social needs, screening and referral to community resources, and using community partnerships and engagement to address identified needs. Rhode Island has taken this on through a three-legged stool approach: certification, payment, and incentives.
How certification works:
In the first year of the program, the EOHHS certified six AEs. The state’s EOHHS uses a set of certification standards that require:
- The identification of three key domains of social need
- Evidence of capacity to address those domains;
- A process for screening, managing referrals; and
- Arranging supports for patients who need them.
AEs work with their providers to identify the best points of contact with their patients, and are able to bring aspects of care management to a broader population. AEs must be able to demonstrate clear evidence of their capacity to address the three priority domains, which could be through defined relationships with community-based organizations, in-house social supports, or an agreement with a separate social supports agency.
Possible key domains include housing stabilization and support, education and literacy, food security, safety and domestic violence, employment, and transportation. As expected, the AEs all received conditional certification because they did not yet meet the necessary standards for providing services and supports from within the community or for screening and referring patients based on the SDOH [ ]. Rhode Island state officials recognize that the AEs need support, in this case in the form of incentive payments, to develop their capacity in this area and to reach the goal of emphasizing community-based resources and services in addition to institutional care.
How payment works:
Certified AEs participate in an EOHHS-designed, value-based, Alternative Payment Methodology (APM) and total cost of care (TCoC) model through contractual partnerships with MCOs. EOHHS contracts with MCOs, which then subcontract with the AEs, which makes the MCOs responsible for ensuring AE contractual compliance. These contracts are intended, over time, to move AEs away from shared savings to increased financial risk and responsibility and to move provider payments from volume-based to value-based arrangements. Payments to AEs, made by the contracted MCO, are based in part on the quality of the care they deliver to their members, as determined by the EOHHS Quality Scorecard, which includes an SDOH measure.
How incentives work:
AE infrastructure development and implementation are supported through the Health System Transformation Project (HSTP), an amendment to the state’s 1115 Medicaid Demonstration Waiver. Entering into APM contracts makes AEs eligible to receive incentive payments from their managed care partners, and AEs receive the funds in exchange for meeting milestones established by AEs and MCOs in an individualized HSTP plan. The milestones initially are based on infrastructure and capacity building and will transition to performance-based outcome metrics. well the AEs perform in accordance with the plan dictates the amount of incentive funding earned.
AEs are required to allocate 10 percent of their received incentive funds to establish partnerships between the AE and community-based organizations that support behavioral health care, substance abuse treatment, or SDOH. A key tenet of addressing SDOH is engaging with community supports so that relationships for referral, follow-up, and tracking are established. As such, it is a requirement of the program that the agreements between community partners and AEs be formalized along with the process of identifying partners’ specific service and referral needs.
How do AEs engage with community partners to help reach their goals and address social determinants of health?
EOHHS identified four steps for AEs to use to develop meaningful community-based partnerships in Rhode Island.
First, it is necessary to identify the appropriate partners to assist in addressing SDOH within a particular community. The next step is to formalize the agreement between the AE and the community partner to establish expectations and hold each party accountable for their responsibilities. The third step is to establish bi-directional care management tracking so that all parties, including the MCO, are as up-to-date as possible on the care of patients within the AE. Finally, partners develop metrics for measuring the SDOH efforts and need for any adjustments to maximize the impact of the partnership.
All of these steps are supported through a requirement that the AEs allocate 10 percent of their incentive funding to community-based organizations.
Why are social determinants so integral to new payment and delivery models?
An increasingly familiar statistic — only 20 percent of health outcomes are due to clinical health care — establishes the importance of addressing societal, behavioral, and environmental factors when attempting to improve health. Addressing SDOH not only improves the overall health of a community, it increases the capacity of a system to prevent poor health outcomes and to manage and treat the health needs of the people it serves. A payment and delivery model that holds providers accountable for the full range of factors that influence health outcomes is a model that is likely to decreases costs and improves results.
What are your next steps?
Thus far, AEs have identified housing, food, and domestic violence as their top social determinants. EOHHS hopes to see AEs increasingly engaged in addressing these issues in their communities while taking on additional financial risk and better meeting certification standards in Year 2 of the program.
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. 
