Essential Lessons for State Medicaid Programs in Tackling Health-Related Social Needs

With the end of the public health emergency and associated funding used to increase capacity, changes to program eligibility due to the federal debt ceiling legislation, and the state of the economy, we are going to see a reduction in capacity among community service providers (CSPs) at a time when need is increasing. This reality is something that states like North Carolina and Washington, with Medicaid programs addressing health-related social needs underway, will need to grapple with. Recent results from the five-year model test run by the Center for Medicare and Medicaid Innovation (CMMI), the Accountable Health Communities model, bring important lessons for states that are even more significant given these factors.

The Background

In 2017, the CMMI launched the Accountable Health Communities Model (AHC) to test if connecting Medicare and Medicaid beneficiaries with health-related social needs (HRSNs) to community resources would improve health outcomes and reduce costs.

A total of 28 organizations, called Bridge Organizations, completed the full test period across 21 states. The organizations participated in one of two tracks:

• Assistance Track: In this track, Medicare and Medicaid beneficiaries were screened for health-related social needs in five areas (housing instability, food insecurity, transportation, utilities, and interpersonal violence) using a standardized screening tool created by CMMI. Beneficiaries who had needs in one or more of the HRSN categories and at least one emergency department visit in the previous 12 months were eligible for referral and navigation support to community service providers (CSPs) that could meet the beneficiary's need(s).
• Alignment Track: In addition to screening and providing referral and navigation support to eligible beneficiaries, Bridge Organizations in this track also were required to engage with clinical delivery sites (CDSs) and CSPs in continuous quality improvement activities with the goal of aligning CDSs, CSPs, and improving community capacity to meet HSRNs.

In the middle of the test period, participating organizations had to grapple with the impact of COVID. This resulted in some changes in how screenings and navigation services were provided. Despite these challenges, over 1 million Medicare and Medicaid beneficiaries were screened during the test period. More than a third of those screened were eligible for referral and navigation support, and of those eligible, more than three-quarters accepted navigation support. Unfortunately, receiving navigation services did not increase beneficiaries' likelihood of connecting with a CSP or having their need met. The reasons cited for this outcome include “lack of transportation, ineligibility for services, long wait lists, and lack of resources.” The HRSN least likely to be met was food insecurity. “Beneficiaries with food needs were more likely to use community services than those with other needs, yet they were the least likely to be resolved.”

The model showed signs of having a positive impact on cost, with Medicare beneficiaries in the Assistance Track showing a reduction in avoidable ED use. This is a critical indicator of immediate impact, as the emergency department is often a primary source of care for many individuals. Still, the evidence wasn’t significant enough to conclude with certainty that addressing HRSN through the AHC model did result in healthcare cost reduction. Evaluators conclude this may result from navigation services that enabled direction to appropriate ambulatory care instead of the ED, reflecting a more appropriate and efficient use of resources. These results may leave some thinking that the model isn’t a ringing endorsement for models addressing HRSNs.

But I disagree.

Instead, it shows we have work to do, but this is an important part of transforming our healthcare system to one that addresses health and wellbeing instead of just treating illness and injury.

Focusing on Lessons Learned

I want to focus on two key findings that we must address to ensure that models like this currently being implemented across the country are successful. For example, the North Carolina Healthy Opportunity pilot program is, in many ways, structured just like the AHC model, with some important differences, including payment to CSPs for the provision of services. Additionally, Washington State, in its Medicaid Transformation Project waiver renewal, has proposed its Taking Action for Healthier Communities and the continuation of its Foundational Community Supports initiative, and it will need to wrestle with these issues as well. It is important to closely consider the lessons from the AHC model's demonstration, as its results have both immediate and ongoing effects that extend beyond the initial pilot sites.

Lack of Capacity

First, a key reason eligible beneficiaries could not address their HRSN was the lack of capacity within the community. This means that there were not enough services available in the community to meet the need. This is even though CSPs' capacity increased during COVID as a result of federal, state, and local initiatives to provide funding to meet needs. Housing and transportation needs were the least likely to be met because of a lack of capacity. In North Carolina, funding is available to pay for services for those eligible. This is also true in Washington’s Foundation Community Supports program. However, this funding is available through Medicaid because of 1115 waivers. This presents a significant question of sustainability.

The Real Alignment

Second, we must do more to link the “two worlds of clinical care and community services.” This was a key finding of the Alignment Track in the AHC Model. By virtue of the advisory boards that Bridge Organizations in the Alignment Track were required to create, the clinical delivery world and the community services world began to “understand and value their respective professions, standards, and regulations.” We must address the cultural barriers that exist between the two and remove them, or at least figure out how to navigate around them. It isn’t enough to require clinical delivery sites and community service providers “work together” on screening, referral, and navigation. We must work toward meaningful integration, which only comes when the parties are engaged with each other directly in a more intentional way to determine how to ensure community needs are understood and that they have the resources to meet those needs.

Roles for Philanthropy and Social Impact Initiatives for Community Organizations

How can this be sustainable? Not only is the funding needed to pay for services, but the community organizations providing the services need investment to ensure they have the capacity and resources needed to operate in this new world. Looking at the models in North Carolina and Washington, CSPs need to build staff capacity and acquire resources, such as information technology, to evaluate the viability of participating as a Medicaid provider, then engage in the contracting process with the entity or entities responsible for payment for services. Next, CSPs must ensure they meet new requirements, such as healthcare privacy and security requirements, submitting service claims, and reporting performance metrics. While some funding is available through the waiver programs to invest in capacity development, it often is not given directly to the CSPs but instead to the regional organizations (Lead Entities, Accountable Communities of Health) to make the investments in education and technical assistance. This is understandable. A limited bucket of money must be applied in the most efficient way possible. But it may not, in the end, be the most effective approach.

This is a ripe opportunity for philanthropy and social impact investment to get in the game. There are two areas where money is needed: 1. Increase the availability of services and supports (we need more CSPs providing the services, and we need the existing CSPs to provide more) and 2. Create capacity and capability within CSPs to engage in the business operations necessary to operate as service providers in this new paradigm (contracting, billing, compliance, and reporting).

There are other important lessons learned from the AHC Model. Organizations involved in similar models across the country would be well-served by spending time understanding the key findings and lessons learned. This is the point of these test models: to ask questions, try solutions, and learn from them. This is another reason to celebrate the conclusions of ACH model demonstration pilots.