POPULATION HEALTH MANAGEMENT · SOCIAL DETERMINANTS OF HEALTH Going forward, the state is proposing to


continue building the partnerships between ACHs and MCOs. “We are going to rely on ACHs to support the community capacity building, and that includes supporting the community-based workforce,” says Chase Napier, Medicaid transformation manager. “On the managed care side, we will pro- mote payment for non-traditional supports, like transportation, housing, and medically tailored meals. It is about both building the community capacity and addressing the payment mechanisms.” In seeking an extension of its 1115


waiver from CMS, the state plans to create 10 “Community Hubs” to further invest in multi-sector, community-based partner- ships and approaches to better support individuals and families. Washington is requesting expenditure authority for the development and operation of nine Community Hubs and one Native Hub. These hubs are centers for community- based care coordination that focus on health-related social needs. They will provide screening for and referral to community-based services for enrollees in Apple Health, the name for the state’s Medicaid program. Hubs will collaborate with other existing care coordination enti- ties. Nine of the Community Hubs will be overseen by existing ACHs—and a Native Hub will be developed and overseen by a to-be-determined entity. Napier says the state realizes it needs a


closed-loop referral and resource directory and the ability to track successful or unsuc- cessful referrals. “We have some examples of that today. We want to continue to build on that, and there is pursuit of the legisla- tive authority for a broader community information exchange solution,” he adds. “That would be our long-term strategy to pull together these disparate systems that are all working on something related to closed-loop referral. We want to address any of the gaps that remain because not every partner, especially community orga- nizations, have a solution.” “We also need a system that connects


those ACH hubs and the MCOs, and that’s a major task in addition to the closed-loop referral system,” explains Jason McGill, assistant director for Medicaid program operations and integrity. “There are lots of questions and complexity to this. To some extent, the MCOs already do at least a bit of this work in terms of community care coordination, but it is not nearly as systematic population-wise as we’d like. We envision this as a pretty significant


transformation. I think the MCOs under- stand that, so they’re at the table, and we’re working hard together.” Ideally, the state would eventually like


to gather more data on the closed-loop referral process, Napier adds. “Is it work- ing and who are we screening? Who are we referring? Are we getting successful referrals? Why or why not? And then beyond that, what are the outcomes? We want to look at the impact on healthcare utilization measures. I think making that connection would be important.”


Progress in Pennsylvania Over


the past several years, the


Commonwealth of Pennsylvania’s man- aged care programs have begun to focus more on social determinants of health, says Sally Kozak, deputy secretary for the Department of Human Services’ Office of Medical Assistance Programs. “The long- term care program has more specific requirements, but in physical health and behavioral health programs, we have requirements that all of our managed care plans screen and assess all of their enrollees for issues related to social needs,” she adds. “In the physical health programs, we do not require that they provide services like housing or food supplements or assistance with utilities, because those are not medi- cal services, per se. But they can provide assistance with targeted case management to help people find housing, maintain hous- ing, and develop skills, and they provide food as nutrition support. Some of our plans are voluntarily investing in initia- tives such as housing rental assistance, and assistance with utilities.” Jamie Buchenauer, deputy secretary for


DHS’ Office of Long-Term Living, says the three managed care plans in the long-term care program called Community Health Choices, meet the whole-person care needs of individuals in different ways. For instance, UPMC has a pilot program where if an individual has a diagnosis of something like diabetes, they work to provide medically tailored meals to that individual, and the member also meets with the dietician periodically. For the long-term care program, address-


ing social drivers often aligns the goals of the patient, family and MCO, says Buchenauer. “Because we provide the long- term services and supports, the goal of the program is to keep people in their homes, where individuals want to be, but it’s also cheaper. Usually someone going into a nursing home is not the ideal situation


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for the family, for the participant, or for the managed care organization. If some- body needs short-term rental assistance until they can get a housing voucher, it’s in the best interest of the managed care organization to assist in those ways. For our Community Health Choices MCOs, this is what they need to do to be successful.” The upcoming procurement of a new


closed-loop resource and referral tool in Pennsylvania is going to make it easier for the state to gather additional data that will give it a more complete picture of what is happening at the community level, Kozak says. “We’ve done a lot of work with our community-based organizations to help guide them as they enter into this realm of value-based purchasing and social determinants of health. We’re looking forward to that moving forward a little bit faster. We continue to have internal conversations about care management bundles. We did one around maternity care management that included incentives for the care management team to address social determinants of health. We’re look- ing to add some additional care manage- ment bundles like that in our value-based purchasing requirements.”


Transition to value-based care Like their counterparts in other states, Medicaid managed care organizations in North Carolina are moving into value-based payment arrangements to promote accountability and focus on total cost of care. That involves all Medicaid enrollees, whether they’re in the Healthy Opportunities pilots or not. Through the state’s transition from fee for service to managed care, the expenditures that health plans make that are tied to value- based payments must increase over five years, so that by year five, essentially half of their payments should be flow- ing through value-based arrangements. “Those value-based payments also pro- mote investing in prevention and non- medical services,” Van Vleet says. “We’re seeing states requiring their


managed care organizations to do things like reinvest a portion of their profits into the communities being served. They also are integrating drivers of health into value-based payment arrangements,” says Manatt Health’s Ferguson. “They are risk-adjusting capitation payments to managed care plans for social factors. There are truly exciting innovations hap- pening across the nation, which I think is a good sign of things to come.” HI


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