This week in St. Louis leaders from state and Medicaid agencies across the nation came together at the MESC Conference to share innovative ideas around Medicaid systems and initiatives. A key theme throughout the conference was the role social determinants of health play in improving the wellbeing of individuals and communities. True to The Center for Medicaid and Medicare Services’ (CMS) overarching goal to achieve better health, better care, and lower cost through improvement, session leaders shared success stories and lessons learned around their different initiatives.
So what are the social determinants of health and why do they matter to Medicaid agencies? According to healthypeople.gov/2020, “the social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” These social factors affect the accessibility of healthcare services and availability of resources to meet daily needs. They play a large and important role in the wellbeing of many Medicaid beneficiaries.
Manatt Health, in partnership with the Milbank Memorial Fund and the NYS Health Foundation, recently created a practical guide entitled, “Medicaid Coverage of Social Interventions: A Road Map for States.” for policymakers who want to know when and how states can use Medicaid to facilitate access to social services. According to Manatt Health, up to 40% of health outcomes are driven by nonmedical factors such as income, education, and occupation. This means that for vulnerable Medicaid populations, concentrating efforts on medical services alone without addressing social needs can result in missed opportunities to improve an individual’s health in addition to inefficient healthcare spending. As states learn more about the impact of social determinants on health outcomes of susceptible populations, Medicaid agencies are researching ways to integrate social interventions into their coverage, payment, and delivery models. The good news is that Medicaid has already begun playing a role in connecting individuals to social resources. Sections 1905(a)(19) and 1915(g)(1) of Title XIX of the Social Security Act allow states to use Medicaid to pay for the costs associated with medical, social, and educational services, as well as housing and transportation services.
Manatt Health’s new practical guide for policy makers outlines the flexibility states now have under Medicaid law and regulations to assist in securing social support services to achieve overall health outcomes. Four specific areas of social support services highlighted in this roadmap are: linkages to social service programs, stable housing, employment and job stability, and peer and community supports.
Linkages to Social Service Programs
States have multiple ways to connect Medicaid beneficiaries with social services such as food supports, rental assistance, child care, legal assistance, and help with utility bills. Using case management, states can assess the specific social needs of each individual, determine their eligibility for available community programs, and provide referrals to the appropriate providers. In their report, Manatt credits the Regional Care Collaborative Organizations in Colorado for their success in linking individuals to social programs.
Colorado has established regional organizations, known as Regional Care Collaborative Organizations (RCCOs) which are tasked with coordinating and improving care for Medicaid beneficiaries across the state. The goal is to enhance the member and family experience, improve access to care, and transform incentives and delivery processes to a system which rewards accountability for health outcomes. RCCO’s responsibilities include helping beneficiaries navigate their various appointments and medication reconciliation, referring beneficiaries to social service programs, and working with local agencies to address food deserts and other community issues. Since its inception in 2011, RCCO has resulted in a reduced use of acute care, better control of chronic conditions, and a lower cost among Medicaid beneficiaries.
Research indicates that stable housing can help reduce healthcare costs for vulnerable populations with a history of homelessness or behavioral health issues. While Medicaid does not pay for housing, it does provide funding for a variety of supportive services for individuals in housing programs, including:
- Transition services – activities that help an individual transition from institutional living or homelessness to secure community-based housing
- Sustaining services – activities that support an individual’s ability to maintain a consistent housing situation and stable environment
- Housing-related collaborative activities – initiatives which work with state and local partners to advocate for and develop additional housing resources
Manatt highlights the state of Louisiana for their work providing supportive housing to individuals with physical or developmental disabilities, serious mental illness, or who are in treatment or recovery from a substance use disorder. The Louisiana Permanent Supportive Housing (PSH) Program links affordable rental housing with voluntary, flexible and individualized services for people with severe disabilities. After Hurricanes Katrina and Rita, advocates for homeless and disabled populations joined service providers and governmental agencies to form a successful partnership leading to the development of over 3,000 units of permanent support housing units. To date, the PSH has provided over 2,000 households with affordable housing resources and support services needed to retain housing. The services provided by PSH are reimbursable through the Medicaid program due to the incorporation of PSH services into the state’s Home and Community Based Services (HCBS) waivers.
Employment and Job Stability
States are now able to provide case management for health services that help individuals keep, learn, or improve skills needed for daily living. For those with disabilities or major barriers to work, this flexibility is critical. HCBS waivers can now be used to provide employment services which assists in finding and maintaining jobs in community settings.
In their brief, Manatt Health highlights Maryland’s use of HCBS waivers to provide habilitation services to youth and adults with developmental disabilities. The Community Pathways Waiver, which is administered by Maryland’s Medicaid office and the Developmental Disabilities Administration, covers 19 services, including “employment discovery and customization” and “supported employment.” Employment discovery and customization is a short-term service (not to exceed six months) intended to help explore employment opportunities and prepare for the workforce through training and job customization. Supported employment, on the other hand, services on a longer-term basis and assists beneficiaries in maintaining jobs in the community, ideally in workplaces where the majority of employees do not have disabilities. Specific employment activities covered by Medicaid include job coaching, job training, monitoring and evaluating performance at the workplace.
Peer and community supports
Peer support services are critical for individuals with behavioral health disorders and are aimed at helping individuals cope with social and emotional challenges while they are in recovery and seeking to prevent a relapse. Although there are multiple different models for providing peer support, the American Academy of Family Physicians Foundation has outlined four key elements:
- Assistance in daily management
- Social and emotional support
- Linkage to clinical care and community resources
- Providing a long-term supportive relationship
In 2001 Georgia became the first state to cover peer support services through its Medicaid program. Certified peer specialists assist individuals with behavioral health disorders to accomplish their goals on their journey to personal recovery. These peer specialists have lived through their own experience with recovery and are consequently able to promote hope, personal responsibility, empowerment, education, and self-determination in the individuals they serve. A portion of the Georgia Certified Peer Specialist Project is funded through Medicaid.
As one can see from these examples, Medicaid is playing a valuable role in linking individuals to critical support services which address their social needs and improve outcomes. Eccovia Solutions is proud to provide a flexible case management platform that coordinates care for Medicaid beneficiaries and connects them to invaluable social services that improve their overall health.
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