Using Social Determinants of Health Data in Medicaid Managed Care – A Webinar for States

 State Health and Value Strategies, a program of the Robert Wood Johnson Foundation, is pleased to announce the third in their series of webinars for state officials on achieving population health goals.

Integrating Social Services into Care for the High-Need, High-Cost Population: Webinar Recording and Resources

Join the Health Care Transformation Taskforce speakers as they walk through a new Task Force-endorsed framework on social services integration, and provide an in-depth case study on how one high-performing community health system has successfully infused social services into its care delivery system.

Using Community Health Workers and Volunteers to Reach Complex Needs Populations

To effectively reach individuals with complex medical and social needs, health care delivery systems are increasingly incorporating alternative roles into care teams, including community health workers, volunteers, neighborhood navigators, community paramedics, or pharmacists. This three-part webinar series from the Center for Health Care Strategies (CHCS) is exploring emerging innovations in the complex care workforce. This first webinar highlighted strategies for integrating community health workers and volunteers into care teams that serve high-need, high-cost individuals in both rural and urban environments.

State Innovations: Oral Health Integration in Statewide Delivery System and Payment Reform

This webinar from the Center for Health Care Strategies, made by possible by the Washington Dental Service Foundation, explored the range of approaches to oral health integration that states are considering in the areas of: (1) Medicaid benefit design and expansion; (2) practice-level oral health reforms; and (3) statewide delivery reform models.



Integration Strategies Toolkit

This toolkit provides various examples of innovative models integrating physical and behavioral health care. The resources are categorized into the following topic areas: physical/behavioral health integration, appropriate emergency department use, and innovations for integrating depression treatment into primary care.

Articles & Briefs

Medicaid and Social Determinants of Health: Adjusting Payment and Measuring Outcomes

State policy makers are increasingly focused on social determinants of health (SDOH) because of the important influence of these determinants on health care outcomes and Medicaid spending. Social determinants include a broad array of social and environmental risk factors such as poverty, housing stability, early childhood education, access to primary care, access to healthy food, incarceration and discrimination. This issue brief from the State Health Reform Assistance Network digs into to opportunities that states have to account for SDOH in Medicaid programs. This topic was also the subject of a recent State Health and Value Strategies webinar.

How Health Care And Community-Based Human Services Organizations Are Partnering For Better Health Outcomes

Health care organizations and community-based providers of human services are now collaborating to address both the social and the clinical determinants of health. What kinds of partnerships exist among what sorts of partners? What's working well, and what could be improved?

Rapid Growth In Mental Health Telemedicine Use Among Rural Medicare Beneficiaries, Wide Variation Across States

Congress and many state legislatures are considering expanding access to telemedicine. To inform this debate, we analyzed Medicare fee-for-service claims for the period 2004–14 to understand trends in and recent use of telemedicine for mental health care, also known as telemental health. The study population consisted of rural beneficiaries with a diagnosis of any mental illness or serious mental illness. The number of telemental health visits grew on average 45.1 percent annually, and by 2014 there were 5.3 and 11.8 telemental health visits per 100 rural beneficiaries with any mental illness or serious mental illness, respectively. There was notable variation across states: In 2014 nine had more than twenty-five visits per 100 beneficiaries with serious mental illness, while four states and the District of Columbia had none. Compared to other beneficiaries with mental illness, beneficiaries who received a telemental health visit were more likely to be younger than sixty-five, be eligible for Medicare because of disability, and live in a relatively poor community. States with a telemedicine parity law and a pro–telemental health regulatory environment had significantly higher rates of telemental health use than those that did not.

Unusual Community Partnerships Offer New Mental Health Interventions

Scouting Health, funded by the Robert Wood Johnson Foundation, is a partnership between Westat, a social science research, statistical analysis, and evidence-based communications firm, and Rare Dots, a health care consultancy focused on provoking connected communities to action. Scouting Health has looked past the traditional sources of care to seek out the unexpected partners and stakeholders within communities that are working to integrate care or advance health in some way. This search led Scouting Health over to Bexar County, Texas (where San Antonio is located), which used an approach from the criminal justice system to expand mental health interventions among youth.

Los Angeles Safety-Net Program eConsult System Was Rapidly Adopted And Decreased Wait Times To See Specialists

This article from Health Affairs provides insight into the Safety-Net eConsult System in Los Angeles. Lack of timely access to specialty care is a significant problem among disadvantaged populations, such as those served by the Los Angeles County Department of Health Services. In 2012 the department implemented an electronic system for the provision of specialty care called the eConsult system, in which all requests from primary care providers for specialty assistance were reviewed by specialists. By 2015 the system was in use by over 3,000 primary care providers, and 12,082 consultations were taking place per month, compared to 86 in the third quarter of 2012. eConsult systems are a promising and sustainable intervention that could improve access to specialist care for underserved patients.

A Framework for Addressing Social Determinants of Oral Health in the Community

This technical assistance brief from DentaQuest describes a framework for assessing and creating partnerships to improve social determinants related to oral health. It outlines how United Way of Central Jersey — which participated in a CHCS-led learning collaborative on addressing social determinants of oral health — applied the framework in developing its Parent Promotoras model to improve oral health for low-income children.

CommunityRx: A Population Health Improvement Innovation That Connects Clinics To Communities

AcademyHealth offers The CommunityRx system, a population health innovation, combined an e-prescribing model and community engagement to strengthen links between clinics and community resources for basic, wellness, and disease self-management needs in Chicago.

Strengthening Integration Of Health Services And Systems

Integration of health services and systems constitutes the fourth Action Area in the Robert Wood Johnson Foundation’s Culture of Health Action Framework, which is the subject of this article from AcademyHealth. This Action Area conceives of a strengthened health care system as one in which medical care, public health, and social services interact to produce a more effective, equitable, higher-value whole that maximizes the production of health and well-being for all individuals.

National Oral Health Innovation and Integration Network

This collaborative grew out the Strengthening the Oral Health Safety Net (SOHSN) partnership. Funded by the DentaQuest Foundation, this initiative engaged partners like the National Association of Community Health Centers (NACHC) and the National Network for Oral Health Access (NNOHA), supporting their work to strategically build capacity to promote oral health on behalf of safety net providers across the country.

Medicaid Expansion: Driving Innovation In Behavioral Health Integration

The blog from HealthAffairs presents case studies from two provider systems that illustrate some of the innovative approaches that are improving the quality of behavioral health care at safety-net institutions.

Promising Practices to Integrate Physical and Mental Health Care for Medi-Cal Members

This brief from the Center for Health Care Strategies describes promising practices to improve collaboration across systems, and to provide a more seamless experience of care for beneficiaries. These insights, while gleaned from California, can inform physical and mental health care integration in other states as well.

Quality Indicators for Physical and Behavioral Health Care Integration

Although the integration of physical and behavioral health services has been shown to improve outcomes and reduce spending, it has failed to take hold. In a JAMA Viewpoint, Commonwealth Fund–supported authors say that the missing link to increased adoption of this model may be quality measures for assessing and rewarding well-integrated care.

Creating Connections: An Early Look at the Integration of Behavioral Health and Primary Care in Accountable Care Organizations

This Commonwealth Fund report explores how ACOs are approaching the integration of behavioral health into primary care by showcasing two models of behavioral health and primary care integration. The two ACOs vary in their approach to integration as well as in other characteristics.

Strategic Guidance: Practical Approaches for Engaging Employers in Community Alliances

This brief highlights employer engagement insights from collaboratives that are currently part of the Aligning Forces for Quality (AF4Q) program. This brief also offers several ideas for community collaboratives to consider in assessing the mix of employers in their region and matching their own products or services with the types of employers most likely to value them.

Using Medicaid Resources to Pay for Health-Related Supportive Services: Early Lessons

CHCS conducted interviews with state officials, community providers, and national experts to identify how these Medicaid programs are determining the appropriate scope of supportive services and incorporating them into their state plans. Drawing from these interviews, this brief provides practical state case studies to help inform supportive service payment strategies within accountable care organizations, health homes, community health teams, accountable communities for health, and other value-based delivery system reforms.

Improving Health Care Quality and Equity: Considerations for Building Partnerships Between Provider Practices and Community Organizations (A4FQ) 

Given the day-to-day hurdles many patients face, practices can benefit from strategic partnerships with community organizations that can help support patient needs. This brief outlines considerations for practices looking to develop partnerships with community organizations.It mainly addresses practices that may have limited experience with community engagement, but that seek to form relationships that can help them improve the quality or equity of their care.