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Cross-Sector Alignment

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Report

02.2021 / By Milbank Memorial Fund

This issue brief summarizes the current landscape of payment reform initiatives addressing social determinants of health.

Report

01.2021 / By Urban Institute

This brief uses new data from the second wave of the Urban Institute’s Coronavirus Tracking Survey, conducted September 11 through 28, 2020, to explore the pandemic’s impact on housing stability and renters’ vulnerability to eviction.

Brief

This brief explores the key challenges faced by the rural ambulatory safety net in delivering primary care and behavioral health services since COVID-19 and the policy changes that have been implemented in response.

Report

This report describes emerging opportunities and contributing success factors for advancing multi-sector data-sharing partnerships to improve health and well-being and advance equity.

Report

This report uses data from September 11–28, 2020 to compare food insecurity in September with levels earlier in the pandemic after major relief legislation was passed.

Brief

This brief provides an introduction to screening for social risk factors, the first step most states are taking through their Medicaid managed care programs to address how social determinants of health influence enrollees' health status and spending.

Commentary

This commentary examines the impact that recent postal delays, COVID-19-related housing and economic crises, and natural disasters have had on state Medicaid and Children’s Health Insurance Program agencies.

Report

This report features lessons learned from Arizona and Michigan and supplements earlier materials on building complex care programs and using a housing as health care approach for complex care populations.

Webinar & Presentations

This webinar details how three provider organizations are using population health management approaches to care for people with complex needs amid COVID-19.

Commentary

This commentary explores how adverse childhood experiences contribute to poor health outcomes, and the ways that these are exacerbated by the COVID-19 pandemic.

Report

This report examines examples from two state Medicaid programs and a nonprofit quality measurement and reporting organization of the data sources used to identify patients’ social risk factors when risk-adjusting payments or measuring quality.

Commentary

This commentary features a conversation with health leaders in Colorado about how their agencies partnered to support families with young children during the COVID-19 pandemic, as well as the challenges they faced. 

Report

This report uses data to examine how the COVID-19 pandemic has affected food insecurity and access to school meals and charitable food distribution for adults and their families in the United States.

Brief

This brief highlights how Nebraska’s Medicaid agency and its Division of Public Health partnered to share antibiotic prescribing information between Medicaid claims and evaluation and management codes to determine where targeted education and outreach efforts were needed.

Commentary

This commentary features an interview on how health care systems can use trauma-informed care to support patients and frontline workers during the COVID-19 pandemic.

Commentary

This commentary presents stories of innovative approaches to address food insecurity needs exacerbated by the COVID-19 pandemic.

Commentary

This commentary presents data on how the COVID-19 pandemic is affecting “deaths of despair” caused by suicides, alcohol abuse, and overdoses from opioids and other drugs. 

Commentary

This commentary examines the importance of home visiting during the COVID-19 pandemic, as families face new or expanding challenges like domestic violence, substance use, or mental health needs.

Commentary

This commentary, part of the Innovations Amid COVID-19 series, profiles a clinic's innovative approach to using online data to identify high-risk patients.

Dataset

This guide compiles more than 100 resources tracking state and local data and policy responses to COVID-19 in health care, food, housing, and income supports.

Report

This report uses new data from the Urban Institute’s Health Reform Monitoring Survey to examine the effects of the coronavirus outbreak on families’ employment and abilities to meet basic needs, as well as disparities in the economic impact of the pandemic.

Commentary

This commentary includes examples of how states can address new needs, including housing, food, transportation, education, and employment, and how the CARES Act can support and amplify states' work to help stop the spread of COVID-19 and assist people with health-related social needs.

Commentary

This commentary examines state strategies for addressing barriers to telehealth for opioid use disorder during the COVID-19 pandemic.

Dataset

The 2020 County Health Rankings highlight how health outcomes and health factors differ by place within states and illustrates how health differs among racial/ethnic groups within places.

Commentary

This post presents two sample hospital reporting templates to help policymakers capture the information they need to critically evaluate the community benefit investments hospitals make in exchange for their tax exemptions.

Report

This report focuses on how Medicaid programs can use data from the American Community Survey (ACS), to inform and target interventions that seek to address social determinants of health and advance health equity.

Report

This report proposes a measurement model for trauma-informed primary care and suggest variables that could be assessed for each major intervention component.

Report

This paper summarizes emerging evidence in the field of how social determinants of health shape health outcomes and identifies key areas where more research is needed to advance implementation and policy development.

Report

01.2020 / By ZERO TO THREE

This annual report compares national and state-by-state data on the well-being of infants and toddlers.

Report

This report gives an overview of the federal authorities under which states are able to cover nonclinical housing-related services for high-need Medicaid enrollees, and also details how states are using these authorities to invest in supportive housing for diverse high-need Medicaid populations.

Report

12.2019 / By Urban Institute

This brief estimates charitable feeding use by demographic and socioeconomic characteristics and explores how use of charitable feeding intersects with other material hardship measures and safety net program participation

Report

These two reports provide national and state-level trends in suicide deaths from 2000 to 2017.

Report

09.2019 / By Urban Institute

This brief describes interviews with 10 Medicare Advantage plans, Medicare Advantage experts, and social service providers to discuss new benefits added under the Centers for Medicare & Medicaid Services' increased flexibility in plan year 2019.

Report

This report provides an overview of the behavioral health system’s engagement in Medicaid value-based payment (VBP) models and provides policy recommendations to support VBP adoption.

Report

This literature review provides an overview of the scholarly work on the drivers of health.

Commentary

This blog outlines how states like Oregon and Connecticut go beyond federal requirements to ensure that hospital community benefit spending is substantial, meets community needs, and addresses state goals in exchange for tax exemptions.

Report

This report examines implementation considerations for fiscal mapping from sites in Maryland and Minnesota to help inform similar mapping activities in additional states and communities.

Report

This report describes preliminary observations regarding implementation of Medicaid housing support demonstrations in California, Maryland, and Washington.

Commentary

This analysis highlights the disparities between characteristics of populations most affected by housing affordability issues.

Brief

06.2019 / By Urban Institute

This fact sheet explores the extent to which families of young children experience material hardship and psychological distress.

Brief

06.2019 / By Urban Institute

This fact sheet explores the extent to which families with young children continue to experience food insecurity.

Commentary

This interview features two physicians who participated in planning New Jersey’s statewide office-based addiction treatment program and their experiences treating addiction within primary and specialty care settings.

Commentary

In this article, Dan Sumrok, MD, DFASAM, ABAM, ABPM, discusses a possible connection between combat experience and physical and behavioral health problems.

Webinar & Presentations

This webinar highlights how two providers operating in vastly different settings have incorporated a trauma-informed approach to care into their day-to-day practices for treating substance use disorder.

Report

05.2019 / By Urban Institute

This report examines changes in material hardship between 2017 and 2018 and finds that, despite a strong labor market, there was only modest progress in families’ ability to meet basic needs.

Report

05.2019 / By Urban Institute

This report assesses trends in self-reported measures of general health, mental health, activity limitations, and obesity by educational attainment from 1997-2017.

Brief

This table highlights new programs and federal initiatives to combat the opioid crisis.

Report

This issue brief explores the “next generation” practices that states are deploying to address social factors using Medicaid 1115 waivers and managed care contracts.

Brief , Graphic

Several states are developing accountable health models to improve health and control costs by addressing health-related community needs, such as transportation, recreation, and housing. This brief examines their organizational and governance structures.

Commentary

This commentary explores a series of case studies and tools developed after a national scan of promising HC/CBO partnerships that examine the operational, financial, and strategic components of successful partnerships.

Report

The annual County Health Rankings measure vital health factors, including high school graduation rates, obesity, smoking, unemployment, access to healthy foods, the quality of air and water, income inequality, and teen births in nearly every county in America.

Report

03.2019 / By ZERO TO THREE

This resource compares national and state-by-state data on the well-being of infants and toddlers, and provides national and state-level data to help advance policies to improve the lives of babies and families.

Brief

This brief reviews the role that social and economic factors--such as housing, healthy food, and income--play in a “whole person” approach to health care, especially among Medicaid’s low-income enrollees.

Brief

This brief explores opportunities to better address patients’ non-medical needs, including: identifying non-medical needs; employing non-traditional workers; partnering with community-based organizations/agencies; testing new technologies; and identifying funding.

Dataset , Report

02.2019 / By Health Impact Project

This project encourages state, local, and national level organizations to include health considerations in policy decisions across multiple sectors, such as housing, transportation, and education. Research shows that the conditions in which people live, learn, work, and play influence their health, so the project also works to create cross-sector partnerships that include the expertise of health care and public health systems.

Dataset

This tool helps identify policies and programs that are a good fit for community priorities. Analysts review and assess research to rate the effectiveness of a broad variety of strategies (i.e., policies, programs, systems & environmental changes) that can affect health through changes to: health behaviors, clinical care, social and economic factors, and the physical environment.

Webinar & Presentations

This webinar by SHADAC researchers examines new measures and highlights how the estimates can be used to explore disparities between states and among sub-populations.

Graphic

This infographic series examines housing affordability, both unaffordable rents overall as well as for specific populations.

Brief

This case study explores how Indiana’s Family and Social Services Administration is working to rethink how to optimize the integration and delivery of health and social services for Medicaid beneficiaries.

Webinar & Presentations

This webinar featured speakers from AccessHealth Spartanburg in South Carolina and Petaluma Health Center in Northern California who shared strategies for addressing social determinants of health.

Brief

This State Health Policy Highlight profiles two issue briefs and a webinar on how state Medicaid programs can address social determinants of health.

Brief

Recognizing an unmet need for toiletries and household products among clients, AccessHealth Spartanburg stocks a closet where eligible clients can “shop” for items. This builds trusting relationships between clients and staff and meets basic client needs.

Report

09.2018 / By Urban Institute

The Well-Being and Basic Needs Survey (WBNS) monitors changes in health and well-being at a time when policymakers seek significant changes to programs that help low-income families pay for basic needs. Most indicators based on data from the WBNS are reasonably consistent with measures from larger federal surveys.

Report

09.2018 / By Urban Institute

As federal and state policymakers weigh changes to federal programs that help low-income people meet their basic needs for food, medical care and shelter, they run the risk of increasing material hardship, which could have detrimental short- and long-term impacts on children and adults.

Graphic

This chart compares the social determinants 11 states targeted in their Medicaid contracts and contract guidance documents to enhance population health, as well as how states monitored outcomes and funded these efforts.

Report

Informed by more than 30 key informant interviews representing programs in 19 states and a small group convening, this report offers a national analysis to uncover opportunities to facilitate state-level, cross-sector strategies that promote health beyond the traditional health care levers.

Graphic

According to 2016 data from the National Survey of Children’s Health, 33.9 percent of children nationwide had trouble affording nutritious meals.

Graphic

This analysis examines educational attainment and access to health care, looking at the extent to which adults (25 years and older) with different levels of education skipped needed care due to cost and did not have a personal doctor.

Journal Article

This article explores efforts by nine state Medicaid and public health agency teams to implement 6|18 interventions related to asthma control, tobacco cessation, and unintended pregnancy prevention. It was published in the Journal of Public Health Practice and Management and covers Colorado, Georgia, Louisiana, Massachusetts, Michigan, Minnesota, New York, Rhode Island, and South Carolina.

Journal Article

This article details a qualitative analysis that (1) identified facilitators and barriers to utilizing a community health worker (CHW) model among patient-centered medical homes (PCMHs) in Minnesota; and (2) defined roles played by the CHW workforce within the PCMH team. Four themes emerged as facilitators and barriers: the presence of leaders with knowledge of CHWs who championed the model; a clinic culture that favored piloting innovation vs. maintaining established care models; clinic prioritization of patients' nonmedical needs; and leadership perceptions of sustainability.

Report

As states transform their health systems, many are turning to community health workers (CHWs) to improve health outcomes and access to care, address social determinants of health, and help control costs of care. While state definitions vary, CHWs are typically frontline workers who are trusted members of and/or have a unique and intimate understanding of the communities they serve. These resources support state efforts to incorporate CHWs into their health and health equity improvement work.

Report

This report examines how organizations participating in Transforming Complex Care (TCC), a multi-site national initiative funded by RWJF, are assessing and addressing social determinants of health for populations with complex needs. It reviews key considerations for organizations seeking to use SDOH data to improve patient care.

Graphic

This map highlights state activity to integrate Community Health Workers (CHWs) into evolving health care systems in key areas such as financing, education and training, certification, and state definitions, roles and scope of practice. The map includes enacted state CHW legislation and provides links to state CHW associations and other leading organizations working on CHW issues in states.

Report

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 report digs into opportunities that states have to account for SDOH in Medicaid programs.

Report

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. This report digs into opportunities that states have to account for SDOH in Medicaid programs.

Brief

Low-income and vulnerable populations often need services and supports outside the scope of a single state agency to live healthy lives. In some states, braiding or blending funding streams lends programs a measure of flexibility, efficiency, and resiliency. Some states are considering whether innovative funding models could help them address the health-related social needs of vulnerable residents.

Brief

State health policymakers are increasingly acknowledging housing as a key component of health and are weaving housing strategies into their broader health system transformations. States have powerful levers at their disposal and a range of funding streams that they can bring to bear to support integrated health and housing, while local public housing authorities also play a large role in community efforts to house vulnerable, low-income households.

Webinar & Presentations

This webinar profiles Louisiana’s Permanent Supportive Housing program and  Virginia’s Children’s Services Act, and examines their use of blended or braided funding to help meet the health-related social needs of vulnerable low-income populations.

Report

This report explores Louisiana’s permanent supportive housing program. The program, administered jointly by the state’s Medicaid agency and housing authority, is a cross-agency partnership that braids funding to serve vulnerable cross-disability populations, address homelessness, reduce institutionalizations, and save money for the state.

Commentary

State and federal policymakers increasingly acknowledge that health is difficult to achieve and maintain for people without a stable home. Numerous studies show that housing and housing supports can help vulnerable populations improve and maintain health while lowering hospital and other costs for state and local governments. This commentary outlines three tips for state policymakers.

Brief

When it comes to prevention, identification, and mitigation of public health crises, states are at the forefront. These crises require a multi-sector state agency approach as often they disproportionally impact disadvantaged communities and are linked with challenging social determinants of health.

Report

Health care leaders are well-positioned to use cross-sector approaches to drive improvements in population health in collaboration with state leaders. Through the use of joint measurement and accountability tools, policymakers can help to improve health outcomes to an extent not possible through isolated, medical-centric efforts. This report outlines how state agencies can use shared measurement and joint accountability across sectors as tools for improving population health outcomes. 

Report

This report describes six potential integration strategies that state agencies might employ to better integrate social services and health care delivery. For each, the report contains examples from several states that have utilized these strategies in their own efforts to increase integration.

Report

10.2016 / By Urban Institute

This report is a detailed analysis of state rankings on 39 health outcomes, and correlations between those health outcomes and 123 determinants of health spanning five domains: health care, health behaviors, social and economic factors, the physical and social environment, and public policies and spending.

Report

This report stems from technical assistance provided to California’s Department of Health Care Services (DHCS). The technical expert facilitated webinars and meetings with DHCS staff and medical directors of contracted MCOs, in order to share information about housing resources and emerging practices for improving care and achieving savings by linking more Medicaid beneficiaries with permanent supportive housing.

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