This brief describes a process used to identify a set of patient- and staff-reported measures for the Advancing Integrated Models initiative, eight pilot sites implementing approaches that seek to improve integrated, person-centered care models for adults and children with complex health and social needs.
This updated brief describes the American Rescue Plan Act’s home and community-based services enhanced federal medical assistance percentage (FMAP) provision, CMS’s recent implementation guidance, and considerations and next steps for state policymakers.
This webinar explores practical strategies to assess and address hunger needs faced by families during the COVID-19 pandemic and beyond, including leveraging early childhood systems and the Help Me Grow system model to address child food insecurity.
This series of policy briefs include evidence-based recommendations to help people through the immediate health and economic crises and longer-term recommendations to ensure a fair and just opportunity for health.
This report shares considerations for health care organizations and government entities seeking to build effective partnerships with the individuals and communities they serve to better address their health and social needs.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.