Integrating Care

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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.

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

This report explores challenges associated with providing complex care in rural and frontier communities and outlines opportunities to ensure effective programs.

Graphic

This infographic shows 10 states’ guidelines for involving community members in the community health needs assessment process, as well as their enforcement levers.

Brief

States can work to make sure hospitals truly seek out and act on meaningful input from a wide range of community representatives — not just community members on a hospital’s board or leaders from high-profile community groups.

Report

In this report, ReSource Team members were interviewed on their methods for addressing the needs of extremely medically complex and socially vulnerable individuals.

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.

Report

This study analyzes three programs that use non-traditional workforce strategies to extend the reach of their clinics to better engage complex patients in their homes, at medical appointments, and other locations.

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.

Report

Six case studies examine lessons from PHNCI Innovation Learning Community grantees, who spent eighteen months implementing public health innovations in their communities.

Webinar & Presentations

This webinar explored how several states are using their multi-payer claims databases, including how they are employing claims databases to enhance the value of care and lessons learned for others.

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

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 considerations for policymakers assessing their state Medicaid managed care programs and exploring strategies for advancing cost, quality, and accountability goals.

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.

Report

This guide provides health departments with the key components to consider before planning the FPHS implementation process.

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.

Report

The Blueprint for Complex Care provides a strategic plan to support multidisciplinary innovations and accelerate opportunities to improve care for individuals with complex health and social needs.

Report

This report highlights three states – Ohio, Oregon, and Washington – work using data, expertise, and evidence to modernize their public health systems.

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

The Minnesota State Employee Group Insurance Program has covered Minnesota state employees and their dependents using a tiered provider model since 2002. A recent SHARE-funded analysis examined the tiering model as well as patient and clinic responses to this tiered provider network approach.

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.

Webinar & Presentations

This webinar featured the use of admissions, discharge, and transfer (ADT) data feeds to coordinate care for patients with behavioral health and other complex care issues in Tennessee and Washington. It provided lessons learned, including operational and financing strategies, linkages to quality metrics and outcomes, and alignment with other statewide payment and delivery system efforts.

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.

Webinar & Presentations

This webinar is first in a two-part series exploring how providers are building on existing complex care program models to extend beyond the walls of a health system.

Dataset , Graphic

This report provides a compilation of data on equity goals and progress for 28 measures of health, socioeconomic factors, physical and social environment, and access to health care. Each measure is presented by race, ethnicity, and socioeconomic status for all 50 states, the District of Columbia, and the nation.

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.

Report

Six case studies on innovations in public health, including: Boston's PHC Bridges Sectors to Combat Overdoses; Chicago's DPH Sees the Future Thanks to Predictive Analytics; Hennepin County Uses Automation in Databook Development; Douglas' CHD Brings STD Testing to Youth-Friendly Locations; Portsmouth's HD Uses CASPER to Collect Neighborhood Data; and Check Out a Book, Check Out a Blood Pressure Kit.

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.

Report

State Medicaid programs are increasingly requiring their Medicaid managed care organizations (MCO) to implement APMs. It is important for states to develop ways to ensure that their MCOs are complying with the APM requirements within their contract, and monitoring the progress and challenges with the implementation of APM strategies with Medicaid providers. This report focuses on different ways in which states may set standard APM definitions to track MCO progress toward meeting state APM goals, and support comparison of APM implementation within a state and nationally.

Report

The Health Care Payment Learning and Action Network Alternative Payment Models Framework (the LAN APM Framework) is an increasingly common method being used by states to measure plan progress toward implementation of APMs. This report provides real-world examples of APMs within the LAN categories and can help states and other interested purchasers develop a common understanding of what types of payment models fit within the framework categories.

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

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.

Report

As the opioid and mental health crises continue to gain national attention, local leaders are stepping up to implement programs to address the prevalence and impact of untreated serious mental illness (SMI) and substance use disorders (SUD). This report explores how cities and counties have launched local initiatives to address the human and economic impact of untreated SMI and SUD.

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.

Brief

06.2017 / By Urban Institute

Mental health and substance use coverage could roll back to pre-Affordable Care Act (ACA) levels if the American Health Care Act (AHCA) becomes law. Analysis finds the AHCA could limit access to mental health treatment.

Report

This report identifies solutions that could be developed, and implemented at the local or community level to advance health equity.

Webinar & Presentations

The “Buying Value Measure Selection Tool” was developed to assist state agencies, private purchasers and other stakeholders in creating aligned measure sets, and was first released in 2014. This webinar explains this tool and recent updates for state officials and other stakeholders involved in developing and maintaining aligned quality measure sets for health care entities and programs including for health plans, accountable care organizations, and patient-centered medical homes. This webinar presents strategies for selecting measures and reveals an updated version of the tool. 

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

In an era of public health system transformation, public health departments around the nation are adapting — or “modernizing” — to meet the growing and changing needs of their communities. To help states navigate the challenges inherent in public health system transformation, three grantee states are participating in a learning community supported by PHNCI. The three states — Ohio, Oregon and Washington — are working to test and implement the systems transformations required to provide the foundational public health services statewide and ensure that all residents have equitable access to public health.

Brief

Changes in population-based payment models in health care delivery have spurred enhanced efforts toward closer integration between state purchasers of health care and state, county, and local public health officials. This issue brief investigates approaches that state agencies might employ in order to better integrate public health and health care delivery as a means of improving health and the value of health care, and it is organized according to seven features of integration. The issue brief is accompanied by three case studies providing additional detail to some of the examples cited in the brief.

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