In our last blog post, we discussed the Biden Administration’s infrastructure package as an example of an upstream policy effort that could promote equity and help address disparities. However, as we pointed out in the first in this series of blogs, stakeholders who interact with community members are best suited to identify social risk factors and connect individuals to resources that meet their social needs downstream. With state, federal, or private support, communities can amplify or develop new resources for addressing social and health disparities. Some activities being implemented by stakeholders under the federally-funded Financial Alignment Initiative (FAI) are examples of downstream efforts in action.
The FAI is funded by the Centers for Medicare & Medicaid Services (CMS) and is testing integrated care and financing models for individuals enrolled in both Medicare and Medicaid (dually eligible enrollees). These people, by definition, have very low income and assets. Thirteen State demonstrations under the FAI aim to coordinate care across the separate Medicare and Medicaid systems and identify and address the complex needs of dually eligible enrollees. Those complex needs include health and social needs. One state, Minnesota, also developed an alternative “administrative” model [PDF] under the FAI.
In this post, we discuss the ways in which stakeholders across state demonstrations under the FAI leverage federal support to identify social risk factors and meet individuals’ social needs. We highlight some key findings from qualitative evaluation work on how FAI demonstration stakeholders are tackling disparities related to social determinants of health (SDOH). Stakeholders include state leadership, health plans, care coordination entities, and others. First, we showcase two demonstration examples. Then we summarize approaches across the demonstrations. We provide more details in a comprehensive issue brief written for CMS.
Washington: meeting social needs through person-centered care
Reducing SDOH-related disparities requires person-centered care. That is, it requires tailoring services so that care is consistent with the needs, preferences, and life circumstances of each individual. Under the FAI, demonstration stakeholders developed data collection materials and processes with this concept in mind.
States or health plans designed and use assessment tools with questions about social risk factors. Care coordinators work with enrollees to develop and follow through on care plans. These care plans recognize each enrollee’s unique capacities, goals, needs, and situations.
Some care coordinators also conduct home visits. These visits are special opportunities to identify environmental needs that may affect people’s health and safety, such as home modifications. Ongoing enrollee-care coordinator communication can identify changing needs and help with social isolation.
These elements are key features of the Washington demonstration. Washington uses Predictive Risk Intelligence SysteM (PRISM) scores [PDF] to identify dually eligible enrollees at risk of high costs, who need care coordination the most. Care coordinators, with enrollees, develop and implement Health Action Plans and make in-home care coordination visits. These activities help care coordinators understand the impact of multiple social risk factors on the enrollee, as well as the enrollee’s immediate social needs.
Another unique aspect of the demonstration is that care coordinators receive training in motivational interviewing. This, along with monthly home visits and ongoing communication, helps care coordinators to:
- build trust with enrollees
- encourage enrollees to openly share their true health and social needs, and
- promote enrollee self-action to achieve personal health and social goals.
Minnesota: cultural context
Cultural context is characterized by factors such as nativity and language. Cultural competence in health care is key to attaining health equity across diverse populations. Recognizing this, most participants in the demonstrations under the FAI are taking steps to enhance cultural competency. Examples include cultural competency training for staff, and prioritizing cultural and ethnic diversity across staff and provider networks to meet enrollee preferences.
To address inequities in program access, Minnesota used Federal demonstration implementation funds for its administrative model to improve the quality of and accessibility to its Medicare-Medicaid programs for members of the Hmong, Lao, Somali, and African American communities. This involved a multi-step approach that included:
- assessing how different communities learned about and participated in the programs;
- engaging community-based organizations to conduct more culturally responsive outreach and education, and to collect data on the cultural responsiveness of state program materials; and
- using feedback from enrollee engagement activities to develop short- and long-term recommendations to help build cultural responsiveness.
These activities improved outreach efforts to underrepresented populations that are now aging into the state’s Medicare-Medicaid integrated care programs.
Demonstration approaches that target SDOH
Stakeholders in all of the State demonstrations under the FAI have committed to efforts that acknowledge and address the disparate impacts of SDOH on enrollees. Their approaches to identifying enrollee social risk factors and meeting social needs vary. Stakeholders’ capacity and experience, locally available resources, contractual requirements, and the circumstances of the populations they serve, lead to different, often creative, strategies. We share some of these strategies in the table below.
What can we do with these lessons from the FAI?
The issue brief provides in-depth sharing of a variety of examples, their contexts, and lessons learned. Others who aim to address SDOH-related disparities–at the community and individual level–can use the issue brief as a resource to:
- identify what they might be able to do
- anticipate and mitigate challenges
- learn ways to identify the needs of their service populations, and
- target efforts to the health and social care and services that their populations most need.
Advocates, policymakers, and decision-makers could also use the issue brief to understand the types of policies, practices, and resources that could support more widespread implementation.
These efforts are currently supported by federal demonstration funding. Demonstration stakeholders will face choices and challenges in sustaining their SDOH-related work beyond the demonstrations. Still, the efforts are admirable and have made a difference in enrollees’ lives.
Amy Chepaitis
Latest posts by Amy Chepaitis (see all)
Amarilys Bernacet