BRIEF | February 2015

Supporting Social Service Delivery through Medicaid

Accountable Care Organizations: Early State Efforts
ByRoopaMahadevanandRobHouston,CenterforHealthCareStrategies

INBRIEF

GiventheoftenoverwhelmingprevalenceofsocialneedsfacingMedicaidpopulations,includinghousing,
transportation,andnutrition,aligningsocialservicesandsupportswithhealthcaredeliveryiscritical.Many
statesrecognizetheconnectionbetweensocialdeterminantsofhealthandhealthcareutilizationand
outcomes,andaretakinginitialstepstoprovideessentialnonmedicalsupportsthroughaccountablecare
organization(ACO)programs.Thisbrief,madepossiblebyTheCommonwealthFund,outlinesearlyefforts
bystateMedicaidagenciestoincorporatesocialservicesintoACOmodels,includingkeythemesand
considerationsforotherstates.

hereisgrowingrecognitionthatsocialdeterminantsofhealthsignificantlyinfluencehealth
careoutcomesandcosts.1InMedicaid,whichservesmanyofthemostvulnerable
Americans,theneedtocoordinatehealthcareserviceswithessentialsocialsupportsincluding
housing,nutritionassistance,andemploymentservicesisparticularlycritical.2Medicaid
stakeholdersareinvestigatinghowtolinksocialservicesandsupportswithclinicalcaredelivery
models.SomestatesarepositioningMedicaidaccountablecareorganization(ACO)modelsas
vehiclestosupportacontinuumofphysicalandbehavioralhealth,aswellassocialservices.
Whenmedicalprovidersbearfinancialriskforhealthcarequalityand
outcomesinACOmodels,theyhaveanincentivetousesocialservicesand
Social Services
supportstomaximizetheimpactoftheircareinterventionsonpatients.
StatesrecognizethatACOsneedkeyinfrastructureinplaceteambased
Forthisbrief,socialservicesaredefined
care,datasharingonclinicalandsocialindicators,efficientreferral
asnonmedicalservicesthatmaybenefita
networks,andacultureofcollaborationamongproviderstoeffectively
personshealth,includinghousing,
nutritionassistance,employment
integratesocialserviceswithclinicalcare.Statesaresupportingthe
counseling,transportation,languageand
developmentofthisinfrastructurethroughprogramrequirements,
literacytraining,legalandfinancial
financialincentives,anddatasharingarrangementswithinACOand
services,peernetworks,and/orother
relatedinitiatives.Stateseffortstoincorporatementalhealthand
supportsthataidindividualswithdayto
substanceuseservicesinparticularalreadyunderwayinmanyACO
daylivingandoptimalfunctioning.
programsareprovidinglessonsonhowtoincludediverse,often
communitybasedproviders,andsettingsincaredelivery.3Thisbrief
highlightsearlystateeffortstobuildthefoundationforsocialserviceintegrationinMedicaid
ACOprograms,andsuggestsstrategiesforotherstatestoconsider.

MadepossiblethroughsupportfromTheCommonwealthFund.

2BRIEF|SupportingSocialServiceDeliverythroughMedicaidAccountableCareOrganizations

EXHIBIT 1: Social Service Approaches of Select Medicaid ACO Programs

STATE

ACOENTITY

DESCRIPTION

HIGHLIGHTEDSOCIALSERVICEACTIVITIES

Regionalentitiesthat
receivecare
coordinationpayments
andareeligiblefor
performanceincentives

RCCOsprovidecarecoordinationacrossmedicalandnon
medicalservices.

Colorado

RegionalCare
Collaborative
Organizations
(RCCOs)

ThestatesStatewideDataAnalyticsContractorworkswith
RCCOstoprofiledemographicsofhighriskmembersforreferral
tononmedicalsupports.

ACsarecloselytiedtothestatesexistinghealthhomes
program,inwhichcommunitycareteamspartnerwithprimary
caresitestoprovidewraparoundsupportandcommunity
linkagestothehighestneedpatients.

ACsarerequiredtohavecontractualorinformalrelationships
withatleastonepublichealthentityandatleastoneproviderof
certaintargetedcasemanagementservices.

IHPshavetheoptiontoincludesocialservicesandprovidersin
sharedsavingsarrangements.

IHPsmustdemonstratepartnershipswithcommunitybased
organizations,socialserviceagencies,andpublichealth
resources.

Modelincludeslinkageswithcriminaljusticeprogramsand
housing,whicharealreadysupportedthroughthestateshealth
homesprogram.

DSRIPprogramsupportsdevelopmentofcommunitybased
integratedcaredeliverybysafetynetproviders.

CCOsmustestablishacommunityadvisorycouncilanddevelop
acommunityhealthneedsassessment.

CCOsareencouragedtobuildpartnershipswithrelevantsocial
serviceandcommunityentities,andcollaboratewiththem
flexiblyundertheirglobalbudget.

CCOsusecommunityhealthworkers,peerwellnessspecialists,
andpersonalnavigators.

ACOshavetheoptiontoincludenonmedicalservicesbeginning
inthesecondyearoftheprogram.

ACOsareencouragedtoleveragethestatesexistinghealth
homes,AdvancedPrimaryCareDemonstration,andSupportand
ServicesatHome(SASH)program.

Stateisusingcrossstateagencydatabase,andpredictive
modelingtool(PRISM)totargetpopulationsandsupport
programdevelopmentandimplementation.

Statewillincludequalitymetricsforeducation,employment,
andhousinginitsACOqualitystrategy.

Maine

Minnesota

NewYork

Oregon

Vermont

Washington

Accountable
Communities
(ACs)

Providerled
organizationsthat
participateinshared
savingsarrangements

Integrated
Health
Partnerships
(IHPs)

Providerled
organizationsthat
participateinshared
savingsarrangements

Under
development

Providerledmodel
closelytiedtoexisting
healthhomeand
DeliverySystem
ReformIncentive
Payment(DSRIP)
programs

Coordinated
Care
Organizations
(CCOs)

Regionalentitiesledby
managedcare
organizations(MCOs)
thatoperateunder
globalbudgetsfor
servicesprovided
undertheprogram

Accountable
Care
Organizations
(ACOs)

Providerled
organizationsthat
participateinshared
savingsarrangements

Under
development

Developingprogram
basedonexisting
healthhomeand
patientcentered
medicalhome(PCMH)
models

Informationcontainedinthistablewasdrawnfromareviewofstatematerialsandinterviewswithstateofficials.

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ThisbrieffocusesontheapproachesofsevenstatesthatparticipatedintheCenterforHealth
CareStrategies(CHCS)MedicaidACOLearningCollaborative:Colorado,Maine,Minnesota,
NewYork,Oregon,Vermont,andWashington.WithsupportfromTheCommonwealthFund,
CHCSworkedwiththesestatestoaccelerateMedicaidACOimplementation.Ofthesestates,
MedicaidACOsareupandrunninginColorado,Maine,Minnesota,Oregon,andVermont,while
programsinNewYorkandWashingtonarestillindevelopment(seeExhibit1).

Building Blocks for Social Service Integration

WhilethesesevenstateshaveuniqueMedicaidACOmodels,4allofthemareleveragingexisting
programstrengthstosupportcollaborationamongmedicalandsocialserviceproviders.States
arebuildingcapacityforACOsocialserviceintegrationatopexistinginitiativesthatcan
contributenecessaryinfrastructureandrelationships,includingreferralstocommunitybased
providers,crossagencyfundingstreams,andmeaningfulengagementwithfamilies.Statesare
usingavarietyofexistingprogramstoreinforcethefoundationofACOs:

Health Homes
Severalstatesarelayingthegroundworkforsocialserviceintegrationthroughafocuson
complexpatientsviatheMedicaidhealthhomemodel.Healthhomesarerequiredtoprovide
referralstocommunityandsocialsupportsasoneoftheirprimaryfunctionsinservingpatients
withchronicphysicalorbehavioralhealthconditions.5Healthhomesalsohavevaluable
experienceintrainingcareteammembersonstandardized,comprehensivehealthassessments,
whichcanhelpMedicaidACOsidentifyhighriskpatientswhomayrequireadditionalsupportsin
thecommunity,suchasnutritionassistanceoremploymenttraining.Maine,NewYork,Vermont,
andWashingtonhaveleveragedhealthhomestrategieswhendesigningtheirMedicaidACO
programs.Forexample,MaineattributespatientstoACOsthroughtheirexistingaffiliationwitha
healthhome.NewYorkisusinglessonslearnedfromhousingandcriminaljusticeprojectswith
itshealthhomestoinformsocialservicealignmentofemergingACOsandotherstatedelivery
reforms.

Community Health Teams

Communityhealthteamsworkcloselywithcaremanagerstomakeconnectionswithexternal
socialservicesandsupportsforpatientsinhealthhomesandotherswithcomplexconditions.
Theseteamsoftenincludelayhealthworkerswhohavetheculturalfamiliarityandexpertiseto
meetpatientsdiversesocialandlinguisticneedsandliaisoneffectivelywiththelocal,non
medicalcommunity.MainesACprogramusesitscommunitycareteams(Mainestermfor
communityhealthteams)fromhealthhomestoprovidewraparoundsupportandcommunity
linkagestothehighestneedpatients.Perstaterequirements,ACsthatincludeahealthhome
mustextendaninvitationforparticipationtothathealthhomescommunitycareteam.

Behavioral Health Integration

Stateeffortsacrossthenationtobettercoordinatephysicalhealthcarewithmentalhealthand
substanceuseservicesarebuildingafoundationforincorporatingsocialservices.Statestrategies

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tosupportbehavioralhealthintegrationinACOs,inparticular,provideausefulblueprint.6These
include:(1)sharedsavingstoencouragecollaborationbetweenphysicalandbehavioralhealth
providers;(2)globalpaymentstosupportcasemanagementandrehabilitationservicesfor
individualswithseriousmentalillness;(3)requirementstoincludebehavioralhealthproviders
andconsumersingovernancestructures;and(4)datareportstohelpprovidersidentifyhighrisk
patients(e.g.,thosewithcomorbidphysicalandbehavioraldiagnoses)forenhancedcare
management.

Levers within State Medicaid ACO Programs

StatescanusethreemainleverstosupportcollaborationbetweenACOandsocialservice
providers:(1)programandgovernancerequirements;(2)financialincentives;and(3)data
sharinginfrastructure.

Program and Governance Requirements

ACOprogramrequirementsofferadirectwaytofostersocialserviceintegration.Stateshave
includedthefollowingtypesofrequirementsforapplyingand/orparticipatingACOstobetter
incorporatesocialservicesintoclinicalmodels:
Support care management and care coordination with local partnerships:AllMedicaid

ACOprogramsrequireACOstoformpartnershipswithexternalentities.Insomecases,the
entitiesaredefinedlooselytoincludepublichealthauthorities,communityorganizations,social
serviceagencies,and/orlocalgovernment.Inothercases,specificpartnershipsaremandated.
OregonsCCOsmusthaveMemorandumsofUnderstandingwithparticularcommunity
emergencyandmentalhealthprograms,includinglocalAreaAgenciesonAgingorstateAging
andPersonswithDisabilitiesoffices.Inaddition,OregonencouragesCCOstodevelopmeaningful
partnershipswithcrisismanagementservices,communitypreventionservices,self
managementprograms,andstatebaseddepartmentsandprograms.MainerequiresthatitsACs
developcontractualorinformalrelationshipswithatleastonepublichealthentityandatleast
oneprovideroftargetedcasemanagementservices,iftherearesuchentitiesorproviders
servingmembersintheACsservicearea.Duringtheapplicationprocess,MinnesotasIHPsmust
demonstratehowformalpartnershipswithcommunitybasedorganizations,publicagencies,and
socialserviceagenciesareincorporatedintothecaredeliverymodel.Coloradorequireseach
RCCOtolinkmembers,asneeded,tononmedical,communitybasedservices,suchaschildcare,
foodassistance,servicessupportingelders,housing,andutilitiesassistance.Thestatespecifies
thatlinksmayrangefromprovidingmemberswiththenecessarycontactinformation,to
arrangingtheserviceand/oractingasaliaisonamongthememberandinvolvedproviders.In
addition,RCCOsmusthaveaTransactionAccessProgramthatcoordinateswithcaremanagers
andsupportscommunityrecoveryby:

Providingaccesstoneededcommunityresourcesviaproviderwebportal,email,fax,or
phone;

Managingnonhospitaltransitionsthroughhomevisitsbyacaremanagerorhealthcare
providerwhocanaddressthemembersmedication,livingskills,andbehavioralneeds;

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ArrangingvisitsfromtheRCCOsmobilephysiciannetwork;and

Providingactivetransitionmanagementtopreventrelapseforconditionssuchas
alcoholwithdrawal,tobaccocessation,andweightmanagement.

Utilize non-traditional providers:Theuseofnontraditionalproviders,suchcommunityhealth

workersorpeerspecialists,mayenableanACOtomoredirectlyassistpatientsinaccessingsocial
supports(e.g.,accompanyingpatientstoemploymentcounselingappointmentsorhelpingto
completefederalnutritionassistanceapplications).Suchworkersoftenareculturallyattunedto
patientsandhavesimilarlivedexperienceand/orfamiliaritywithcommunityresources,which
cansupportattainmentofpatientshealthcaregoalsandbuildpatientstrustinthehealthcare
system.OregonencouragesitsCCOstointegratecommunityhealthworkersandpeerwellness
specialistsintocareteamsforbroaderoutreachandpreventiveeducationfunctions.Colorado
encouragesitsRCCOstousecommunitybasedhealtheducatorstofosterbehavioralchange
throughclinical,personal,and/orcommunitybasedstrategies.Useofnontraditionalproviders
byMinnesotasIHPsisfacilitatedthroughastateplanamendmentthatallowscommunityhealth
workerstobillMedicaiddirectlyforsomeoftheirservices.
Create community governance or board structures:NearlyallstatesrequireACOsto
developformalstructuresforregularcommunityinput.Theseentitiesareexpectedtorepresent
theindividualsservedbytheACOs,aswellastheinterestsofthelocalcommunity.ACOsmust
interfacewiththesegovernancestructuresregularlyforfeedbackonACOserviceofferingsand
performance.
Inventory local needs and make community resources available:OregonsCCOsare

requiredtoproduceacommunityhealthneedsassessment,whichmustidentifyanysocio
economic,geographic,orracial/ethnicdisparitiesinpatientcareandhealthstatus.CCOsare
encouragedtodevelopthesecollaborativelywiththelocalpublichealthauthorities,hospitals,
mentalhealthsystems,andAreaAgenciesonAgingtoavoidduplicationwithexisting
assessments.OregonsOfficeofHealthEquityandInclusionhelpsCCOsidentifydataand
requiredresourcesfortheseassessments.ColoradorequiresitsRCCOstocreatealibraryof
communityresourcesandawebsitethatconnectsprovidersandpatientswithresourcesforchild
care,nutritionassistance,eldercare,housing,utilityassistance,andothernonmedicalsupports.
RCCOSarealsorequiredtodevelopalistofcasemanagementagenciesandcommunitybased
serviceprovidersincludingeligibilitycriteriaandcontactstofacilitatepatientfollowupthatis
updatedeverysixmonths.
Pay attention to the diverse cultural and linguistic needs of patients:Understandingthe

roleofpatientscultureandlanguageintheirhealthcarecanhelpACOsidentifythemost
effectivesocialservicesandsupports.Moststateslooselypromoteafocusonracial/ethnic
equity,encouragingACOstobesensitivetomembersculturalandlinguisticneeds,whileother
statesaremoreprescriptive.ColoradosRCCOs,forexample,mustmakehealthdisparityand
culturalcompetencytrainingavailabletotheirprovidernetworksonatleastanannualbasis(or
within60daysoftheirstartdateoranylargeprogramexpansion).OregonsCCOsarerequiredto
developtransformationplansdescribinghowtheywill:(1)developinitiativesaddressing
memberscultural,healthliteracy,andlinguisticneeds;(2)enhanceproviderandadministrative

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staffingtobetterservediversecommunityneeds;and(3)establishqualityimprovementplansto
eliminateracial,ethnic,andlinguisticdisparities.

Financial Incentives
Financialincentivesofferapowerfulvehicleforfosteringsocialservicecoordination.By
institutingasharedsavingsorcapitatedpaymentforACOprograms,statescanmotivatecloser
collaborationbetweenthehealthcaredeliverysystemandnonmedicalagenciesandproviders.
Stateapproachesrangefromintegratedpaymentmodelsconnectingsocialservicesand
providers,toonetimegrantssupportingprovidercapacitybuilding.Exhibit2presentspayment
optionsforstatesconsideringhowtoconnectsocialserviceswithcaredeliverymodels.
EXHIBIT 2: Payment Approaches to Connect Social Services with ACO Programs
PAYMENTMETHODOLOGY
UpfrontGrants
EnhancedPerMemberPer
Month(PMPM)Payment

BENEFITS
Onetimeinvestment
Moreflexiblefundingthanservicebasedpayments
Providesadditionaldollarsforsocialservicestoaidcaremanagement
Riskadjustsforvulnerabilityofpopulation
Cantiesavings/lossestosocialservicequalitymetrics

SharedSavings

Encouragesuseofsocialservicesupportstobringdowntotalcostofcare
Savingscanbeutilizedtoreinvestinthesystem
AbilitytobraidorblendMedicaidandnonMedicaidfunds

GlobalPayments

Communitybudgetcanbecommonsourceoffundingformedicalandnonmedical
collaborators
Encouragesuseofsocialservicesupportstobringdowntotalcostofcare
Savingscanbeutilizedtoreinvestinthesystem

StateswithMedicaidACOprogramsareemployingsomeofthefollowingfinancingapproaches:
Grants:OregonsCCOshaveaccesstofinancingthroughthestatesHealthSystem
TransformationFund7toproposearangeofprojectstoaddresssocialdeterminantsofhealth.
ThestateisalsobuildingcapacitytoaddresshousingthroughStateInnovationModel(SIM)
funding.8Otherstatesarealsoleveragingresourcesfromexistingfederalinitiatives,suchas
healthhomesandSIM,tohelpACOswithstartupcosts.ManystatesareusingSIMresourcesfor
capacitybuildingtosupportsocialservicecoordination,including:(1)providertrainingoncare
managementandcommunityengagement;(2)uniformdatastandardsacrossstateagencies;(3)
datasupportforastatewidehealthinformationexchange;and(4)developmentofpopulation
healthmeasuresforperformancebasedcontracts.
Enhanced PMPM:Statescanuseanenhancedpermemberpermonth(PMPM)paymentto
covercarecoordinationcostsforproviderstolinktosocialservices.Thesefeesareusuallysmall
($410),butcoverawidevarietyofcarecoordinationresponsibilities.ColoradosRCCOsreceive
anenhancedPMPMforeachattributedmember.

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Shared savings:Maine,Minnesota,andVermontsMedicaidACOprogramsareoperatingunder

sharedsavingsarrangements.MinnesotasIHPsareallowedtoincludesocialservicesorany
otherservicesoutsidethecoresetfortheACOprogramwithinthetotalcostofcare(TCOC)
calculationforeligiblepatients.ProviderswhoseservicesareincludedintheTCOCcanalso
participateinthedistributionofsharedsavingsandlosspayments.Minnesotaawardsbonus
pointsforIHPsthatincludecommunityorganizations,localpublichealthentities,and/or
behavioralhealthandlongtermcareprovidersindistributionofsharedsavingsandloss
payments.Vermonthasadoptedanencourageincentrequireapproachforcalculatingthe
TCOCoverathreeyearperiod.Startinginthesecondyearoftheprogram,inadditionto
receivingsharedsavingslinkedtocorequalitymetrics,ACOsinVermontcanincreasetheir
sharedsavingsratefrom50to60percentbyassumingaccountabilityforadditionalservices,
suchasnonemergencytransportation.Whiletyingsharedsavingstospecificsocialservice
qualitymetrics(e.g.,housingstatus)wouldbeadirectwaytoencouragesocialservice
integration,MedicaidACOprogramshavenotincludedsuchmetricstodate(althoughmany
statesbelievethatACOprovidersshouldleveragenonmedicalservicesandsupportstoimprove
performanceratesforexistingmeasures).9
Global payments:OregonsCCOsareregionalentitiescomprisedofmultiplepayers,

providers,andcountypublichealthdepartmentsthatacceptasingleglobalbudgetandare
accountableforthecostandqualityofMedicaidbeneficiariesphysical,behavioral,anddental
healthcare.Throughtheglobalbudget,CCOscanincludeMedicaidcoveredservices,suchas
nonemergentmedicaltransportation,aswellasservicesthatarenottraditionallycovered,to
supportpatientsneeds.Thelatterservicescanincludehealtheducation(e.g.,healthymeal
preparationclasses);peersupportgroups(e.g.,postpartumdepressionprograms);homeand
livingenvironmentimprovements(e.g.,airconditioners,athleticshoes);housingsupports(e.g.,
shelter,utilities,criticalrepairs);andimprovementstocommunityhealth(e.g.,farmers
markets);amongothersocialresources.10AnincreasingpercentageofCCOsglobalbudgetsare
withheldeachyear(twopercentin2013;threepercentin2014),whichcanberecoupedby
meetingqualitytargets.ThisstrategyencouragesCCOproviderstocoordinatewithothersectors
tomeetcostandqualitytargets,eveniftheservicesprovidedbycollaboratorsmaynotbe
directlyincludedinthebudget.AtotalspendingcapfurthermotivatesCCOstoinvestlimited
resourcesinservicestospurimprovedhealthoutcomesandreducedcosts.

Data-Sharing Infrastructure
Datasharingisonethemostimportantaspectsofsocialserviceintegration.Sharedpatientdata
enablesmedicalandnonmedicalcollaboratorstofacilitateeffectivepatienthandoffs,
continuousfollowup,and/orlongtermmonitoringofoutcomes.Statesarelayingthe
groundworkfordataexchangestosupporttheenhancedcarecoordinationpromisedbyACOs,
butthisdatasharinggenerallydoesnotyetencompasssocialservices.Statestrategiestoexpand
datasharinginclude:
State data reports for ACO providers:ColoradosStateDataAnalyticsContractorhostsaweb
portalgivingprovidersaccesstoadatabasethatpresentspatientdemographicinformation,
utilization,anddiseaseburdenprevalencetoidentifycomplexpatientsbycomorbidityand
relatedcosts.Coloradoisalsoworkingtoidentifydataonsocialdeterminantsofhealthtolink

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Medicaidoutcomeswiththoseofotherstateagencyprogramsandlargerhealth/socialsystems.
MinnesotaprovidesitsIHPswithmonthlycaremanagementreportsonhighneedpatientsandis
lookingintoincludingsocialrisksinthesereports.
Cross-agency databases:Washingtondevelopedanintegratedsocialserviceclientdatabase

thathelpsfostercollaborationamongstateagencies(e.g.,Medicaid,criminaljustice,family
services).Itallowsthestatetoidentifypatientrisks,costs,andoutcomesatthestateor
communitylevel,aswellastheindividualorfamilylevel.Thedatabaseincludesapredictive
modelinganddecisionsupporttoolPredictiveRiskIntelligenceSysteM(PRISM)tohelp
providersandadministratorsimplementcaremanagementinterventionsforhighriskpatients.
Thestateisusingthesedatatoolstoidentifyhighutilizersofemergencyandinpatientservices,
thejailinvolved,and/orthehomeless,andlinkthemtoprogramsthatcanmeettheirbasic
housing,substanceuse,andrehabilitationneeds.AsWashingtondevelopsitsMedicaidACO
program,integratedclientdataandPRISMwillbekeyassetstothestateandACOproviders.

CHALLENGESFACINGSOCIALSERVICEDATA/HEALTHINFORMATIONINTEGRATION
Whilehealthinformationtechnology(HIT)offersmanybenefitstocollaboration,successfuleffortsinthesocialservice
realmwillrequireheightenedattentiontomakedatamorebroadlyaccessibleandmeaningful.
Socialserviceproviders,especiallysmallercommunitybasedorganizations,maynothaveaccesstoadvancedelectronic
infrastructure,includingthecapacityfordataexchange,interoperability,andsecurity/privacy,northestafffamiliarityto
integrateHITintoworkflow.Manyclinicalproviders,especiallycommunitybasedprovidersofmentalhealthand
substanceusedisorderservices,areexcludedfrommeaningfuluseandrelatedincentivepaymentprogramsthatwould
supportopportunitiestobuildHITcapacity.11
Inordertofacilitateseamlessdataexchangeacrosstheseproviders,additionalfieldsincludinghousingstatus,
incarceration,medicationlists,employment,andsocialnetworksshouldbeincludedinelectronichealthrecords.12
Thesekeymarkerscanbeusedtotriggerreferralstononmedicalservicesandsupportsandtohelppayersriskadjust
paymentstoproviders.TrendsinthesedatacanalsoindicatethedegreetowhichACOcaredeliveryimpactsnotonly
healthcare,butalsosocialwellbeing.Associalservicesbecomemoreintegrated,itwillbeimportantformembersofthe
careteambeyondclinicalcareproviderse.g.,communityhealthworkers,languageinterpreters,diabeteseducators
tohaveaccesstothisdata.

Considerations for Medicaid ACO Social Service Integration

WhilefullsocialserviceintegrationmayseemadistantprospectforstateMedicaidagenciesthat
areintheACOplanningstages,statesshouldthinkearlyandcreativelyaboutkeyissuestoguide
implementation.Decisionsaroundtiming,scope,staffcapacity,andtheprescriptivenessof
requirementscanimpactthelongtermeffectivenessofsocialservicecoordinationefforts.
Consider phased-in timing:Whilesomestatesmaywanttopromotesocialserviceintegration

earlyintheirMedicaidACOprograms,othersmayprefertoincreaseexpectationsofACOsover
time.MinnesotausedinitialACOexperiencestomakechangestosubsequentrequestsfor
participation(RFP),leadingtoitsmostrecentRFPthatrewardsIHPsforinclusionofsocial
servicesintheACOandtotalcostofcare.Vermontsencourageincentrequireapproach
increasesqualityandcostrequirementsincrementally,allowingACOstobuildcapacitytohandle
riskbasedpaymentsoverthreeyears,withoutpenalty.Maine,Minnesota,andVermontdonot

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requiredownsideriskduringthefirstyearoftheirsharedsavingsmodeltoproviderampuptime
forprovidersastheytransformintotheACOmodel.Insubsequentyears,allthreestatesoffer
optionsforACOstoacceptdownsiderisk.
Determine the ACO programs scope:Therearemanytypesofsocialservicese.g.,weight

counseling,smokingcessation,transportation,childcare,andhousingthatmayyieldpositive
healthoutcomes,butintegratingallofthematoncemaybechallenging.Statesmaychoose
specificservicestofocusoninitiallytotargettheresourcesnecessaryforbuildingcollaborative
agreements,referrals,andmonitoringmechanisms.Initialeffortscanserveaspilots,providing
lessonsthatcanbeappliedmorebroadly.
Align care management programs and reduce duplication:Thereareoftenmultiplecare

managementinitiativesinastatethatprovidesupportsbeyondmedicalcare.Theseprograms
and/orservicesmightinclude:(1)AreaAgenciesonAging;(2)AssertiveCommunityTreatment;
(3)communitybasedmentalhealthandsubstanceuseandtreatmentprograms;(4)homeand
communitybasedprograms;(5)longtermservicesandsupports;and/or(6)targetedcase
managementforchildrenwithdevelopmentaldisabilitiesorchronichealthconditions,andadults
withdevelopmentaldisabilitiesorHIV.Statesshouldinventory,andfosterconnectionswith,
theseinitiativestofacilitateACOalignment,mitigateturfissues,andhelpACOsadhereto
federalorstateregulationsthatminimizeduplication.MainerequiresACstoleverageexisting
caremanagementservicesbeforeofferingtheirown,recognizingthecontributionofhealth
homestosavingsrealizedunderanAC.Accordingly,statepaymentstohealthhomesand
communitycareteamsthatarepartofanACaredeductedfromsharedsavingspaymentsmade
toACs.Minnesotaalsohasoverlapinmembershipbetweenitsbehavioralhealthfocusedhealth
homesandtargetedcasemanagementefforts,andhasdevelopedpoliciestoensureservicesare
notbeingduplicated.
Build state agency capacity and seek external input:Medicaidagenciesareusingsubject

matterexpertstobuildinstitutionalknowledgeanddevelopstrategiesforsocialservice
integration.Seekingtheinputofkeystakeholderse.g.,providers,patients,community
organizations,andpublichealthagenciescanalsogarnercriticalstakeholderbuyinand
credibility,whichisimportantforsocialserviceprogramsthatmayrequirenewwaysofworking
acrosssiloswithinthestateoracrossthehealthsystem.VermonthasusedSIMfundingtoform
severalpublicprivateworkgroupschargedwithcreatingcommondefinitionsforcare
managementandpopulationhealth.VermontsGreenMountainCareBoardhasalsobeen
involvedindevelopingqualitymeasuresthatfocusonnonmedicalservicesandsupports.
Oregonestablishedacommissiontocreatereimbursementpolicies,andtrainingand
certificationstandards,forastatewideworkforceofcommunityhealthworkers,personal
navigators,andpeerwellnessspecialists.Washingtonisusingabroadstakeholderprocessto
developadashboardof4050performancemetrics,includingsocialservicerelatedmeasures.
Determine the appropriate level of prescriptiveness:Statescantakedifferentapproaches

towardfinancialincentivesandregulationindetermininghowtoincorporatesocialservicesinto
ACOs.Amoreprescriptivestrategymayrequirecontractswithsocialserviceandcommunity
basedorganizations.Somestatesmayoptformoreflexibility,makingACOsresponsiblefor
qualitymetricsthatcouldbeimprovedbyconnectingwithsocialserviceentities.Overall,

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choosingtherightlevelofstringencywilldependonprovidercapacity,existingintraagency
relationships,politicalfactors,stakeholderinput,andstategoalsfortheMedicaidACOprogram.
Includingtheinputofconsumers,communitybasedorganizations,publichealthentities,and
socialserviceprovidersindecisionmakingwillbekeytosuccessfulcollaboration.

Conclusion
Stateshavetakenimportantfirststepstowardfosteringcollaborationbetweenmedicalandnon
medicalentitiesthatimpactpatienthealth.Largely,theseeffortshaveincludedcrossagency
partnershipsandworkgroupsatthestatelevel,andACOprogramregulationsthatinstitute
connectionsatthegroundlevel.Movingforward,stateswilllikelypursuemoreintegrated
paymentandqualitystrategiestocreateamoretenablelinkbetweenthehealthcaredelivery
systemandsocialservicesandsupports.Bybroadeningthefocusbeyondmedicalcare,ACOscan
betteraddresscriticalsocialdeterminantsofhealthandultimatelybebetterpositionedto
improveoutcomesandcontrolcostsforMedicaidpopulations.

ABOUT THE CENTER FOR HEALTH CARE STRATEGIES

TheCenterforHealthCareStrategies(CHCS)isanonprofithealthpolicyresourcecenterdedicated
toadvancinghealthcareaccess,quality,andcosteffectivenessinpubliclyfinancedcare.Thisbrief
wasdevelopedthroughtheMedicaidAccountableCareOrganizationLearningCollaborative,aCHCS
initiativesupportedbyTheCommonwealthFund.Throughthecollaborative,CHCShasassisted
numerousstatesindevelopingandlaunchingMedicaidACOprograms.Formoreinformationand
resources,visitwww.chcs.org.

ENDNOTES
1SocialDeterminantsofHealth.Availableat:http://www.cdc.gov/socialdeterminants/FAQ.html
2J.DeCubellisandL.Evans.InvestingintheSocialSafetyNet:HealthCaresNextFrontier.HealthAffairsBlog.July7,2014.Availableat:

http://healthaffairs.org/blog/2014/07/07/investinginthesocialsafetynethealthcaresnextfrontier/
3D.BrownandT.McGinnis.ConsiderationsforIntegratingBehavioralHealthServiceswithinMedicaidAccountableCareOrganizations.

CenterforHealthCareStrategies,July2014.Availableat:http://www.chcs.org/resource/considerationsintegratingbehavioralhealth
serviceswithinmedicaidaccountablecareorganizations/
4TechnicalAssistanceTool:MedicaidAccountableCareOrganizations:ProgramCharacteristicsinLeadingEdgeStates.CenterforHealth
CareStrategies,February2014.Availableat:http://www.chcs.org/media/ACO_DesignMatrix053014.pdf
5CenterforMedicaidandCHIPServices(CMCS).StateMedicaidDirectorLetter#10024.HealthHomesforEnrolleeswithChronic
Conditions.November16,2010.Availableat:http://downloads.cms.gov/cmsgov/archiveddownloads/SMDL/downloads/SMD10024.pdf
6D.BrownandT.McGinnis,op.cit.
7Seecurrentprojectshere:http://transformationcenter.org/transformationfunds/
8CenterforMedicareandMedicaidInnovation.StateInnovationModelsInitiative:GeneralInformation.Availableat:
http://innovation.cms.gov/initiatives/stateinnovations/
9TechnicalAssistanceTool:QualityMeasurementApproachesofStateMedicaidAccountableCareOrganizationPrograms.Centerfor
HealthCareStrategies,September2014.Availableat:http://www.chcs.org/resource/qualitymeasurementapproachesmedicaid
accountablecareorganizations/
10SeeOregonAdministrativeRules,4101410000(53)forthefulllistofOtherNonMedicalServices.Availableat:
http://arcweb.sos.state.or.us/pages/rules/oars_400/oar_410/410_141.html
11CentersforMedicare&MedicaidServices.EHRIncentivePrograms.MeaningfulUseRegulations.Availableat:
http://www.healthit.gov/policyresearchersimplementers/meaningfuluseregulations
12InstitutesofMedicine.CapturingSocialandBehavioralDomainsinElectronicHealthRecords:Phase1.April2014.

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