NC Department of Health and Human Services Opportunities for Health: Addressing Social Determinants of Health in Primary Care Elizabeth Cuervo Tilson, MD, MPH State Health Director/Chief Medical Officer
All N orth Carolinians should have the opportunity for health Therefore, need to address “the other 80%” at scale 2
North Carolina 9 th largest state Multi-Payer Transition to “Purple” Alignment Medicaid Managed Rural/urban Move to Value Care Racially diverse • “Buying Health” (not just healthcare) unified agenda • “W hole Person” approach across DHHS portfolio • Integration of Health and Human Services • Keys to success: Data strategy and culture change
North Carolina is not as healthy as it could be th in o Nor North Car h Carolina ranks 3 lina ranks 37 th in overall stat erall state health outcomes e health outcomes • 47% of North Carolina women have experienced intimate partner violence • 20% of children have had 2 or more Adverse Childhood Experiences • 10.6% of adults are uninsured • 29% of low-income adults went without care due to cost • More than 1.2 million North Carolinians cannot find affordable housing
Percent of Children Who Do Not Have Consistent Access to Food 21% (1 in 5 N C children)
babies die at a rate 2.5 times white babies In N C, black higher than Infant Mortality Disparity 43 rd in the 7.1 country AVG:
Priority Domains Food Interpersonal Housing Transportation Security Violence Stability Toxic Stress/ Employment Early Brain Development
Healthcare Costs Associated w/ Food Insecurity Annualized Estimated Expenditures 7000 6071 6000 2015 US Dollars 5000 4208 4000 3000 Difference: $1800 2000 1000 0 Food Secure Food Insecure N HIS/MEPS data adjusted for: age, age squared, gender, race/ethnicity, education, income, rural residence, and insurance. Berkowitz, Basu, and Seligman. Health Services Research: 2017. 8
SNAP Participation Associated w/ Lower Heath Care Costs Estimated Connecting Seniors with SNAP: Savings Reduces the odds of nursing • associated w/ home admission by 23% SNAP: Reduces the odds of hospital • $1,400 per admission by 14% person per year Estimated healthcare savings of • $2,120 per senior SNAP enrollee per year $6,300 over 3-year • recertification period Berkowitz, Seligman, Rigdon, Meigs, and Basu. J AMA Internal Medicine 2017 . 9
Healthy Opportunities Landscape Healthy Opportunities Framework for all populations Robust elements within Medicaid Managed Care Healthy Opportunity Pilots 10
Infrastructure and Elements across all populations • GIS map of social determinants of health indicators at Hot Spot Map census tract level Screening • Statewide Standardized Screening Questions • Statewide coordinated network with shared NCCARE360 technology platform Workforce • Community Health Workers, Permanent Development Supportive Housing • Rapid Rehousing for Victims of Hurricane Back@Home Florence Aligning • Coordinating enrollment across programs e.g., Enrollment Medicaid, WIC, SNAP 11
Screening Questions Screening Questions • Developed by Technical Advisory Group • Drew from validated and commonly used tools (e.g PRAPARE, Accountable Health Community) • Routine identification of unmet health-related resource needs • Statewide collection of data • Implementation − Public Review − Fall 2018 Pilot testing in 18 clinical sites and telephonically (n=804) − Ready Providers/Systems adopting − Encouraging everyone to use for all populations − Launch of Managed Care • PHPs Required to Include in initial Care Needs Screening • Need to tackle data flow next 12
Results from Field Testing of Screening Questions N=804 High Acceptability 100 90 80 70 60 50 40 30 20 10 0 Felt Screening Length was good Felt Comfortable with Screening Questions Understood Questions English speaking patients Spanish speaking patients Clinic Staff 13
Results from Field Testing of Screening Questions Need Prevalence and Desire for Resource Connection 50 45 42% 40 35 30 25 20% 20% 20 14% 15 9% 10 5 0 Food Insecurity Housing Insecurity Utilities Transportation Interpersonal Violence Screened Positive Desire for Resource Connection 14
What is NCCARE360? NCCARE360 is the first statewide coordinated network that includes a robust repository of shared resources and a shared technology platform to connect healthcare and human services providers together to collectively provide the opportunity for health to North Carolinians. NCCARE360 Partners: 15 PROPRIETARY & CONFIDENTIAL 15
Three Functions Functionality Partner Timeline Directory of statewide resources verified by a Resource Directory Ongoing work professional data team adhering to AIRS standards 24/7/365 call center with a Call Center Support team of NCCARE360 Navigators, and the addition of text and chat capabilities. APIs integrate resource Phased Approach directories across the state to Resource Repository share resource data. Referral & Outcomes Referral platform with closed Rolled out by community loop functions. Platform January 2019 – December Community Engagement 2020 Managers for workflow, Community Engagement change management, Managers continued in person support. 16 PROPRIETARY & CONFIDENTIAL PROPRIETARY & CONFIDENTIAL 16
2-1-1 Resource Verification ( as of 7/25/19) Organizations verified 1695 Programs Verified 5441 Counties with at least 80% of resources verified 50 PROPRIETARY & CONFIDENTIAL 17
NCCARE360 Creating a Collaborative Network through Shared Technology Platform A coordinated network connects providers (such as health care providers, insurers, or community organizations) through a shared technology platform to: • Communicate in real‐time • Make electronic referrals • Securely share client information • Track outcomes together 18 PROPRIETARY & CONFIDENTIAL 18
State Coverage – to be statewide by Dec 2020 19 19
NCCARE360 Status Update (as of 7/26/19) Engaged Organizations by Service 12 Counties launched 23% 13 26% Healthcare Counties started on implementation Housing Organizations engaged in socialization process (77 1471 Employment counties) Food 7% 280 Organizations with NCCARE360 licenses Interpersonal Safety 12% 7% Transportation 1260 Active Users Other 8% 17% 496 Referrals Sent 265 Clients Impacted 20 PROPRIETARY & CONFIDENTIAL 20
Robust Elements within Medicaid Managed Care Care Management Integration with Quality Address 4 Priority Domains: Department Strategy Partners Housing Food Healthy Interpersonal Transportation Opportunity Violence Pilots Value-Based Payment Contributions to Health- In Lieu of Related Services Resources 4
Care Management Care Management Competencies in Trauma Informed Care, Resource N avigation Multi-disciplinary team – RN , SW s, Housing Specialist, Legal Specialists Standardized screening for food, housing, transportation, interpersonal violence needs N avigation to resources and closed loop referrals through N CCARE360 Providing additional support for high-need cases, such as homeless, actively experiencing interpersonal violence 22
Financial tools and Strategies Value-Based Payments PHPs expected to incorporate non-medical drivers of health into value-based payment strategy to align financial incentives and accountability around total cost of care and overall health outcomes By the end of contract Year 2, the portion PHP’s medical expenditures governed under VBP arrangements must either increase by twenty (20) percentage points or represent at least fifty percent (50%) of total medical expenditures. Contributions to Health-Related Resources PHPs are encouraged to voluntarily contribute to high-impact health-related resources PHPs that voluntarily contribute to health-related resources may count the contributions towards the numerator of their Medical Loss Ratio (MLR) as part of Quality Improvement Activities A PHP that voluntarily contributes at least one-tenth percent (0.1%) of its annual capitation revenue to health- related resources may be awarded a preference in auto-assignment 23
Healthy Opportunities Pilots Pilot Overview Sample Regional Pilot North Carolina • The Healthy Opportunities Pilots will test the impact of providing selected evidence-based interventions to high risk Prepaid Prepaid Prepaid Medicaid enrollees. Health Plan Health Plan Health Plan Care Care Care • Over the next five years, the pilots will Managers Managers Managers provide up to $650 million in Medicaid funding for capacity building and pilot services in two to four areas of the state that are related to housing, food, transportation and interpersonal safety Lead Pilot Entity and directly impact the health outcomes and healthcare costs of enrollees. • Pilots will allow for the establishment Human Service Organizations (HSOs) and evaluation of a systematic approach to integrating and financing evidence- HSO HSO HSO based, non-medical services into the delivery of healthcare. 24
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