Figure 1
Map of Integrated Care Reforms in the US Medicaid Program.
Table 1
Overview of Integrated Health and Social Care Reforms in the US Medicaid Program.
| REFORM | DESCRIPTION |
|---|---|
| Accountable Health Communities | Federally-funded model to systematically test social risk screening, referrals, and community navigation services to address social needs of Medicaid and Medicare beneficiaries. |
| Section 1115 Waivers Programs | Waiver that allows states to test new approaches in Medicaid that differ from federal requirements. In the last decade, states have applied to use waivers to implement new SDOH-related programs. |
| Managed Care Contracts | Contracts between state Medicaid agencies and private managed care organizations (MCOs) that deliver Medicaid services to beneficiaries. In the last decade, states have used contracts to require or incentivize MCOs to implement SDOH interventions. |
Table 2
Examples of SDOH-Related Activities Implemented Via 1115 Waivers.
| STATE | EXAMPLE SDOH-RELATED ACTIVITIES |
|---|---|
| New York | Conducting household assessments and interventions for environmental health hazards related to asthma, indoor air quality, structural issues, fire safety, etc. [30] |
| Michigan | In response to the 2016 Flint Water Crisis, which exposed thousands of Flint, Michigan residents to lead-contaminated water. Provided targeted case management to children and pregnant women, funded lead abatement activities typically not covered by Medicaid, and connected families to community-based resources focused on early education programs, financial assistance, housing, etc. [31] |
| Rhode Island | Created “Accountable Entities” (AE), consisting of service providers and community-based organizations across health and social sectors, who are responsible for care of a defined population. AE’s conduct social needs screenings and are engaged in value-based payment arrangements to incentivize addressing social determinants. [32] |
| Oregon | Allows state Medicaid funding to be used on “health-related services” that improve quality such as case management, housing supports, and transportation services, as well as “community benefit initiatives” that focus on population-level interventions [33] |
| Illinois | Consolidated nine previously approved 1115 waivers to drive comprehensive change in service delivery. Includes measures such as connecting individuals to social supports like housing and building a robust workforce (e.g., leveraging community health workers to address cross-sector needs) [34] |
Table 3
Examples of SDOH-Related Activities Supported Via Managed Care Contracts.
| STATE | EXAMPLE SDOH-RELATED ACTIVITIES |
|---|---|
| New Mexico | Contract requires MCO to hire full-time housing supportive specialist to help beneficiaries access housing resources [46] |
| Arizona | Contract requires MCOs to invest six percent of profits into the community (e.g., community-based social services) [46] |
| Washington D.C | Contract requires MCOs to create quality improvement plan to address social determinants of health through targeted interventions [43] |
| Virginia | Contract requires MCOs to screen beneficiaries for social, economic, and housing needs, with referral mechanisms for community resources [46] |
| Michigan | Contract ties “pay for performance” bonuses for planning and reporting interventions to address SDOH (e.g., housing) [47] |
| Iowa | Contracts requires MCO to coordinate with state agencies (e.g., Juvenile Justice Services, Department of Education), and community-based organizations [48] |
Table 4
Lessons Learned.
| INTEGRATED CARE DOMAIN | LESSONS LEARNED AND POLICY IMPERATIVES IN THE US |
|---|---|
| Governance & Culture | Integrating health and social care requires buy-in from front-line clinicians, insurers, and government actors. Future initiatives should explore how to better engage social service providers and local communities in integrated care reforms. |
| Financing | New flexibility granted from policymakers has enabled health care organizations to use healthcare dollars to fund social care interventions. Future efforts should explore bi-directional funding mechanisms that align priorities across health and social sectors, and pool funds to achieve shared outcomes. |
| Service Delivery | The health sector has tested and evaluated new interventions to screen patients for social risks and refer them to social services. Ongoing implementation efforts should consider how services can be tailored to local contexts and clinical settings in order to maximize patient and provider adoption. Additional research on comparative and cost effectiveness can help identify which social risks and patient populations should be prioritized in scale-up efforts. |
| Workforce | Healthcare organizations have successfully deployed a variety of individual workers and interprofessional teams to address patients’ social risks. However, the US may benefit from a national strategy to develop and fund a new workforce committed to integrating health and social care, as seen in Europe. |
| Information and Research | Increased uptake of electronic health records has enabled capture of SDOH data, and new technology platforms have allowed for referrals from healthcare to social services. Future initiatives should address the lack of cross-sector data sharing due to confidentiality laws and poor interoperability. |