Research shows up to 80% of a person’s health is dependent on social, environmental, and behavioral factors. However, 90% of healthcare spending in the United States is devoted to medical care.
The North Carolina Department of Health and Human Services (NC DHHS) is looking beyond what is typically thought of as “healthcare” to help North Carolinians access "healthy opportunities" for specific “social determinants of health” (SDOH). To improve health outcomes, NC DHHS has partnered with others to
- create an interactive GIS map of SDOH indicators;
- develop screening questions to identify patients’ unmet health-related needs;
- roll out an electronic platform to support a statewide coordinated care network;
- design a pilot program to test and evaluate the impact of non-medical interventions on the health of high-needs Medicaid enrollees.
- Prepaid Health Plans (PHPs) must use multiple methods to identify beneficiaries with high, unmet resource needs. PHPs are accountable for addressing identified needs.
- Care managers will conduct a comprehensive assessment with identified beneficiaries to address physical, behavioral and social areas of need.
- Providers will play a critical role helping PHPs address beneficiaries’ unmet resource needs.
NC Medicaid Healthy Opportunities Pilots
In addition to these statewide efforts, NC DHHS will launch NC Medicaid Healthy Opportunities Pilots in two to four geographic areas of the state to test evidence-based interventions for a subset of Medicaid enrollees. NC DHHS will rigorously evaluate how well pilot services improve health outcomes and reduce healthcare costs. Based on the results, the state will consider integrating effective pilot services into Medicaid managed care throughout the state.
The federal government has authorized up to $650 million in state and federal Medicaid funding for the 5-year duration of the 1115 waiver. Pilot funds will be used to pay for:
- Federally approved pilot services related to food, housing, transportation, interpersonal violence and toxic stress;
- Capacity-building for Lead Pilot Entities (LPEs) to develop and manage Human Services Organizations (HSOs) who will deliver pilot services
To qualify for pilot services, Medicaid Managed Care beneficiaries must have:
- At least one Physical/Behavioral Risk Factor which will vary by population; AND
- At least one Social Risk Factor related to housing, food, transportation, interpersonal violence, or toxic stress.
NC DHHS is currently developing a Request for Proposals (RFP) to procure two to four LPEs for the Healthy Opportunities Pilots. The Department anticipates releasing the LPE RFP in fall 2019 and selecting LPEs in early 2020 through a competitive bidding process. In preparation for the RFP, NC DHHS released on July 15, 2019, two technical documents for stakeholder feedback related to the Pilots.
- Healthy Opportunities Pilots Service Definitions and Pricing Methodology Interested stakeholders (especially frontline human services providers) were asked to provide feedback by August 2, 2019, on detailed pilot service definitions, provider descriptions, payment approaches, and pricing inputs.
- Healthy Opportunities Lead Pilot Entity (LPE) Statement of Interest and Supplementary Guidance: Organizations interested in serving as an LPE were asked to submit a voluntary, non-binding Statement of Interest (SOI) by August 12, 2019. This document provides information about roles, responsibilities, governance, and organizations eligible to be and LPE.
- Responses to the SOI were posted to the Healthy Opportunities Pilots website in August 2019 to encourage collaboration.
Pilot Roles and Responsibilities
Below are the primary Pilot roles and responsibilities as identified by NC DHHS.
Prepaid Health Plans (PHPs):
- manage a Pilot budget;
- approve which enrollees qualify for Pilot services and which services they qualify to receive;
- ensure Pilot enrollees receive integrated care management.
Care Managers are frontline service providers predominantly located at Tier 3 Advanced Medical Homes (AMHs) and Local Health Departments (LHDs) who:
- interact with beneficiaries;
- assess beneficiary eligibility for the Pilot;
- identify and manage coordination of Pilot services along with physical and behavioral health needs;
- track enrollee progress.
Lead Pilot Entities (LPEs):
- develop, manage, oversee, and pay a network of HSOs;
- provide support and technical assistance for an HSO network;
- convene Pilot entities to share best practices;
- assist care management teams in connecting beneficiaries to the right HSOs or resources;
- collect and submit data.
Human Services Organizations (HSOs) are social service providers who:
- contract with the LPE to deliver authorized, cost-effective, evidence-based Pilot services to Pilot enrollees;
- participate in the healthcare delivery system, including submitting invoices and receiving reimbursement for services delivered
NCCARE360 Resource Platform
NCCARE360 is North Carolina’s first statewide coordinated care network and is intended to serve as the state's core resource platform as it moves to whole person health and health system transformation. The goal is for NCCARE360 to become the singular, trusted repository of community resource information through which all providers in the state can securely send and receive referrals, share client data, and track outcomes. NCCARE360 launched in Alamance, Guilford, and Rockingham counties and will be rolled out to all counties by December 2020.
All Medicaid PHPs must work to address non-medical drivers of health outcomes. They must use standardized screening questions to assess enrollees’ non-medical social needs related to housing, food, transportation, interpersonal violence, and toxic stress. PHPs are expected to use the NCCARE360 tool statewide to connect patients to community resources when unmet, non-medical social needs are identified. The tool will also be used to track and monitor referrals.
Providers are not required to use NCCARE360 but are encouraged to do so. Those who use NCCARE360 can refer patients to any resource in the Resource Directory. However, providers can only send a referral through the system and receive outcomes data on referrals to other organizations who use NCCARE360.
Healthy Opportunities Pilots
For Medicaid beneficiaries who are enrolled in a Healthy Opportunities Pilot, care managers will use NCCARE360 to identify HSOs who can provide pilot services and then make electronic referrals. After making referrals, care managers can track beneficiaries’ access to pilot services and their progress in meeting care plan goals. LPEs will work with care managers and HSOs in their network to ensure pilot beneficiaries’ needs are met. HSOs will work with care managers, the LPE, and beneficiaries to ensure care plans are updated and reassessed for needs related to pilot services.
While the state expects the platform to be used by stakeholders in the Healthy Opportunities Pilots, NCCARE360 is not a pilot project. It can be used to impact the health outcomes of all North Carolinians—not just those who are part of Medicaid or Healthy Opportunities Pilots.
NC Medicaid Healthy Opportunities Timeline
Healthy Opportunities Pilot policy paper published
Due date to submit RFI responses to inform Pilot design
RFP released to procure LPEs and define Pilot regions
LPEs/Pilot regions awarded
Begin capacity-building of LPEs and HSO networks
Pilot service delivery begins
Pilot ends as 1115 Waiver ends