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March 15, 2022
State Health Policy Leadership COVID-19
William K. Bleser
Katie M. Huber
Hannah L. Crook
Rebecca G. Whitaker
James J. Zheng
Michelle J. Lyn
Robert S. Saunders
Feb 3, 2022
Oct 21, 2021
Jun 28, 2021
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Copublished with the Duke-Margolis Center for Health Policy
The North Carolina Department of Health and Human Services launched its COVID-19 Support Services Program in August 2020 to address multiple pandemic-related social needs in counties with COVID-19 hot spots in four target regions of the state. Lessons from the COVID-19 Support Services Program can inform other states’ and payers’ efforts to address social needs, as well as North Carolina’s soon-to-launch $650 million Healthy Opportunities Pilots, which will pay for and provide social services through Medicaid managed care programs. To study the COVID-19 Support Services Program, we interviewed its administrators and frontline providers across the program’s service regions and partnered with one of the program’s largest grantee organizations to analyze survey data.
We offer key recommendations to health policymakers (e.g., state health officials, commercial payers) creating or administering health policy programs to address social needs in local populations; our findings are also relevant to frontline implementers of such programs. Key recommendations include:
Across the United States, especially in the wake of the COVID-19 pandemic, there is increased attention to social determinants of health (SDoH)1,2 — the structural, social, and economic factors that affect community health — which contribute to inequities in individual-level social needs and health outcomes.3 The focus on SDoH and unmet social needs is reflected in the recently released strategy for the Centers for Medicare & Medicaid Services (CMS) Innovation Center, including its focus on advancing health equity, delivering whole-person care, and partnering with diverse health care stakeholders.4
During the COVID-19 public health emergency, several states, counties, and cities across the United States created new programs to address social needs. The North Carolina Department of Health and Human Services (NC DHHS) launched its COVID-19 Support Services Program (SSP) to address multiple pandemic-related social needs by providing services, such as financial relief and home-delivered groceries, to help people safely quarantine or shelter in place due to COVID-19.5 Due to similarities in design and service provision, the SSP is informally seen as a smaller-scale preview of the state’s soon-to-launch $650 million Healthy Opportunities Pilots, and its lessons can guide implementation of the Pilots.6 Lessons can also help inform the design and implementation of other state and federal efforts to address health-related social needs, especially as states consider how to leverage recent American Rescue Plan Act (ARPA) funding to build infrastructure to address SDoH and social needs.7
This report draws on key informant interviews with 17 different expert stakeholders: 16 involved in the SSP — including state administrators, clinical leaders, local human service organizations, frontline health and social service providers, and community health workers — and one administrator from another state with Medicaid programs to address social needs. We also analyzed two survey datasets from one of the four SSP grantee organizations to understand clients’ access to services and experiences with the program, as well as community health workers’ job satisfaction and roles. Based on these lessons, we offer recommendations for other state and national health policy programs focused on beginning or expanding their efforts to address SDoH and social needs.
Leveraging a combination of funding from the Coronavirus Aid, Relief, and Economic Security (CARES) Act and the state (H.B. 1043),8,9 North Carolina’s SSP paid for a suite of support services, including direct financial relief, transportation, food, medications, and COVID-19 protection supplies to help people safely quarantine or shelter in place due to COVID-19. Overseen by NC DHHS’ Medicaid office, the SSP launched in August 2020, and provided more than 171,000 support services to nearly 42,000 households from September 2020 until April 2021. The SSP was implemented in four regions of the state and administered through four contracted organizations, also referred to as grantees or vendors. Three of the four grantees are non-profit health service provider organizations, and the fourth is a non-profit community development corporation. The grantees are responsible for coordinating community health workers (CHWs) and networks of local human service organizations (HSOs), which are responsible for frontline service delivery.8 These grantee organizations were required to submit plans demonstrating their capacity to: ensure delivery of all covered services; manage invoicing, reimbursement, and reporting; and understand the local community and its needs.9 During the SSP, grantee organizations were responsible for collecting invoices of services delivered by their HSO networks and sending them to the state each month. The state then provided funding to grantee organizations to retroactively reimburse HSOs for the delivered services based on payment rates set by the state.9
Independent of but complementary to the SSP, NC DHHS used funding from the CARES Act, Centers for Disease Control and Prevention (CDC), and Medicaid to create a CHW program to assist with COVID-19 needs in August 2020, and CHWs were deployed into the SSP.10 Both programs used NCCARE360, a data platform allowing for closed-loop bidirectional referrals between health and human service providers.11 After all available funding for the original SSP was spent by May 2021, NC DHHS narrowed the focus of the program in order to sustain it.5 The NC DHHS Office of Rural Health partnered with the Food Bank of Central & Eastern North Carolina to re-launch the SSP in October 2021 to provide food assistance to residents of 34 counties. Residents are eligible for food box deliveries if they need food access to quarantine, isolate, or shelter-in-place due to COVID-19.12
The SSP was unique relative to other states’ COVID-19 programs to address social needs and health equity. The SSP addressed many social needs in one program such as living expenses and food, while many other programs tended to focus on one specific social need.13–16 In addition, it was open to any North Carolina resident living in one of the four service areas and attesting to experiencing difficulty with social isolation or quarantine for COVID-19. SSP also intentionally focused on equity by prioritizing grantee organizations led and staffed by historically marginalized populations and targeting communities disproportionately affected by COVID-19. Results from the SSP show that over 70% of support services were delivered to historically marginalized populations.17 The SSP is a kind of forerunner to North Carolina’s Healthy Opportunities Pilots, which will provide up to $650 million of Medicaid funding to deliver and evaluate pilot services related to housing, food, transportation, and interpersonal violence and toxic stress for Medicaid enrollees in three regions of the state beginning this year.6 See the Appendix table for a high-level comparison of the two programs.
Both clients and CHWs reported positive experiences. We analyzed multiple survey datasets from an SSP grantee organization, including a survey of clients’ experiences and access to services and a survey of CHWs’ job satisfaction and roles. Notably, 86% of surveyed clients reported that it was very easy or easy to access services through SSP. Additionally, 92% of surveyed CHWs reported feeling like their work with SSP was valued by the community (see Figure 1).
This positive reception may suggest that cross-sectoral health-social service programs like the SSP can strengthen client-provider relationships. Prior studies support this idea; patients offered support addressing social needs in a clinical setting report higher satisfaction with health care, improved ratings of individual self-worth in other settings, and better access to care.18,19
HSOs needed more upfront capital and capacity-building support than anticipated. The SSP depended on HSOs to coordinate and deliver services, providing an opportunity to build capacity within the human services sector during a time when COVID-related increases in social needs were stretching HSOs’ bandwidth.21 However, interviewees emphasized that HSOs in SSP had to quickly adapt and build infrastructure capacity for data monitoring and reporting, billing, and referrals that were not a part of their usual operations.
“While we are pretty financially sound as an agency, we still did not have enough money… upfront… we found ourselves upfronting money and then having to wait to get reimbursement. That was one of the biggest challenges, because we were okay until our checking account got to the point where it might interfere with daily operations.”
One capacity challenge for HSOs in the SSP centered around available cash reserves. Because the SSP was developed to respond quickly to emergency needs, the model was initially based on retrospective reimbursement after service delivery. As a result, HSOs needed to use their existing capital and personnel to build infrastructure, start service provision, and handle surges in demand. Smaller HSOs, which were the majority of the HSOs in SSP, typically had fewer cash reserves to handle these tasks. Some HSOs managed their capacity by creating waitlists, triaging needs, or referring to other community resources. One SSP region, however, was in the financial position to provide its HSOs with upfront capital immediately, which helped them meet service needs from the outset. Later in the SSP’s provision, the state shifted to provide 50% of HSOs’ budgets as prospective payments in November 2020 and January 2021. Further context about the magnitude of upfront support needed for complex health policy programs to address social needs is evident in the Healthy Opportunities Pilots program, where $100 million of its $650 million budget (>15%) is allocated for upfront capacity-building funding for nine months before its service provision period begins.
The program needed to quickly adapt to feedback and clearly communicate about adjustments. Most evidence to date on services aimed at SDoH and social needs focuses on time-limited and targeted interventions for subpopulations.22,23 Because of this limited evidence, and because coordinating and delivering social support services is still new to many organizations providing health services, these programs must be prepared to adjust iteratively as they learn what does and does not work for their particular circumstances. North Carolina’s SSP was no exception. SSP interviewees frequently noted as challenging the rapid adjustments and resulting communications that were required throughout the program’s evolution.
“The leadership has to take the time to talk directly with people… making sure leadership, decision makers are accessible, regularly, to everybody… it’s not enough to just listen; the voice actually has to have an influence.”
Local CHWs supported improved care delivery. North Carolina was designing a statewide “CHW Initiative” program prior to COVID-19 and began small pilots in early 2020.8 When the COVID-19 pandemic struck, North Carolina utilized CARES Act, CDC, and Medicaid funding to create the CHW COVID-19 Program to rapidly scale the CHW Initiative across the state.8 CHWs were hired and managed by seven contracted organizations, including community-based organizations and health care organizations, across the state.8 The development of the CHW program and SSP happened in parallel, but, over time, the state had the two programs work in tandem.
CHWs in the SSP were charged with functioning as resource navigators who screened clients to identify social needs and make referrals to appropriate resources.8 CHWs fulfilled multiple roles in the SSP (see Figure 2), most notably supporting community engagement and outreach, which interviewees viewed as CHWs’ intended role. CHWs have a range of training and are also often asked to take on numerous roles in referral workflow and program administration, and interviewees expressed that some CHWs felt they were asked to perform more administrative duties than anticipated or desired, which limited their time in communities.
The SSP illustrated how to effectively deploy CHWs in cross-sectoral programs aimed at addressing SDoH.8 First, interviewees reported that more effective CHWs lived in the community being served and knew the local geography, populations, and community resources. Relatedly, completed referrals were more likely for those CHWs and HSOs that had worked together before. In contrast, interviewees were skeptical about using national or regional contractors.
“The CHWs should be viewed as professionals that can be part of a care management team… they should not live in a silo and should not just be focused on equity. [CHWs] need to be focused on relationship of access to the health system, where they’re the expert on the person and the system and that go-between.”
Second, CHWs improved identification and engagement of historically marginalized or isolated community members, according to the SSP interviewees. This finding tracks with others’ experience,26,27 and it shows how CHWs can help improve delivery of needed services.27,28 Interviewees recommended that CHWs not only provide screening but also be integrated into care delivery by providing services, such as patient education.
Finally, technology and human capital must be strategically deployed to maximize the CHW role. In the SSP, CHWs were asked to document referrals and services using the NCCARE360 platform. Interviewees observed that CHWs spent substantial time learning the NCCARE360 technology platform and documenting screening and referrals in the field, which left less time for face-to-face conversation with clients and service delivery. Several interviewees suggested that CHWs would be most valuable if paired with a “CHW helper” in the field to assist with administrative and technology-based tasks, and interviewees suggested the state facilitate credentialing of such a role. Additionally, standardized training programs, like the NC CHW Standardized Core Competency curriculum, are important to defining necessary skills and training for CHWs. More clarity can help ensure that CHWs serve in community-oriented roles.29
Community leaders fostered equitable community relationships. Several interviewees highlighted the importance of engaging key community members and organizations, described as “community quarterbacks,” who can facilitate equitable outreach. These informal partners were able to draw on their networks and community knowledge to identify ways to reach clients and mobilize resources that complemented the role played by CHWs.30
interviewees that might not be readily apparent to external collaborators included:
To partner with community quarterbacks, interviewees suggested states, payers, and provider organizations hold “meet and greet” events — disseminated by community quarterbacks — at gathering places like houses of worship, farmers markets, grocery stores, public housing complexes, and major community events. According to interviewees, these partnerships and public events were especially critical for engaging non-English speaking communities that faced barriers to accessing care. Community quarterbacks helped increase community members’ trust and willingness to accept services through the SSP. To encourage engagement of trusted community leaders, future programs, including the Pilots, should incentivize contracting with local HSOs run by and serving a higher share of historically marginalized populations.
Technology needs to easily facilitate two-way referral between health and human service providers. Through a public-private collaboration, North Carolina partnered with Unite Us to create NCCARE360, the nation’s first statewide system to facilitate two-way referrals between health and human service providers.33 NCCARE360 serves as both a centralized directory of community resources and an electronic platform to streamline service delivery—and will also be used for referrals and invoicing in the Pilots program.34 In June 2020, NCCARE360 launched statewide ahead of schedule to aid in COVID-19 response efforts and was used by the SSP to facilitate cross-sector referrals to services.
NCCARE360 is still evolving, and its accelerated, rapid rollout during the SSP, while necessary, caused challenges for some users who were simultaneously learning, using, and troubleshooting the software. Interviewees reported that support was initially available in near-realtime, but as demand increased, support response times grew to several days. Additionally, NCCARE360 was only available in English during the first phase of the SSP, which created barriers to access for some HSOs and CHWs. Interviewees were interested in more frequent and lay-accessible training on the platform in multiple languages.
Interviewees identified some desired functions of NCCARE360 that could streamline service delivery, including:
Interviewees felt conflicted about how sophisticated programs like NCCARE360 should function in the future. If NCCARE360 focused on the minimum data and functionality necessary for cross-sector referrals within the SSP, it would create a simpler structure but at the cost of broader utility. Alternatively, if NCCARE360 were to function as a complete data warehouse for health and social information, it would have broader referral capabilities but become subject to multiple sectors’ laws and regulations concerning the use and exchange of data. There is also a philosophical debate around whether technologies like NCCARE360 might impede building trusted relationships among HSOs and health care providers by replacing person-to-person referral processes with automated referral through the platform.
Cross-sectoral referral technology should:
Multiple types of technical assistance were required. Because of the rapid design and implementation of North Carolina’s SSP, the state did not establish a formal technical assistance program; instead, the state facilitated venues for communication and learning among grantee organizations as rapidly as they could. The SSP tasked each of the four grantee organizations to coordinate CHWs and a network of local HSOs to deliver a large array of social services. Grantee organizations had to navigate payment and provision nuances for different sectors and operate within social support service delivery guidelines and fees established by the state. Given this complexity, interviewees noted that having multiple technical assistance programs tailored to the array of social services in the SSP would be useful.
Future programs that address multiple SDoH domains will need to consider how to provide timely technical assistance with specialized expertise to troubleshoot issues unique to each service domain (e.g., food, transportation, housing) as well as cross-cutting challenges.
North Carolina’s COVID-19 Support Service Program is perhaps the most expansive health policy program to address social needs to emerge during the COVID-19 pandemic in terms of requirements to directly address many social needs domains. We identified lessons from this program, which not only informs North Carolina’s Healthy Opportunities Pilots program that is about to begin to address many social needs through Medicaid managed care, but also other states and payers with health policy programs targeting SDoH and unmet social needs (See Table 1). These lessons may be particularly useful to states as they consider how to how to invest their ARPA funding for building infrastructure to address SDoH and social needs.
We would like to thank the following individuals for completing interviews with us during our information gathering stage of this policy brief. They provided crucial insight and answered key questions we had, and we greatly appreciate their time and contributions to this work. The viewpoints expressed in this brief do not necessarily reflect the view¬points of the individuals below nor their organizations.
David Allgood, Pastor, True Worship Ministries
Sherri Allgood, Pastor, True Worship Ministries
Lisa Bennett, Executive Director North Carolina, Kepro
Maria L. Brisbon, MBA, Vice President and COO, Wisdom Care Transportation
Vaughn Crawford, MSW, Associate Director, Customer Success, Unite Us
Chris DeMars, MPH, Interim Director, Delivery Systems Innovation Office & Director, Transformation Center, Oregon Health Authority
Andrew Herrera, MPH, MBA, Executive Director, Curamericas Global
Fred Johnson, MBA, Assistant Professor of the Practice in Family and Community Health, Duke University School of Medicine; Director, Medicaid Accounts, Population Health Management Office, DukeHealth
Liliana Marin, Program Manager, Division of Community Health, Department of Family Medicine & Community Health, Duke University School of Medicine
Shemecka McNeil, Executive Director and Founder, SLICE 325
Kathy Moore Norcott, MS, MPA, Executive Director, Piedmont Health Services and Sickle Cell Agency
Maria Ramirez Perez, Program Manager, NC Medicaid Strategy Office, North Carolina Department of Health and Human Services
Maggie Sauer, MHA, MS, Director, Office of Rural Health, North Carolina Department of Health and Human Services
Jimmy T. Tate, EdD, President, Mt. Calvary Center for Leadership Development
Amanda Van Vleet, MPH, Associate Director, Innovation, NC Medicaid Strategy Office, North Carolina Department of Health & Human Services
Lisa Wigfall, MSW, CEO, Quality Comprehensive Care Center
We would like to thank the members of our broader research team at the Duke-Margolis Center for Health Policy for strategic guidance and input, including Mark McClellan.
Dr. Bleser has previously received consulting fees from Merck for research for vaccine litigation unrelated to this work, from BioMedicalInsights, Inc. for subject matter expertise on value-based cardiovascular research unrelated to this work, from Gerson Lehrman Group, Inc. on health policy subject matter expertise unrelated to this work, and from StollenWerks LLC on health policy delivery system change unrelated to this work. He also serves as Board Vice President (uncompensated) for Shepherd’s Clinic, a clinic providing free healthcare to the uninsured in Baltimore, MD. Dr. Saunders has a consulting agreement with Yale-New Haven Health System for development of measures and development of quality measurement strategies for CMMI Alternative Payment Models under CMS Contract Number 75FCMC18D0042/Task Order Number 75FCMC19F0003, “Quality Measure Development and Analytic Support,” Option Year 2.
Support for this brief was provided by the Robert Wood Johnson Foundation. The views expressed in this brief do not necessarily reflect the views of the foundation.
For more information about this brief, please contact: William Bleser at firstname.lastname@example.org
The Robert J. Margolis, MD, Center for Health Policy at Duke University is both an academic research center and a policy laboratory. Its mission is to improve health, health equity, and the value of health care through practical, innovative, and evidence-based policy solutions. To learn more, please visit healthpolicy.duke.edu.
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