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August 1, 2022
Primary Care Transformation Medicaid Social Determinants of Health
Nicolette E. Wise
Sep 13, 2023
Jun 20, 2023
Jun 6, 2023
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Engaging health care providers, community-based organizations, and other state agency partners to address Medicaid members’ nonmedical risk factors is essential to delivering on TennCare’s mission of providing high-quality and cost-effective care. TennCare’s Health Starts Initiative encompasses the agency’s efforts across programs that aim to improve health outcomes by addressing members’ nonmedical risk factors. In fact, the Health Starts moniker reminds TennCare’s staff that all members’ health starts in environments where they spend most of their time outside the health care setting. These factors, such as housing, education, and transportation, are also known as social determinants of health (SDOH). Within the Health Starts Initiative are three programs: Provider Partnerships, Workforce Development Exploration, and Closed-Loop Referral System.
TennCare launched the Health Starts Provider Partnerships on April 1, 2021, in conjunction with its three managed care organizations (MCOs). The managed care contract requires MCOs to address nonmedical risk factors and participate in the Health Starts Provider Partnerships. The Partnerships aim to improve the quality of care provided to TennCare members by systematically addressing nonmedical risk factors at the provider level and identifying practical solutions and best practices that can scale sustainably. Each MCO selected four to eight health care provider organizations to participate in the program and codesigned workflows with each organization. The Partnerships are designed on one-year cycles and work to integrate support for social risk factors that includes:
So far, 15 provider groups across the state, representing patient-centered medical homes, behavioral health providers, and long-term services and supports, have partnered with the MCOs to integrate these efforts into their daily practice. Each provider group, with the direct support of their MCO partner, designed practice-specific approaches to achieve each workflow components. While these efforts are ongoing, TennCare has captured early reflections and lessons learned about these core components.
Providers and MCOs quickly learned that screening for social needs in primary and community mental health care settings is a challenge given the sensitive nature of questions about individuals’ nonmedical risks. Providers have delivered the screenings in different ways. Screenings can be self-administered or conducted by nonclinical or clinical staff. They are offered in multiple locations (e.g., provider’s waiting room, exam room, patient’s home), and providers are exploring the effectiveness of recording screening responses on paper versus using electronic devices.
One provider shared that they typically conduct assessments in one of their examination rooms, but they often hear from members that they prefer to do the assessment in the privacy of their homes. Several members have asked for the screening to be conducted virtually during a time most convenient to them. The provider noticed that people have different levels of comfort with sharing personal experiences and circumstances in public settings, even in a private examination room. Further, the questions members are most uncomfortable with often pertain to the areas in which they need assistance. The provider stated: “The hard questions are the questions that people actually need help on. If there’s a question [and] they say, ‘Oh, I’m not comfortable with that,’ it is likely they need help in that area.” Adjusting the workflow to allow screenings to be completed at home improved member engagement and decreased members’ hesitancy to complete the screening.
Each approach has shown some success in different situations, but implementing screening remains complex. Many practices report member discomfort and hesitancy with questions in the assessment because they fear what might be done with their personal data. Additionally, some questions in the screening assessment are not applicable for pediatric members, which necessitates tailoring questions to meet the population’s needs.
One early key lesson learned is that initial and periodic, ongoing training for the staff who administer the screening is paramount to ensure member comfort and trust during the screening process. The providers with the highest screening and referral rates are equipped with training on empathic inquiry, motivational interviewing, and proper administration and documentation of the results. The tactics gleaned from these trainings contribute to greater member willingness to discuss their needs in- depth and disclose other circumstances that impact their health.
Elena came in with her brother and parent for a routine wellness exam. Miranda, the care coordinator, completed the PRAPARE assessment and provided information on how any needs for her and the family can best be addressed. Elena immediately informed the care coordinator that her family was having a hard time with food and often had to eat fast food when they did not have food at their home. Elena and her brother, who are minors, also mentioned having trouble with stable transportation because their parents were often at work.
Elena mentioned experiencing domestic abuse as well, and her stress and emotional health had declined as a result. Elena and her brother are students, and both reported feeling stressed overall in their daily lives.
From the information gathered in the survey, Elena and her brother were referred to the provider’s food pantry. For Elena’s specific needs, she was referred to rural transportation services, a domestic violence shelter, emergency assistance, and a neighborhood center.
Follow-up revealed that Elena’s use of her resources allowed her to connect with support groups for domestic violence and to seek help. She also received assistance with getting transportation to her medical appointments and was able to join a group that meets to discuss stress management techniques. She and her brother were able to visit the food pantry and take groceries home to feed their family. Her mom said that without the resources, they would still be struggling with food, and she would need another job to support their family and provide financial flexibility.
While not all members have identified needs, for those who do, connecting them with resources to address their needs is essential.
In-house services, such as food pantries or diaper banks, and formal resource directories alleviate some of the challenges related to making referrals. However, the lack of resources available in certain areas of the state, especially rural areas, limits providers’ ability to create referrals for identified needs. Providers in rural areas have expressed reluctance to inquire about needs they are unable to meet with available area resources. To address hesitancy and increase the likelihood of referrals, the MCOs provide support by searching for additional resources not listed in the directories and consistently updating the directories.
One family indicated a need related to utilities. When the provider’s care coordination team reached out, the member shared that they were behind on their utilities. The care coordinator reached out to the utility company and arranged a plan to work with the family until they could get up to date on their payments. Through the follow-up call, the care coordination team also learned the family had food and clothing needs. The care coordinator reached out to a local community-based organization to meet these needs. Their strong relationship with this local community-based organization allows families to get help quickly after a need is identified. Without the efforts of the care coordinator, the member would not have gotten their needs met as quickly.
Practices that had in-house services or access to resource directories prior to the Partnerships did not include data tracking in their workflows because they were not previously asked to track and report referrals to other entities like the MCOs. While many providers have been referring members to community resources for years, the additional step of documenting these referrals adds complexity to the providers’ workflow. To lessen the burden of documenting referrals, MCOs, and providers engaged in codesign sessions before the Partnerships began, and the MCOs continue to work with the providers. During these sessions, MCOs provide the guidelines of the Partnerships and aim to understand the providers’ current practices and how the requirements can be nested into their existing workflow.
The ability to meet practices where they are and leverage their existing workflows while meeting members’ social needs has been one of the most significant best practices gleaned from the program. By doing so, the MCOs help providers view addressing social needs as feasible, increasing the likelihood of sustainability beyond the Partnerships.
Closing the loop on referrals has been the most challenging part of the process for providers. For the purposes of the Partnerships, loop closure is defined as when an individual is referred for services and the result is one of the following outcomes: (1) the individual accessed services/resources, (2) the individual stated they no longer need services/resources, or (3) the individual has connected with the community-based organizations or government agencies and is on a waiting list to receive services/resources.
Providers often cite difficulty in reaching members after appointments, leaving them unable to follow up on the referral. To mitigate this barrier, the MCOs have emphasized the importance of closing the loop during the appointment if needs are met, especially for practices with in-house services. For those who do not have in-house services, dedicating one staff member or care coordinator to contact members has proven to be an effective strategy. The MCOs are exploring ways to use external resources to give extra support to providers. This support includes connecting practices with technology vendors that have embedded care coordination efforts to reach out to members to confirm that services were accessed and inquire about additional needs.
TennCare’s ability to track each component for reporting purposes is important. Providers submit a Current Procedural Terminology (CPT) code to their MCO to indicate a screening was completed, submit ICD-10-CM codes or Z codes based on the needs identified, and document the loop closure in the appropriate system. Z codes and other information related to members’ demographics are aggregated and stratified by the provider when reported to TennCare. The demographics reported include age, race, ethnicity, and gender. Race, ethnicity, and gender are optional categories and disclosed by the member.
The standardized reporting of members screened, social domains identified, referrals created, and loops closed contributes to consistency across MCOs and providers, allowing for easier data analysis. However, this approach has limitations. The list of applicable Z codes is expanding because of the increased research and awareness surrounding SDOH, requiring MCOs to adapt their reporting to meet these changes. Additionally, some providers are burdened with staffing and technological challenges. Staff turnover and a lack of staff impact how quickly and accurately data are reported and tracked. Some providers are using new and often unfamiliar technology systems for the Partnerships or building out their electronic health record systems to support the initiative. In some cases, adjusting to these enhancements has caused interruptions in the flow of data from the provider to the MCO, demonstrating the need for additional training to appropriately use the enhancements in a way that supports Health Starts efforts.
When new information becomes available and requirements must shift, TennCare strives to communicate this information promptly and remain understanding of challenges at the provider level and ultimately impact the health plan-level data.
The most salient lesson gleaned from the Partnerships is the importance of flexibility and adaptability. While SDOH have a consistent influence, the field and resources available are ever-changing. As a result, at TennCare, we have prioritized flexibility in the program requirements as more information, and best practices arise. One way TennCare is operationalizing this practice is by expanding screening tool options during the next phases of the Partnerships. Additionally, TennCare will broaden the guidance to allow the inclusion of external vendors on a wider scale to help support providers’ workflows. These changes represent TennCare’s commitment to coordinating an effort that reflects our available resources and knowledge. By doing so, we can uphold our goal of providing high-quality, cost-effective care to all individuals we serve.
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