Amanda Van Vleet, Associate Director of Innovation, North Carolina Medicaid | Jay Ludlam, Deputy Secretary for Medicaid, North Carolina Department of Health and Human Services
Over the past year, the North Carolina Department of Health and Human Services (NCDHHS) has tested the health impacts of providing services to address certain social drivers of health—the conditions in which people live, work, learn and play—to qualifying Medicaid enrollees through its Healthy Opportunities Pilots (the Pilots). Authorized by the Centers for Medicare & Medicaid Services as part of the NCDHHS 1115 Demonstration Waiver, the Pilots were the first in the United States to allow a Medicaid program to fund a wide range of health-related services—addressing nutrition, housing, transportation and interpersonal violence (IPV)/toxic stress—to a broad range of eligible populations including children, pregnant women and adults enrolled in managed care. Central to the Pilots is a commitment to evaluate, reflect and improve throughout their implementation, including through deployment of rapid-cycle evaluations. The purpose of this brief is to provide an update on Pilot rollout and share early lessons.
Reflecting on the First Year of Pilot Service Delivery
Since their soft launch in March 2022, the Pilots have provided more than 50,000 services to over 5,000 members in three rural, under-resourced regions of North Carolina. The Pilots are structured to address population health broadly—offering 29 services to a diverse set of individuals enrolled in Medicaid, including children—and invest in a foundational infrastructure that, over time, will enable cross-sector collaboration and provide a pathway to sustainability beyond the Pilot demonstration period.
The Pilot results have been as individual as the participants’ needs.1 For example, one family received healthy food boxes to support their health and well-being. An elderly woman could stay in her home, thanks to getting help with utility bills. Larger-scale evaluation of Pilot impacts is still underway. However, reflections from Pilot leadership, partners and enrollees, and a review of preliminary Pilot data, point to several early findings.
Clear Definition of Roles and Responsibilities Helped Accelerate Pilot Launch: The Pilots rely on a diverse set of stakeholders across the health and human services continuum working together for the first time, each with a clear delineation of their roles and responsibilities. Key Pilot entities include:
- Health Plans: Determine eligibility, authorize services and pay community-based organizations (CBOs) for services delivered from separate funding available exclusively for Pilot services.
- Network Leads: Develop and manage a high-quality network of CBOs and provide technical and financial assistance to build CBO capacity.
- Care Managers: Working in and with primary care providers in the community, care managers serve as the Pilot “quarterbacks” for individuals by screening for nonmedical needs, identifying high-value interventions, connecting individuals and families to services, and coordinating Pilot-related care.
- CBOs: Deliver Pilot services to qualifying individuals, which identify potentially eligible individuals, and support community outreach and education. Fanning out across the three Pilot regions, approximately 115 are participating in the Pilots today.
Having clear and consistent program rules, roles and responsibilities—including standardized contracts between participating parties; standardized services, eligibility criteria and fees; and standardized approaches to data exchange, oversight and monitoring, and billing and payment—dramatically accelerated the program launch and has proven crucial to align stakeholders and program partners around shared goals and expectations.
“Bridge” Organizations Crucial to CBO Network Development: Network Leads serve as a single point of accountability between health plans and CBOs, bridging the gap between health care and social services. Network Leads are responsible for building and overseeing a robust network of CBOs that are trusted in their communities and are prepared to provide the full range of Pilot services to all health plan members in the Pilot region. This alleviates both the need for each CBO to negotiate and contract with multiple health plans and the need for each health plan to contract with multiple CBOs.
Network Leads also provide centralized administrative and technical support to CBOs, including training, quality oversight, and troubleshooting and dispute resolution with the health plans. Finally, the Network Leads distribute and oversee capacity-building funding, both to help build out pilot services where supply is lacking and to help CBOs gain the infrastructure necessary to successfully partner with health care organizations—including data sharing and billing capabilities. Ultimately, Network Leads could be well positioned to support CBO networks in negotiating contracts with payer and provider organizations, and other potential funding partners, to help improve the health of populations beyond the Pilots.
Phasing Pilot Launch Enabled a More Responsive System: The Pilots were strategically launched with a limited scope and scale, focusing first on food and nutrition services before expanding to housing and transportation and, most recently, services targeted to address IPV/toxic stress. The cadre of trained care managers also gradually increased. The phased approach allowed NCDHHS to work with its partners to quickly learn from and address unanticipated program challenges and opportunities before the program was brought to scale.
Here again, the Network Lead proved crucial, aggregating feedback from its network CBOs to provide live feedback from the field. Regular convenings, robust monitoring and evaluation systems, and the collection and analysis of real-time data, providing transparent, public updates and convening Pilot stakeholder engagement sessions, allow NCDHHS to make real-time modifications to ensure the Pilots are operating with maximum effectiveness and efficiency.
A Common, Flexible Data Sharing Platform Has Been Key: North Carolina’s statewide technology solution (called NCCARE360) allows Pilot entities to exchange data in real time. Pilot participants use the platform to make instant referrals for Pilot services, track Pilot service utilization, monitor enrollee progress over time and invoice for Pilot services. Having a single platform also brings challenges—different users may want different capabilities and interfaces, and changes to the system can take time to implement. However, the common platform has contributed to consistency in practices and helped to accelerate operational readiness across Pilot partners.
Incorporating IPV Services in the Pilot Ecosystem Requires Special Consideration: Disclosing that a survivor of IPV is seeking IPV-related services can place the survivor at risk of experiencing stigma or increased abuse. Even the release of non-IPV-specific information—such as an address or the number of people in the household—can pose a serious safety risk to survivors. For this reason, it is essential that Pilot entities, including care managers and CBOs that work with IPV survivors, take extraordinary care when handling the information of individuals who are or might be facing IPV.
Federal law imposes special requirements on organizations receiving federal funding under the Violence Against Women Act (VAWA), the Victims of Crime Act (VOCA) and the Family Violence Prevention and Services Act (FVPSA) prohibiting the disclosure or sharing of any personally identifiable information, including whether or not the organization has had any contact with the individual in the absence of informed, written, time-limited consent. To address these critical issues, NCDHHS worked closely with IPV providers to develop new requirements and modify existing Pilot workflows before launching IPV services under the Pilots. For example, these additional steps included requiring specialized training on IPV issues for all Pilot entities (not just frontline care managers) prior to launch of IPV services, as well as establishing clear, enforceable requirements that Pilot entities contact clients only at times of the day and using methods that they have deemed acceptable and safe.
Expanding Services Requires Investment: The Pilots are authorized to deliver 29 nonmedical services across four domains: housing, food, transportation and IPV/toxic stress. These services were chosen based on evidence of need within North Carolina communities and evidence of their potential to improve health. Yet community capacity to deliver these services across the state varies.
In the existing Pilot regions, which are highly rural, the most utilized services are those with existing community capacity to deliver them (e.g., healthy food boxes, fruit and vegetable prescriptions). While capacity-building funding is available to expand access to services, this can take time. Focusing on scaling up and spreading the services with existing capacity to serve a large number of people, while investing in the community capacity to deliver other services that do not yet have a strong foothold in the Pilot regions, has been crucial to increasing enrollment and readying communities to engage members in whole person care.
Reaching People Is a Team Effort: Since the Pilots’ inception, NCDHHS has been committed to a “no wrong door” policy. Early implementation focused more heavily on referrals by health plans and provider-based care managers and less on referrals from CBOs and their Network Leads. This was quickly realized as a missed opportunity. CBOs can help reach individuals who otherwise may not engage with their providers or plans. In recent months, NCDHHS has collaborated with Network Leads and CBOs to conduct outreach to individuals whom they serve to provide education and information about Pilots and get members connected to the enrollment process.
The Road Ahead
North Carolina’s Healthy Opportunities Pilots will continue to scale over the upcoming months with the addition of new populations—including those with significant behavioral health needs and intellectual/developmental disabilities—and the rollout of additional Pilot services to address interpersonal violence. Throughout these changes, NCDHHS will remain committed to continuous improvement, transparency and learning. The Pilots rely on partnerships among organizations with different missions, cultures and business models that have historically existed in separate silos for health and social care. Continuous improvement is vital to promoting an environment of shared learning and collaboration. With this in mind, NCDHHS will continue to make listening—to its partners, to enrollees and to the communities in which they live—foundational to its work as it seeks to improve the Pilot experience for enrollees, simplify Pilot operations across all stakeholders and promote the long-term sustainability of newly formed partnerships committed to improving the health of North Carolinians.
This article was written with support from Melinda Dutton, Sawhel Maali and Mandy Ferguson of Manatt Health.
NOTE: To learn more about the Healthy Opportunities Pilots, view Manatt’s recent webinar Innovative Strategies to Address SDOH: Lessons From North Carolina’s Healthy Opportunities Pilots.
1 Visit the “Healthy Opportunities Pilots at Work” webpage for more stories on the impact the Pilots have had on the lives of North Carolinians and key metrics on individuals served.