A grand experiment in wellness: solving social issues that underpin health

A pilot program is underway in North Carolina with the laser-focused goal of studying whether improving life conditions can reduce the price tag for Medicaid, a cost borne by taxpayers to cover medical care for the poor.

The Healthy Opportunities Pilot is the first program in the nation that address social determinants of health for those on Medicaid.

“Most of what affects someone’s health is outside a doctor’s office,” said Jennifer Caldwell, communications manager at Impact Health, the entity managing the pilot program in the 18 westernmost counties.

Caldwell cited other forms of care such as therapy, mental health counseling, behavioral health needs, transportation, food and housing that are essential to staying healthy. The pilot program that rolled out a year ago evaluates the impact of providing non-medical services to Medicaid recipients.

“The pilot authorized 29 services eligible for reimbursement through Medicaid Managed Care,” Caldwell said. “It’s for members identified as higher-need in terms of health, and social needs and chronic health conditions.”

Community partners are contracted to provide the services, which in Haywood includes Mountain Projects, Haywood Christian Ministry, Waynesville First United Methodist Church, HIGHTS and Haywood Pathways Center. (See related article.)

Services can include home safety modifications, transportation assistance, a one-time payment for security deposits and utility services, mileage or car repairs, moving support, and healthy home goods such as clean bedding.

In addition, recipients can get food boxes that will provide two-thirds of what they need to eat healthy in a week, Caldwell said. This includes fresh produce, healthy proteins and shelf-stable goods. Client choice is emphasized. For clients unable to pick up the food boxes, delivery is offered.

To avoid duplication, contracted community partners must use the NC Care 360 database, a central portal with a detailed history of clients and benefits received.

“The whole point is for all to see the client base in a secure way so the data is protected,” Caldwell said. “This not only avoids duplicated services, but makes sure none are falling through the cracks.”

Getting the word out

The federal government has authorized up to $650 million in funding to North Carolina over five years for the pilot program. The program got off to a slow start because of Covid, however, and may not last the entire period unless the scheduled 2024 end date is amended.

The pilot program works hand-in-hand with the state’s relatively new Medicaid Managed Care model — one that divvies up the bulk of the low-income population and assigns them to an insurance provider. The provider agrees to cover all the medical costs of those in their pool for a set contract price.

Around 9,000 of the 14,000 people in Haywood County on Medicaid are under the Managed Care model.

However, only a small percentage are covered under the pilot program. Ten months in, local community partners collectively report serving about 150 clients.

Amanda Bauman, the director of programs for Impact Health, said it has taken a while to get the word out about the program to places such as physician offices, social service organizations or even to potential recipients themselves.

While there is a phone number on the back of the managed Medicaid card explaining benefits available under Healthy Opportunities Pilot, many haven’t noticed it or taken advantage of the benefit.

In addition, the enrollment process was clunky at first. However, a new referral method called “No Wrong Door” launched in January is making a huge difference, Bauman said.

“Folks aren’t used to telling their doctors they need food or have housing needs,” she said. “What’s changed with the No Wrong Door approach is that service organizations can make referrals through NC Cares 360. We’ve seen such an increase in referrals just since January.”

If an individual is found to be eligible for HOP through the insurance provider, a case manager is assigned, and arrangements have been quickly made to start addressing the family needs.

Medicaid recipients generally eligible for HOP services include most children and families those who are disabled but not on Medicare, Bauman said, adding new categories of eligibility will be rolled out in April.

“If the pilot succeeds, we hope the model of care would be expanded way beyond Medicaid managed care,” Caldwell said.

Beyond the five contracted partners serving Haywood residents, Caldwell said Impact Health is not looking for new partnerships at this time.

“We need to make sure we can support the ones we have across Western North Carolina,” she said. “We may add others in the future. If an organization is interested in getting connected, they can contact us, and as we identify gaps in services, we may reach out to organizations.”