In a webinar titled Strategies for Providing Whole Child Care: A Blueprint for Meeting Children’s Social Needs, Manatt facilitated a panel discussion with state and national leaders who are pioneering new ways to address the health-related social needs (HRSNs) of children, which the Centers for Medicaid & Medicare Services (CMS) defines as an individual’s unmet, adverse social conditions that contribute to poor health. HRSNs can include but are not limited to food insecurity, housing instability, social isolation and/or lack of reliable transportation. The program also reviewed emerging opportunities for financing children’s HRSN interventions, including 1115 waivers, “in lieu of services” (ILOS), and Children’s Health and Wellness Funds.
To view the full webinar free on demand and download a free copy of the presentation, click here. Below are a handful of questions posed by webinar participants that we did not have the time to address.
Key Questions on Strategies for Providing Whole Child Health Care
Approaches for Addressing HRSN
What is a Children’s Health and Wellness Fund? How can it support initiatives that address the social needs of children and families?
Addressing the social needs of children and their families is particularly important in light of the strong evidence that investments in the earliest years can have a potent impact on children’s development and their ability to thrive and grow to be healthier adults. Yet children have largely been left behind with respect to these types of investments in part because the financing for these initiatives has relied heavily on the potential for a relatively short-term return on investment (ROI) for the health sector. HRSN interventions focused on children will produce health-related financial returns but typically on a longer time horizon, and they often will also result in savings outside the health care sector (for example, to the child welfare system), giving rise to what is known as the “wrong pockets” problem.
A Fund offers a mechanism to address the wrong pockets problem by facilitating a shared financing approach that reflects the shared interest and benefits of the many sectors that serve children, e.g., child welfare, education and juvenile justice in addition to health care. Each would invest in interventions that address HRSNs for children, thereby spreading the cost, reducing fragmentation and duplication of services and amplifying the impact of investments—including health care, education, child welfare and juvenile justice. This may be achieved by blending and/or braiding various funding streams, and it can be begun with seed funds and expanded over time. A Fund can be statewide or local and can focus on a broad range of children’s HRSNs or a targeted set of initiatives/needs. Those organizing a Fund will need to consider:
- An initial framework for the Fund and the activities it will support, including determining how the Fund will be disbursed, the population it will service and how it can enhance equity.
- Governance, to define the scope of the Fund’s responsibilities and how those responsibilities will be executed.
- Potential funding sources, including identifying a mix of public and private actors with a stake in children’s health development.
- Program accountability and evaluation, to promote accountability, program performance, equity goals and continued investment.
How can medical-legal partnerships be leveraged to support whole child care?
Medical-legal partnerships integrate legal services into health care in order to address issues that may prevent individuals, including children and youth, from realizing optimal health. Specifically, health care providers, social workers and other professionals may partner with medical-legal partnership lawyers through an interdisciplinary approach to address social factors that impact their patients’ health. Medical-legal partnerships can be leveraged to support whole child care by, for example:
- Supporting individuals with specific issues such as resolving landlord disputes or establishing guardianships
- Consulting with health care providers on patients’ legal needs
- Training providers and other clinical staff on strategies to address systemic barriers to care and the social drivers of health (SDOH)
- Advocating with partners for policies that improve the health and safety of communities and break down barriers to health equity (e.g., successfully advocating for the U.S. Department of Housing and Urban Development to update its definition of lead poisoning to ensure earlier housing authority intervention for children with elevated blood lead levels).
How can pediatricians and other health care providers who serve children and families provide a whole child approach to care (i.e., care that supports children and families beyond their clinical needs) given limited time to serve their patients?
Evidence shows that health and well-being start outside the four walls of a hospital or clinic. However, pediatricians and other health care providers who serve children and families are in a particularly opportune position to help identify issues their patients are confronting. The key to effective engagement is to bring together a team and work through workflows and reimbursement issues. Pediatric practice teams may include social workers and community health workers to conduct HRSN screening and serve as the link between the family and community resources. The practice itself is likely not going to be the entity that actually provides the HRSN intervention; different models exist for how those relationships, referrals and exchange of information might work best for the practice and the community.
Examples of How States Are Addressing HRSN
How does Oregon’s 1115 waiver address HRSN for children, including children with special health care needs?
Under the authority of its recently approved 1115 waiver, Oregon will cover a defined set of HRSN services to support qualifying individuals during life transitions. One of the priority groups to receive these services includes Youth with Special Health Care Needs (YSHCN) up to age 26 and youth who are child welfare involved and transitioning in and out of foster care homes. Oregon will ensure that YSHCN are screened for specific HRSNs and qualify for related services for up to 12 months. Allowable HRSN services include housing (e.g., rent/temporary housing for up to six months, utility costs, pre-tenancy/tenancy sustaining services, housing transition navigation services, moving costs, housing deposits, medically necessary air conditioners, heaters, and other supports during climate emergencies, and medically necessary home accessibility modifications) and nutrition supports (e.g., nutrition counseling, medically tailored meals, meals/pantry stocking, and fruit and vegetable prescriptions).
Have states used ILOS to support children? How?
Yes. In lieu of services (or ILOS) allow managed care organizations to pay for nonmedical services instead of standard Medicaid benefits when medically appropriate and cost-effective. Prompted by a request from California, CMS recently broadened its reading of allowable ILOS and cost-effectiveness via guidance released in January 2023, and proposed regulations in April 2023. Specifically, ILOS can include preventive services and do not need to be an immediate substitute for a Medicaid service. Furthermore, ILOS must be cost-effective overall but do not need to be cost-effective on the individual level. As an example, in California, managed care plans may opt to offer up to 14 “Community Supports” (i.e., ILOS) in lieu of or in order to avoid higher-cost Medicaid services, such as inpatient hospitalization or ER visits. For example, California offers “asthma remediation,” which is specifically targeted to children by removing asthma triggers in the home. In addition to asthma remediation, children/youth may benefit from the other California Community Supports listed below:
- Housing Navigation
- Housing Tenancy and Sustaining Services
- Housing Deposits
- Caregiver Respite
- Day Habilitation Programs
- Nursing Facility Transition/Diversion to Assisted Living Facilities
- Community Transition Services/Nursing Facility Transition to a Home
- Personal Care and Homemaker Services
- Environmental Accessibility Adaptations
- Medically Tailored Meals/Medically Supportive Food
- Sobering Centers
- Short-Term Post-Hospitalization Housing
- Recuperative Care (Medical Respite)
The ILOS allowed in a state must be identified in the state’s Medicaid managed care contracts; CMS approval is needed, but no waiver is required. Services are financed by including the cost in the build-up of the managed care rates. Additional information on California’s Community Supports program can be found here.
What types of housing services have been covered under 1115 waiver authority?
Arizona, Arkansas, Massachusetts, New Jersey and North Carolina offer housing services under 1115 waiver authority. The scope of services covered across each state varies, and, for the first time, in 2022, CMS allowed Medicaid to cover up to six months of rent for certain groups of enrollees. As an example, under Oregon’s recently approved 1115 waiver, the state may cover the following housing-related services:
- Rent/temporary housing for up to six months, for individuals transitioning out of institutional care or congregate settings such as nursing facilities, large group homes, congregate residential settings, institutions for mental diseases (IMDs), correctional facilities and acute care hospitals; individuals who are homeless, at risk of homelessness or transitioning out of an emergency shelter as defined by 24 CFR 91.5; and youth transitioning out of the child welfare system including foster care. Note that this is a new service.
- Utility costs, including activation expenses and back payments, limited to individuals receiving rent/temporary housing.
- Pre-tenancy and tenancy sustaining services, including tenant rights education and eviction prevention.
- Housing transition navigation services.
- One-time transition and moving costs (e.g., security deposit, first month’s rent, utility activation fees, movers, relocation expenses, pest eradication, pantry stocking, and the purchase of household goods and furniture).
- Housing deposits to secure housing, including application and inspection fees and fees to secure needed identification.
- Medically necessary appliances, including air conditioners, heaters, humidifiers, air filtration devices, generators and refrigeration units as needed for medical treatment and prevention.
- Medically necessary home accessibility modifications and remediation services such as ventilation system repairs/improvements and mold/pest remediation.