Medicaid’s Next Generation SDoH Strategy

Building Shared SDoH Infrastructure to Deliver Whole Person Care 

Medicaid leaders across the country are aligning around a common vision of a more person-centered Medicaid program that addresses social drivers of health (SDoH), improves coordination of care, and invests in health-related social needs (HRSN). To make this vision a reality, states need new tools and technology to facilitate collaboration, to measure person-level outcomes and system impact, and to drive accountability across sectors and providers. Addressing HRSN and the broader SDoH also requires deep community engagement and cross-sector partnerships of the providers and community-based organizations (CBOs) that are committed to delivering whole-person care. 

 At Unite Us, we combine technology infrastructure with supported community infrastructure to break down silos across sectors and government programs. Through Unite Us’ interoperable referral platform—which uses an electronic master person index to empower cross-sector care teams and evaluate individuals’ longitudinal community care journeys—we create seamless system linkages and closed-loop workflows across historically fragmented systems of care. The common platform we provide supports a true “any door” system of social care, produces system-wide analytics to measure social needs and community capacity at scale, and helps government leaders strategically shift investments upstream to maximize health benefits and better manage government spending. 

Addressing HRSNs and SDoH through Medicaid Managed Care 

Medicaid programs across the country are updating quality measures, establishing new care management requirements, and testing innovative risk modeling to encourage a greater focus on SDoH amongst managed care plans. Shared end-to-end SDoH technology infrastructure can break down access and quality gaps between coverage options. It also standardizes approaches to program oversight by using common measurement, data, and systems to identify members’ needs, facilitate effective outreach, engage members in services, track member- and system-level outcomes, and facilitate investments in needed community-based services. 

Nationwide, Unite Us’ end-to-end SDoH data and technology suite provides a blueprint for plans and Medicaid programs to proactively leverage SDoH data and infrastructure to drive measurable health outcomes and return on investment. 

States Taking The Lead

1. Quality Measures: Through their recently approved 1115 waiver demonstration, Oregon Healthcare Authority (OHA) redesigned its quality incentive program to include a new health equity upstream metric, “Social Determinants of Health: Social Needs Screening and Referral,” which incentivizes managed care plans not only to measure but also address HRSNs. The evolution of quality improvement measures related to SDoH is also being driven by leading healthcare quality standard entities, such as the National Committee for Quality Assurance (NCQA). The Social Need Screening and Intervention (SNS-E) measures are included in NCQA’s 2023 updated Healthcare Effectiveness Data and Information Set (HEDIS) quality measure slate. With this newly established measure, health plans can be evaluated on their ability to screen and provide interventions for members with housing, food insecurity, and transportation needs.

2. Care Management Programs: In Mississippi, managed care plans will be required to implement comprehensive care management programs inclusive of SDoH screening, risk stratification, and trackable closed-loop referrals. These requirements underpin a program-wide commitment to advancing health equity that is financially incentivized through minimum investment requirements in SDoH, as well as Medical Loss Ratio (MLR) allowances for costs associated with closed-loop referral platforms.

3. Risk Modeling: Incorporating social needs data into quality and risk adjustment programs is another important trend that ensures adequate funding is allocated to manage members’ social care needs. MassHealth, the Massachusetts state Medicaid agency, developed its medical risk adjustment model for managed care organizations (MCOs) and accountable care organizations (ACOs) by incorporating data found to be associated with heightened SDoH needs. The updated model considers age, unstable housing, a “neighborhood stress” score, disability, serious mental illness, and substance use disorders.

Shifting Investments Upstream

Through Medicaid waivers and other reinvestment initiatives, state Medicaid programs are advancing new initiatives to address HRSNs by directly funding CBOs that traditionally have not been financed by healthcare. The implementation challenge that states now face is how to create streamlined billing and reporting infrastructure for social care providers without over-medicalizing the delivery of needed community-level services. 

Implementation efforts for these initiatives must include a plan for supporting and reimbursing CBOs that provide health-related social services to create adequate capacity. In many instances, CBOs’ existing systems and workflows do not generate service-level invoices, manage reimbursements, or track outcomes. This is particularly true for smaller CBOs, which are often best positioned to serve vulnerable populations. These smaller CBOs and the populations they serve are likely to be left behind if states and health plans don’t provide them with the tools and support they need to participate. As Medicaid programs increasingly adopt requirements for connecting members to community partners, they must also invest in the protocols and technology needed to strengthen CBO capacity, including those needed for rate setting, reimbursement, and reporting.

With Unite Us Payments, CBOs can streamline service tracking and billing for social care services provided. Medicaid agencies using Unite Us Payments can track the flow of CBO funding and pair reimbursement with outcomes data to better understand impact and return on investment. Unite Us also generates data and insights, like our Health Equity dashboard, to provide our partners with actionable information that they can use to target resources and interventions to address local priorities, such as health disparities and inequities in access to care. 

Opportunities for Cross-Sector, Interagency Partnerships 

As state Medicaid programs take the lead in promoting statewide coordinated care networks, local government and other agencies need coordinated care networks to address priority populations and advance specific policy objectives. In a mature network, Medicaid programs improve coordination across agencies to support multi-system members, including foster children, justice-involved individuals, people with substance use disorders, or children with special health care needs. Establishing reusable statewide SDoH infrastructure to advance community-level care coordination is core to Medicaid’s role as a safety net coverage option. Statewide plans to invest in SDoH technology as part of a state’s Medicaid Enterprise Systems strategy can include more than just the healthcare delivery system by engaging a cross-agency governance team to proactively set system-wide priorities and needs across multiple at-risk populations. 

Unite Us is the only SDoH technology vendor that has scaled statewide with government partners. We leverage a robust, cross-sector planning and community engagement methodology to ensure that government partners maximize state and federal investments through regular access to, and use of, key SDoH indicators collected through our robust structured outcome taxonomy and standard data visualizations. 

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