New Opportunities to Expand Services Through Aligning Health and Social Care

As the population of older adults and people with disabilities continues to grow, the availability of services and supports that help many remain independent at home and in their communities will be increasingly important. To be effective, those services and supports must address health-related social needs (HSRNs) — the social and economic needs, such as housing instability, food insecurity, and lack of transportation, that impact an individual’s ability to maintain their health and well-being. This month, the U.S. Department of Health and Human Services (HHS) announced important new policies and efforts to address HSRNs: new payment policies for Medicare Part B providers, a Medicaid HRSN framework for coverage of services, and a Call to Action to catalyze community-level partnerships. 



The Centers for Medicare & Medicaid Services (CMS) recently published the 2024 Physician Fee Schedule, finalizing new codes for payment of Community Health Integration and Principal Illness Navigation services under Medicare Part B. These services include a person-centered assessment, home and community-based care coordination, care transition support, social and emotional support, and other services to enable holistic, person-centered care. Importantly, CMS has indicated that the billing practitioner can arrange to have these services provided under contract by outside personnel employed by community-based organizations (CBOs), specifically calling out area agencies on aging (AAAs), centers for independent living (CILs), aging and disability resource centers (ADRCs), and other organizations in ACL’s aging and disability networks. While these new codes reimburse for a similar scope of services, Community Health Integration services address unmet HRSNs, whereas the Principal Illness Navigation services help Medicare beneficiaries with high-risk conditions like dementia identify and connect with appropriate clinical and community services and supports.  



This week, CMS also released a Medicaid HRSN Framework to clarify existing coverage policies available to state Medicaid programs to address HRSNs. In addition to these Medicare and Medicaid payment policies, CMS is reinforcing the need to routinely screen beneficiaries for HRSNs through quality measures for hospitals, physicians, and Medicare Advantage Special Needs Plans. Routine screening for HRSNs is anticipated to lead to the identification and referral of an increasing number of individuals to CBOs for assistance with housing, nutrition, transportation, and other needs. All of these changes create an important opportunity for sustainable partnerships between health care and CBOs to better align health and social care, address health equity, and improve health outcomes. Aging and disability CBOs are increasingly contracting with health care organizations to address HRSNs, and contracting as part of a network, led by a community care hub, is growing as well. Hubs provide administrative and operational infrastructure for a network of CBOs and enable efficient contracting and sustainable financing to better serve populations in need. 



Beyond the HHS actions, the Biden administration released a Social Determinants of Health (SDOH) Playbook highlighting a broad set of federal agency actions to improve health and individuals’ social circumstances through 1) data capture and sharing, 2) flexible funding to address social needs, and 3) support for bridge organizations (or hubs). For decades, the aging and disability networks have been an important complement to Medicare and Medicaid and have addressed the social needs of the people they serve through information and referral, coordination of public and private sources of funding, and delivery of comprehensive services through networks of CBOs. To advance data sharing, ACL is collaborating with the Office of the National Coordinator for Health IT (ONC) to advance the interoperability of SDOH data, including publication of a FHIR Implementation Guide for community resource directories and technical assistance to states to support interoperable social care referral platforms. ACL, in partnership with our colleagues at CDC and others, is also supporting the growth of hubs through several actions. Fortunately, we’re building from existing community care hubs that AAAs, ADRCs, CILs, and other CBOs have developed over the last decade across the country to increase access to social care, as well as deliver and finance services with a culturally competent workforce that is trusted in the community. They are partnering with health care organizations and coordinate funding from social services, Medicaid, Medicare, housing, transportation, and other sources to provide comprehensive services to individuals in need. 



In September, ACL established a new Center of Excellence to Align Health and Social Care that will fund competitive subawards to support infrastructure costs for up to 20 community care hubs. In October, we opened applications for the second Community Care Hub National Learning Community to further the capacity of hubs nationwide through peer support and technical assistance. Last week, in partnership with HUD and other HHS agencies, we announced the Housing and Services Partnership Accelerator to enable state teams with Medicaid 1115 demonstrations and 1915(i) state plan amendments to work with community, health care, and housing partners to coordinate all available resources to address housing instability. In November and December, we’re hosting a Community Care Hub 101 learning series for CBOs interested in learning more about this growing CBO network model. In January, we will be launching a larger-scale technical assistance opportunity using the ECHO Model®, an all-teach, all-learn approach for hospital and CBO teams to collaborate on implementation of HRSN screening, referral, and care transitions. 



ACL is calling on our networks to expand efforts to align health and social care. We need our networks to build on the hospital partnerships that exist to enable safe transitions from hospital to home and to collaborate with health plans and housing agencies to ensure Medicare and/or Medicaid funding can be coordinated with other funding sources to ensure people have the nutrition, housing, and transportation supports they need to live where they choose and fully participate in their communities. We have the challenge and opportunity to expand community care hubs across the country to align health and social care in ways that create fair and sustainable partnerships between health care and CBOs. We can do this — there are many successful hubs to lead the way. It will require deeper and sustained collaboration, committed leadership, and new ways of working while always being centered in organizational mission and culture to support the growing populations we serve.