Practical, Timely Lessons for Advancing and Aligning North Carolina's Health Care Transformation Leadership to Address Social Needs

Practical, Timely Lessons for Advancing and Aligning North Carolina's Health Care Transformation Leadership to Address Social Needs


Background

 In October 2018, CMS approved North Carolina’s 1115 waiver to move the state’s Medicaid system from fee-for-service to a managed care program. A key part of this 1115 waiver is a groundbreaking demonstration project, the Healthy Opportunities Pilots, to pay for and deliver services to address unmet social needs in three regions across North Carolina. In the program, each pilot region’s Network Lead organization—with support from managed care plans in identifying patients, assessing needs, collecting data, and managing budgets—will oversees a network of local human service organizations to pay for and deliver evidence-based interventions that address unmet needs in food, housing, transportation, interpersonal safety and toxic stress. In July 2021, the Pilots officially began its capacity-building phase where $100 million is supporting the Network Leads to do things like establishing policies, hiring staff, and building their network of human service organizations. Service delivery started in early 2022 and will continue through October 2024. 

Project Overview

Given the substantial challenges that exist for integrating health and social services, however, there is need for timely and practical guidance. This project’s objective is to understand early real-world experiences in preparing for and implementing the Healthy Opportunities Pilots, in order to generate learnings and insights to improve the implementation of the Pilots, North Carolina’s broader Medicaid transformation, and similar initiatives by other states or payers to address social needs.

Following two expert stakeholder guiding committee convenings in the first year of the project with over 50 key stakeholders locally and nationally to guide our work, we are in the process of conducting our research. In June 2021, our team moderated a policy roundtable at the 2021 AcademyHealth Annual Research Meeting to discuss the Pilots, our work, and work occurring across the nation to address social needs through Medicaid. For the first stage of our work, we studied North Carolina’s COVID-19 Support Services Program—developed during the COVID-19 public health emergency to address multiple pandemic-related social needs—as it is informally seen as a smaller-scale preview of Pilots due to similarities in design and service provision. We partnered with one of the program’s largest grantees to analyze their program survey data and we completed interviews with 16 experts involved in every level of the COVID-19 Support Services Program statewide. We published findings in a policy brief with Milbank Memorial Fund in March 2022. By Summer 2022, we: finished conducting a set of interviews about planning, building capacity, and early administration of the Pilots; held two focus groups with NC Medicaid enrollees in the Pilots program; and developed a summative, cross-cutting manuscript of findings for local and national policymakers.  

The first phase of our project was funded as part of the Robert Wood Johnson Foundation’s “Research in Transforming Health and Health Care Systems” program, which sought to build the evidence base on the potential effects of policies or policy changes intended to transform health and health care systems.

The second phase of our project, which is funded by the Kate B. Reynolds Charitable Trust, extends our work into the first two years of service provision of the Healthy Opportunities Pilots (2022-2024) and allows us to generate insights and lessons learned from NC health care stakeholders conducting innovative work to address social needs outside of the Pilots. Throughout this multi-year project, we are coordinating with the NC Department of Health and Human Services.

Addressing Housing-Related Social Needs Through Medicaid: Lessons From North Carolina’s Healthy Opportunities Pilots Program

Addressing Housing-Related Social Needs Through Medicaid: Lessons From North Carolina’s Healthy Opportunities Pilots Program

Research Article - February 2024

Using a mixed-methods approach, Duke-Margolis researchers mapped the distribution of severe housing problems and then examined the design and implementation of the Pilots housing services in the three program regions. Four cross-cutting implementation and policy themes emerged: accounting for variation in housing resources and needs to address housing insecurity, defining and pricing housing services in Medicaid, engaging diverse stakeholders across sectors to facilitate successful implementation, and developing sustainable financial models for delivery.

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HOP 1.0 report

Addressing Social Needs through Medicaid: Lessons from Planning and Early Implementation of North Carolina’s Healthy Opportunities Pilots

Policy Report - September 2023

States, payers, and health systems across the United States are developing cross-sectoral solutions to address health-related social needs. However, most evidence on the effectiveness of these interventions to date is from time-limited interventions focused on specific subpopulations or services and often in urban areas only. In 2019, as part of North Carolina’s Section 1115 Medicaid Demonstration, the Centers for Medicare & Medicaid Services (CMS) authorized up to $650 million in Medicaid funding to implement the Healthy Opportunities Pilots (“Pilots”). To support the implementation of the Pilots, we conducted a multi-method qualitative study to generate timely and practical findings and recommendations from the planning, capacity-building, and early implementation of the program. Through this report, we offer key findings that can be useful for the Pilots’ policymakers, implementors, and providers, as well other stakeholders interested or involved in similar or smaller-scale initiatives in other states.

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Pilots Webinar Graphic

North Carolina’s Healthy Opportunities Pilots: A Medicaid Managed Care Program to Address Social Needs

Webinar - July 2022

This webinar provided an overview of practical cross-cutting themes from the planning, capacity-building, and early implementation periods of the Healthy Opportunities Pilots, including successes, lessons learned, challenges encountered, and innovative solutions for overcoming challenges. Policymakers, researchers, evaluators, implementation leaders, and frontline providers shared their experiences over the past two years, thoughts on the future of the program, and lessons for similar programs.

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Fact Sheet

North Carolina Healthy Opportunities Focus Group Findings

Fact Sheet - July 2022

This fact sheet describes key takeaways from focus groups conducted to assess the initial awareness of and access to the Healthy Opportunities Pilots services in North Carolina. 

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North Carolina’s COVID-19 Support Services Program: Lessons for Health Policy Programs to Address Social Needs

North Carolina’s COVID-19 Support Services Program: Lessons for Health Policy Programs to Address Social Needs

Policy Brief - March 2022

The North Carolina Department of Health and Human Services launched its COVID-19 Support Services Program in August 2020 to address multiple pandemic-related social needs in counties with COVID-19 hot spots in four target regions of the state. Lessons from the COVID-19 Support Services Program can inform other states’ and payers’ efforts to address social needs, as well as North Carolina’s soon-to-launch $650 million Healthy Opportunities Pilots, which will pay for and provide social services through Medicaid managed care programs. We offer key recommendations to health policymakers (e.g., state health officials, commercial payers) creating or administering health policy programs to address social needs in local populations; our findings are also relevant to frontline implementers of such programs.

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Duke-Margolis Team

William K. Bleser - Margolis headhot

William K. Bleser, PhD, MSPH

Research Director, Health Care Transformation for Social Needs and Health Equity
Senior Team Member
Anti-Racism and Equity Committee Member

Katie Huber

Katie Huber, MPH

Senior Policy Analyst

Rebecca Whitaker Headshot

Rebecca Whitaker, PhD, MSPH

Research Director, North Carolina Health Care Transformation
Core Faculty Member
Senior Team Member
Anti-Racism and Equity Committee Member

Andrea Thoumi headshot

Andrea Thoumi, MPP, MSc

Area Lead, Community Health and Equity
Faculty Director of Health Equity Educational Programming
Senior Team Member
Anti-Racism and Equity Committee Member
Core Faculty Member
Adjunct Assistant Professor
2020 Intern Mentor

Yolande Pokam Tchuisseu

Yolande Pokam Tchuisseu, MSc

Senior Policy Analyst

Robert Saunders

Robert Saunders, PhD

Senior Research Director, Health Care Transformation
Adjunct Associate Professor
Executive Team Member
Margolis Core Faculty

headshot Vibhav Nandagiri

Vibhav Nandagiri, BA '25

Margolis Scholar
2023 Margolis Intern

Margolis Summer Experience

Karina Vasudeva

2022 Margolis Intern

James Zheng

James Zheng

2020 Margolis Intern
2021 Margolis Intern

Picture of Jasmine Masand

Jasmine Masand, (MPP '21)

Anti-Racism and Equity Committee Member

Additional Collaborators

Hannah Crook (former Duke-Margolis Staff member)

Michelle Lyn, Assistant Professor in Family Medicine and Community Health at Duke University

Raman Nohria, Family Medicine Physician and Medical Instructor at the Duke Department of Family Medicine and Community Health