The state of the field of complex care 2023
Building the complex care field Funding & financing Policy & advocacy Public benefits SDOH & health equity Workforce development
What a difference a year makes — or, more specifically, six years. That’s how long it has been since the Camden Coalition first partnered with the Center for Health Care Strategies (CHCS) and the Institute for Healthcare Improvement (IHI) in 2017 to put together a Blueprint for the emerging field of complex care, which focuses on the health and well-being of society’s most vulnerable individuals.
Despite a global pandemic and an epidemic of another kind — rampant healthcare worker burnout and attrition — the country (parts of it at least) seems to be catching up with those of us in the complex care field, which includes leaders and providers from multiple sectors including healthcare, community-based social services, housing, legal services, and more, as well as advocates with lived experience of complex needs. On good days, I would even dare to say that our time has come.
Increasingly, health equity and social determinants of health have become part of the healthcare delivery system. In nearly half the states in our country, Medicaid 1115 waivers have opened up the possibility of covering members’ social needs. Regular screening to assess these needs is also now being incorporated into the core quality measures that health plans pay the most attention to, like Healthcare Effectiveness Data and Information Set (HEDIS) Then there is California’s CalAIM initiative, which uses a community- and individual-centered enhanced care management model to help ensure the well-being of populations that once fell through the cracks — those without housing, or with substance use disorders or serious mental illness, among others. There has also been increased attention to previously overlooked populations, such as individuals experiencing homelessness and justice-involved individuals, with significant policy and practice developments addressing the needs of these groups.
The bottom line: the ideas and practices that the Camden Coalition has advocated for since its inception — many of which make up the principles of complex care as defined in the Blueprint — are now hitting the mainstream.
Of course, enlightened policy is just the first step, and there remains enormous work to be done to ensure effective implementation. We recognize also that this progress is occurring in a country that’s increasingly divided. State-level rollbacks of hard-won services — including access to abortion, trans healthcare, and services for undocumented communities — threaten the health and well-being of millions, including many of the individuals we serve as complex care providers. It’s an important reminder that the same policy levers that are being used in some parts of the country to close health disparities — namely Medicaid flexibility and MCO contracting — are being used in other parts of the country to widen them.
Here, though, are some of the recent developments we’re most excited about and a look at what’s coming down the pike.
Better research, done in a more inclusive way
Two of the original Blueprint recommendations were to develop quality measures for complex care programs and to identify research and evaluation priorities that would accelerate progress in improving care for people with complex needs.
In 2022, the Center for Health Care Strategies (CHCS) released a complex care research agenda for the field. This was notable because it was done in an incredibly person-centered way, including getting recommendations from a patient-family advisory board. The product of more than one hundred leaders in complex care, including clinicians, researchers, and consumers, the document sets out critical milestones to help keep the field moving forward. These include:
- the need for more and higher quality research on the most effective and efficient approaches to complex care
- how to meaningfully include patients and communities in research
- measuring outcomes in a more consistent and patient-centered way
We look forward to working with CHCS and others to build on this important research agenda in the years ahead.
Social needs as a focus of measurement and payment
We know that measurement drives accountability and action. That’s why it’s been heartening to see both HEDIS and CMS embrace social care screening and referral measures.
Last August, the National Committee for Quality Assurance (NCQA) announced that it would release new quality measures for HEDIS, meant to advance health equity. These include collecting data on patients’ race and gender identity, as well as data on patients’ food, housing, and transportation needs. The Centers for Medicare & Medicaid Services (CMS) is also proposing two social risk screening measures for hospitalized patients: one that measures the percentage of inpatients screened for social needs, and another that captures the percentage of patients who screen positive. While these measures are still optional, CMS will make them mandatory for hospitals participating in the Hospital Inpatient Quality Reporting (IQR) Program, a pay-for-reporting quality program that reduces payment to hospitals that fail to meet program requirements.
Incentivizing screening and referrals, though, is only half of the equation: the other half is expanding community funding for services that address the social needs people are being screened for. Through 1115 waivers and In Lieu of Services, more states (and their managed care plans) are paying for social care as a form of medical expense and are contracting with community-based organizations to deliver social care services to members.
Building social sector capacity
I’m excited about the Camden Coalition’s involvement in the Partnership to Align Social Care, a national effort to advance partnerships between health plans and community-based organizations (CBOs).
We know that many CBOs have deep, trusting relationships with their community, but don’t always have the data security, IT systems, and operational capacity to meet healthcare’s rigorous standards. To address this challenge, the Partnership is advancing adoption of Community Care Hubs, which are community-focused entities that organize and support a network of community-based organizations providing services to address health-related social needs. By providing shared administrative and operational capacity, Community Care Hubs enable the participation of a wide range of CBOs, including small grassroots initiatives, in healthcare contracts.
This model may soon be tested at-scale in the state of New York, where a proposed Medicaid waiver calls for “Social Determinant of Health Networks” to organize CBOs by region and create shared infrastructure.
We are looking to a future where health plans routinely hire CBOs to provide social needs screening and services, which could include everything from home repairs to care management. Making the contracting process easier creates an opportunity for healthcare to partner with and invest in the organizations already providing excellent, community-based services, rather than turning to for-profit startups to try to meet their members’ social needs.
CalAIM, California’s bold experiment, is a model to watch
CalAIM took center stage at the Camden Coalition’s Putting Care at the Center 2022 conference in Sacramento last September, with good reason. We can’t take credit for CalAIM, but it looks a lot like what we have been talking about in the field of complex care — and it’s happening at a state-wide scale.
In this blog post, I talked about how CalAIM was proposing to integrate complex care services and benefits with Medicaid managed care. It’s now happening on the ground, as the state rolls out a wealth of new benefits meant to support populations, including those experiencing homelessness, serious mental illness, or substance use disorders; who are pregnant or post-partum; who are at risk of avoidable hospital or ED utilization; and eventually justice-involved individuals. Instead of addressing these populations’ needs piecemeal, CalAIM makes them part of the core benefits offered to enrollees by the state’s managed care plans.
This transition comes with expected implementation challenges, including developing the requisite networks, data-sharing, and referral/enrollment processes to effectively serve populations that are highly transient and often wary of the healthcare system. Yet, California has invested significant resources to build system capacity at the local and regional level to enable this broad transformation. We are excited to be working with local stakeholders to address these challenges and realize the promise of CalAIM in our role as facilitators of three Collaborative Planning and Implementation groups as well as certified providers of technical assistance on the TA Marketplace.
Connecting justice-involved populations to care
There is also exciting work being done across the country to improve care for justice-involved populations. In February, California became the first of 15 waiver applications approved to allow Medicaid coverage of services to justice-involved individuals while they are still incarcerated, with this population slated to join CalAIM in January 2024. We anticipate a slate of similar waiver approvals over the upcoming year.
These policy changes will enable exciting innovation at the state and local level. The Health and Rentry (HARP) Project aims to promote continuity of care and maximize the benefits of policy changes to Medicaid that help justice-involved populations access services and achieve better health during their transition out of incarceration. The US Department of Health and Human Services recently released a report on promising practices for facilitating healthcare transitions during reentry.
Partnering with consumers to improve systems
We are seeing more interest in consumer partnership within philanthropy and among thought leaders, and growing consumer partnership activity among health plans and health systems. However, there is still a big need for best practices to ensure that these partnerships are meaningful and mutually beneficial.
I’m hopeful that policies that elevate the voices of consumers and people with lived experience will accelerate this process. For example, a new CMS final rule requires Dual Eligible Special Needs Plans (DSNPs) to have an enrollee advisory committee (EAC) to provide input on what’s working — and what is not. For instance, plans could work with their EACs to track the accessibility of transportation or home services, helping plans measure what is most crucial to its members.
The Camden Coalition will also be helping to fill this gap. In 2023, we’re looking forward to working alongside other organizations and people with lived experience to develop and document strategies for implementing meaningful consumer partnership at greater scales.
Reinforcing the importance of core competencies — and collaboration
None of the exciting developments above are sustainable if we don’t have enough community health workers, primary care physicians, social workers, behavioral health specialists, and others trained to provide high-quality, effective care to individuals with complex needs. In order to better train the workforce needed, one of our priorities for the upcoming years is education and training.
Later this year, we will release the first-ever complex care certificate on the Camden Coalition Learning Center. This program, which includes nine e-learning modules, will provide learners from across health and social care disciplines with a comprehensive introduction to the core knowledge, skills, and attitudes outlined in the complex care core competencies.
While it is exciting to see so much of our work in complex care come to fruition, the truth is that the enormous strides we’ve made in the past few years alone have been a collaborative effort — like complex care itself. No one can do this work alone. As we embark on our organizational goal to strengthen ecosystems of care in 500 communities over the next three years, partnerships and collaboration will be key to our success. It’s heartening to see that many of the systems we work with are starting to value them as well.