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Research Article

Housing

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

Affiliations
  1. Katie Huber, Duke University, Durham, North Carolina.
  2. Raman Nohria, Duke University, Durham, North Carolina.
  3. Vibhav Nandagiri, Duke University, Durham, North Carolina.
  4. Rebecca Whitaker, Duke University, Durham, North Carolina.
  5. Yolande Pokam Tchuisseu, Duke University, Washington, D.C.
  6. Nicholas Pylypiw, Elicit Insights, Raleigh, North Carolina.
  7. Meaghan Dennison, Cape Fear Collective, Wilmington, North Carolina.
  8. Brianna Van Stekelenburg, Duke University, Durham, North Carolina.
  9. Amanda Van Vleet, North Carolina Department of Health and Human Services, Raleigh, North Carolina.
  10. Maria Ramirez Perez, North Carolina Department of Health and Human Services.
  11. Madlyn C. Morreale, Legal Aid of North Carolina, Inc., Raleigh, North Carolina.
  12. Andrea Thoumi, Duke University, Washington, D.C.
  13. Michelle Lyn, Duke University, Durham, North Carolina.
  14. Robert S. Saunders, Duke University, Washington, D.C.
  15. William K. Bleser ([email protected]), Duke University, Washington, D.C.
PUBLISHED:February 2024Open Accesshttps://doi.org/10.1377/hlthaff.2023.01044

Abstract

North Carolina Medicaid’s Healthy Opportunities Pilots program is the country’s first comprehensive program to evaluate the impact of paying community-based organizations to provide eligible Medicaid enrollees with an array of evidence-based services to address four domains of health-related social needs, one of which is housing. Using a mixed-methods approach, we mapped the distribution of severe housing problems and then examined the design and implementation of Healthy Opportunities 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. The lessons learned and actionable insights can help inform the efforts of stakeholders elsewhere, particularly other state Medicaid programs, to design and implement cross-sectoral programs that address housing-related social needs by leveraging multiple policy-based resources. These lessons can also be useful for federal policy makers developing guidance on addressing housing-related needs in Medicaid.

TOPICS

As the Centers for Medicare and Medicaid Services (CMS) encourages states to address social needs through Medicaid authorities, generating evidence on implementation lessons, innovations, and policy implications of related efforts is critical.1–3 The North Carolina Department of Health and Human Services (NCDHHS) Healthy Opportunities Pilots program is, in scope and design, among the nation’s most expansive Medicaid programs to address health-related social needs, including housing.4,5 We conducted a mixed-methods study of design and implementation of Healthy Opportunities Pilots housing services, using data from the period December 2020–November 2023, to identify lessons and actionable insights for other states and federal policy makers addressing housing insecurity through Medicaid.

Authorized by CMS in 2018 through a Section 1115 waiver, the Healthy Opportunities Pilots program delivers twenty-nine services across four social needs domains (housing, food and nutrition, transportation, and interpersonal safety and toxic stress), including three cross-domain services (for example, legal supports). The Pilots began distributing funding for capacity building in June 2021 and began phased service delivery in March 2022, with all housing services launching on May 1, 2022.5 The program is available for eligible Medicaid enrollees with at least one qualifying social need and one physical or behavioral health condition in 33 of North Carolina’s 100 counties, grouped into three regions in western, eastern, and southeastern North Carolina. The waiver authorizes up to $650 million for the Healthy Opportunities Pilots (including up to $100 million for capacity building) through October 2024, and NCDHHS requested a waiver renewal in October 2023.6 A unique social service fee schedule sets prices for and defines twenty-nine evidence-based interventions.7,8

The delivery model involves partnerships among North Carolina’s five prepaid health plans (Medicaid managed care plans), twenty-three care management entities, three regional Network Lead organizations, and approximately 150 community-based organizations. Prepaid health plans manage program funding, identify eligible members, and authorize and reimburse for services. Network Leads are regional community care hubs that create, coordinate, and support networks of community-based organizations that deliver services.9 Care management entities, typically employed by prepaid health plans or clinically integrated networks, work to identify, screen, and enroll eligible members into any of the twenty-nine services that are applicable and track members’ care over time. Members can also be referred for screening through clinicians, community-based organizations, and self-referral. Healthy Opportunities Pilots entities use NCCARE360, the first statewide cross-sectoral closed-loop referral software, for eligibility documentation, referrals, and invoicing.

Addressing housing insecurity is one of the Healthy Opportunities Pilots’ focal points, motivated by local housing cost inflation and affordable housing shortages exacerbated by rapid population growth.10–12 Accordingly, the Pilots’ housing service domain includes nine services, which we classify into three categories: housing navigation case management, housing quality and safety modifications, and housing and utility cost mitigation. In addition, all three cross-domain services have significant ties to housing. See online appendix A for detailed service information.13 These services are informed by literature that links housing instability to poor health outcomes, reduced care access, and health disparities and that links health system–provided housing supports to reduced hospital and emergency department use, increased use of primary care and mental health services, and health system savings.14–16 By mid-November 2023, more than 22,500 housing services had been delivered across the three Pilots regions.

Federal policy allows states to address certain housing-related needs through various Medicaid authorities, including the state plan, Section 1915 waivers, Section 1115 waivers, and managed care flexibilities, although there are trade-offs associated with each.2,3,5 In general, Section 1115 waivers allow states to test broader expansions of services and eligibility criteria. To date, CMS has approved Section 1115 waivers offering housing supports in seventeen states, although the Healthy Opportunities Pilots program is among the most expansive in terms of eligible populations, service provision requirements, and service definitions.17

In this study, which was a collaboration among academic health policy evaluators and key government, community-based organization, and data stakeholders involved in the Healthy Opportunities Pilots, we used a mixed-methods approach to identify implementation and policy themes. Our findings are timely for North Carolina, as the Pilots’ first CMS evaluation report only covers seven months of housing service implementation, which is too short a period to detect impact on health outcomes, yet enrollment in the Pilots is expected to increase after North Carolina’s Medicaid expansion (effective December 1, 2023) and, pending federal approval, the state’s application to renew its Section 1115 waiver and significantly expand the Pilots.6,18 Lessons from the Healthy Opportunities Pilots are also timely for federal policy makers and other states, which are increasingly addressing housing-related needs through Medicaid.1,17,19

Study Data And Methods

We conducted a mixed-methods study of North Carolina’s housing landscape and the Healthy Opportunities Pilots’ design and implementation from December 2020 to November 2023.

Quantitative Data

We used data on housing problems from Cape Fear Collective’s Community Data Platform, which compiles North Carolina data from public sources and partner organizations. From this platform, we mapped the Census Bureau’s American Community Survey 2017–21 five-year estimates data on “severe housing problems,” defined by the Department of Housing and Urban Development (HUD) as housing with inadequate kitchens, inadequate plumbing, overcrowding, or housing cost burden, in Healthy Opportunities Pilots census tracts. In each Healthy Opportunities Pilots region, we identified tracts in the top quartiles statewide for each severe housing problem and then categorized them into tracts with quality issues (inadequate kitchen or plumbing) and tracts with availability issues (overcrowding or cost).

We used internal NCDHHS data on Healthy Opportunities Pilots housing service delivery by county and Pilots region (from delivery start on May 1, 2022, through November 22, 2023) to determine total service delivery by county and to calculate percentages of housing service provision by service category, overall and by region.

Qualitative Data

To understand diverse stakeholders’ perspectives on design and implementation of Healthy Opportunities Pilots housing services, we employed three types of novel qualitative data collected by the Margolis Institute for Health Policy at Duke University. The first type was sixty-one virtual, semistructured interviews with ninety-four unique individuals across Healthy Opportunities Pilots regions, service domains, and levels of administration (NCDHHS, prepaid health plans, Network Leads, and community-based organizations) plus other subject-matter experts. Twenty-one interviews with thirty-eight people focused on housing, with roughly half occurring during planning and capacity building and half taking place one year into implementation (including people interviewed in both periods). We created semistructured interview guides, tailored to different stakeholders, based on the Framework for Comprehensive Community Wellness’s elements of cross-sectoral collaboration to address health needs.20

The second data type was six expert stakeholder meetings organized by the Margolis Institute for Health Policy at Duke University, with a total of 146 unique attendees between December 2020 and June 2023, to discuss our research design, capacity-building, and implementation experiences and implementation and policy recommendations. Attendees represented all levels of Healthy Opportunities Pilots administration plus other subject-matter experts.

The third type of data included two virtual focus groups conducted in May 2022 involving eight people with experiences in North Carolina Medicaid, six of whom were receiving Healthy Opportunities Pilots services.

All qualitative research activities were conducted in English. We identified potential interviewees and meeting attendees by soliciting recommendations from stakeholders (for example, from NCDHHS and Network Leads) and reviewing literature and online information (for example, key contacts) about the Healthy Opportunities Pilots and related programs. We identified focus-group participants in partnership with NCDHHS and Network Leads through program data and regional marketing. See appendices B and C for details of the participants and topics addressed.13 We used established, consensual, team-based qualitative research methods to analyze qualitative data and synthesize themes. Analysis used both inductive and deductive reasoning.21 Theme abstraction strategies included drafting thematic memos for each interview, convening, and focus group; debriefing on memos with our multidisciplinary research team to reflect and expand on findings and reconcile interpretations; performing thematic reduction and synthesis from memos using principles such as intensity and repetition; and workshopping themes and manuscript content with our study team.21–24

Limitations

We acknowledge several limitations. First, we used census tract–level measures of severe housing problems as a proxy for Healthy Opportunities Pilots enrollees’ housing needs. However, these data included people with higher incomes and less marginalized sociodemographic characteristics, on average, than Medicaid enrollees; therefore, our quantitative results were likely conservative. Second, participants in qualitative research activities did not fully represent all Healthy Opportunities Pilots stakeholders, especially Pilots enrollees (consistent with our focus on implementation), but we made significant efforts to achieve diversity by geography, stakeholder type, service domain, and sociodemographics. Last, we examined one state’s program providing housing services to selected Medicaid enrollees in one-third of its counties; therefore, findings are not necessarily generalizable to all North Carolina Medicaid enrollees or to other states or settings.

Study Results

The following sections describe four key themes that emerged from our research.

Theme 1

Our first theme was that the housing landscape varies within and across Healthy Opportunities Pilots regions. Several features of the housing landscape make these regions distinct from other areas of the country, with important implications for addressing housing needs. Although all Pilots regions are predominantly rural (North Carolina has the second-largest number of people residing in rural areas nationwide), each also has metropolitan areas, which interviewees noted creates housing cost challenges.25 North Carolina also has the second-largest number of heirs’ properties nationwide (that is, land passed down through generations without wills or titles), which interviewees noted creates challenges to addressing housing needs in all Pilots regions.26 Heirs’ property ownership, which is disproportionately concentrated among racial and ethnic minority groups and low-income households, presents unique challenges to repairing homes, qualifying for public assistance, and selling property.

There are also distinctive features of each Healthy Opportunities Pilots region. Coastal North Carolina is vulnerable to hurricanes; interviewees in the eastern and southeastern regions noted that this creates housing challenges. Interviewees said that the southeastern region includes coastal areas where most construction is for luxury properties, contributing to insufficient affordable housing in the region. Western North Carolina has the highest proportion of older homes with inadequate plumbing.27

Together, these landscape features contribute to the observed variation in severe housing problems (exhibit 1), influencing the distribution of the types of Healthy Opportunities Pilots housing services provided as of November 22, 2023, across the Pilots regions (exhibit 2). See appendix D for additional details on the distribution of housing problems and Healthy Opportunities Pilots service delivery.13 The western region had the highest percentage of census tracts with significant quality issues (exhibit 1); accordingly, that region provided the highest proportion of Healthy Opportunities Pilots services for housing quality and safety modifications (20.1 percent). The southeastern region, in contrast, had the highest percentage of tracts with significant availability issues. Although the western region provided the highest proportion of Pilots services for housing and utility cost mitigation overall (38.3 percent), the vast majority were for utilities (data stratified beyond exhibit 2 not shown). The southeastern region provided the highest proportion of services specific to housing cost mitigation (data stratified beyond exhibit 2 not shown), which is likely more indicative of addressing availability issues. The eastern region had the highest proportion of tracts with significant challenges in both quality and availability; hence, the distribution of Pilots housing service delivery by category in the region was closest to the overall average. As housing navigation case management is a prerequisite for several housing services, it represented the largest proportion of services provided in each region and overall (68.3 percent).

Exhibit 1 Geographic distribution of severe housing problems in North Carolina Healthy Opportunities Pilots regions, by census tract, 2017–21

Exhibit 1
SOURCE Authors’ analysis of data from the Census Bureau’s American Community Survey 2017–21 five-year estimates compiled in the Cape Fear Collective Community Data Platform. NOTES Map indicates census tracts in Healthy Opportunities Pilots regions in the top quartiles statewide for at least one of four severe housing problems, as defined by the Department of Housing and Urban Development. Housing availability issues are severe problems with overcrowded housing or high housing cost. Housing quality issues are severe problems with inadequate kitchen facilities or inadequate plumbing. Data for nine tracts were suppressed because of a small population. Additional details are in appendix D (see note 13 in text).

Exhibit 2 Distribution of housing services delivered in North Carolina Healthy Opportunities Pilots regions, by service category, May 2022–November 2023

Exhibit 2
SOURCE Authors’ analysis of housing service delivery data from the North Carolina Department of Health and Human Services from May 1, 2022, through November 22, 2023 (covering the initial 19 months of housing service delivery through the Pilots). NOTES Housing navigation case management includes housing navigation, support, and sustaining services. Housing quality and safety modifications includes inspection for housing safety and quality, home remediation services, home accessibility and safety modifications, and healthy home goods. Housing and utility cost mitigation includes one-time payment for security deposit and first month’s rent, housing move-in support, essential utility setup, and short-term posthospitalization housing. The southeastern region had 12,650 housing services delivered; the western region, 5,333 housing services delivered; and the eastern region, 4,889 housing services delivered. All regions combined had 22,872 housing services delivered. Regions are depicted in exhibit 1. Additional details on housing service descriptions are in appendix A (see note 13 in text).

Theme 2

Our second theme was that defining and pricing housing services in Medicaid is complex and requires balancing flexibility with quality guardrails. NCDHHS engaged many local and national stakeholders to develop the Healthy Opportunities Pilots fee schedule and identified reference points, where possible, to similar services covered through other Medicaid mechanisms, such as Section 1915(c) waivers.8,28 Interviewees appreciated this process but noted that housing services were particularly challenging to define and price.

Several Healthy Opportunities Pilots housing services have flexible definitions to cover a variety of housing-related issues (for example, safety modifications can cover dozens of different fixes). Interviewees appreciated this flexibility but noted key limitations. First, although the Pilots’ legal support service helps members understand their legal rights and options, interviewees noted that its impact would be enhanced if community-based organizations providing this service had the authority to request information from landlords (for example, leases, payment histories, and grounds for eviction) and provide assistance in resolving landlord disputes. Second, flexibility in housing service definitions must be paired with appropriate quality guardrails to protect against fraud, waste, and abuse (for example, some Pilots housing services require a housing inspection that adheres to HUD’s housing quality standards, which the Pilots’ inspection service can cover). Last, several Pilots housing services are based on the Housing First model, which is an approach to houselessness assistance that is supported by strong evidence.29 In the Pilots, these services can be offered to both housed and unhoused enrollees. Accordingly, the impact and return on investment for this program may be smaller than in prior studies, complicating definitions (and pricing). Nevertheless, the Healthy Opportunities Pilots program presents an important opportunity to understand the impacts and costs of housing services in a broader population.

Healthy Opportunities Pilots housing services were also difficult to price to accommodate definitional flexibility. First, the housing domain contains the Pilots’ most expensive services (for example, accessibility and safety modifications authorize up to $10,000); nevertheless, interviewees felt that caps on certain housing services were too low. For example, many clients had unpaid utility bills that were quadruple the cap. Second, the first month’s rent service depends on Fair Market Rent standards that lag behind both inflation and the current housing market.

Several interviewees noted the need for continual reassessment of fees to reflect the “true cost” of services, including considering housing inflation. Recognizing this, NCDHHS adjusted several housing service prices in May 2023. Community-based organizations also emphasized that time spent on administrative tasks related to service delivery (for example, interacting with clients, landlords, or contractors and travel time to homes) was not adequately covered. Some services have embedded administrative fees, whereas others are intended to be delivered in conjunction with services that cover administrative costs; many community-based organizations reported that this was insufficient to cover their costs. Housing navigation can require sequencing different referrals (for example, inspection, then utility setup, then move-in support) and communicating with landlords, community-based organizations, and contractors; interviewees thought that the per member per month rate underestimated the true cost of these steps.

The flexibility provided through Healthy Opportunities Pilots housing service definitions allowed community-based organizations to creatively address emergent pricing challenges. For example, one Pilots client’s home had significant flooring damage, creating safety risks and problems with pests. The repair estimate was $2,000 over the service cap for safety modification only. By providing a combination of remediation (pest control) and safety modifications (flooring), the community-based organization was able to complete repairs.

Theme 3

Our third theme was that successful implementation of housing services involves engaging diverse stakeholders. Interviewees noted that Healthy Opportunities Pilots housing service implementation (identification, enrollment, referrals, and delivery) is particularly complex. First, many housing problems are not revealed until housing navigation or inspection services are delivered. Despite the cross-domain services’ links to housing, one community-based organization shared that care managers are often unsure when to make a cross-domain service referral; they worked with a care management entity to clarify guidance. One Network Lead responded by convening biweekly meetings with care managers and community-based organizations to share issues and innovations. Interviewees recommended increased technical assistance specifically for housing-related services.

Second, most Healthy Opportunities Pilots housing services require community-based organizations to work with landlords. Home remediation or accessibility and safety modifications require landlords to provide written consent approving service delivery. Further, for services covering rent, landlords must agree to maintain a satisfactory dwelling for a defined time. Initially, this agreement included not raising rent, but this requirement was later dropped. These agreements pose a concern to some landlords, hindering service delivery. Network Leads and community-based organizations had not anticipated the need to create landlord agreements and thus developed them ad hoc until Network Leads regionally standardized the language.

Third, interviewees stressed the complexity associated with ensuring a sufficient workforce to provide Healthy Opportunities Pilots housing services. Many housing service providers are independent construction contractors whom community-based organizations contract with instead of employing directly. Some community-based organizations reported challenges with securing contractors who would accept fee schedule prices and balancing contractors’ availability with unpredictable referral volumes.

Housing community-based organizations maximized success by leveraging existing infrastructure, partnerships, and services outside of the Healthy Opportunities Pilots. One community-based organization had extensive experience participating in HUD initiatives and adapted knowledge and service delivery approaches from these programs for the Pilots. The organization also works with a local HUD Continuum of Care program to refer unhoused Pilots clients for additional assistance. Several community-based organizations deliver housing-related services through programs outside of the Pilots that help fully address clients’ needs. Several stakeholders wanted NCCARE360 to interface with local housing systems (for example, Homeless Management Information Systems), to improve coordination and evaluation.

Theme 4

Our fourth theme was that housing is the most expensive Healthy Opportunities Pilots service domain, necessitating creative financial models to sustain community-based organization capacity. Interviewees highlighted challenges with the Pilots’ financial model that hinder sustainability, especially for community-based organizations. They emphasized that because housing is the most expensive Pilots service domain, and prepaid health plans have up to sixty days after receiving an invoice to reimburse a community-based organization, up-front costs can become increasingly unmanageable as referral volume increases. Cash-flow challenges, which one interviewee emphasized were the biggest program challenge to date, caused some community-based organizations to decline new referrals—despite having staff bandwidth—because of reimbursement delays, hindering enrollee access. Some interviewees noted opportunities to reduce the detailed documentation requirements for invoices, hastening payment approval.

Accordingly, Healthy Opportunities Pilots entities developed creative solutions. NCDHHS permits community-based organizations to cover up-front costs with capacity-building funds while waiting for reimbursement. One Network Lead developed three innovative solutions, supported by local philanthropy. First, they established a Business Solutions Center for community-based organizations that provides coaching and support for health information technology, accounting and finance, and human resources needs; sustainability planning; and other resources.5 Second, they partnered with a local data-focused community-based organization to create a directory that links to NCCARE360 and helps monitor community-based organizations’ capacity to accept referrals and deliver services. Third, they established a zero-interest credit line for community-based organizations when capacity-building funds are unavailable. There is interest in developing these innovations into sustainable programwide solutions.

Discussion

Below, we discuss additional considerations for the Healthy Opportunities Pilots and similar programs that could help maximize their initial and ongoing success.

Connections To Prior Literature

Our study presents timely findings for other states and federal officials on implementation challenges and innovative solutions to deliver housing services through Medicaid. Studies of other states’ Medicaid housing programs note between-state variation in housing needs and emphasize the need for flexibility in service design;30,31 this study also identified significant within-state variability, and its findings illustrate the importance of housing service flexibility in practice. On housing service design, this study and others emphasize the importance of multistakeholder input, care coordination, and pairing definitional flexibility with implementation guidance and guardrails against low-quality services;30–33 this study adds the importance of legal supports for housing needs. Finally, this study adds novel discussion of how Medicaid housing service pricing design and definitional flexibility can influence solutions to emergent cost issues.

Relevance For Evolving Regulatory Context

Our findings are critical as Healthy Opportunities Pilots implementation continues in the context of the state’s evolving health policy landscape.

Our findings are critical as Healthy Opportunities Pilots implementation continues in the context of the state’s evolving health policy landscape. Medicaid expansion in North Carolina in December 2023 increased the eligible population for Pilots services. Studies from other states show that Medicaid expansion in itself is associated with positive housing-related outcomes, including reduced evictions.14 North Carolina’s waiver renewal application proposes extending the Healthy Opportunities Pilots for another five years, expanding the program statewide, broadening eligibility criteria, expanding some existing services (including housing), and offering several new services.6

Comparing North Carolina’s recent waiver renewal application with the Healthy Opportunities Pilots’ current design (approved in 2018) illustrates some policy design impacts of the evolution in CMS policy guidance and waiver approvals.1–3,6 Compared with social service agencies, Medicaid’s role in providing housing services may be limited, but CMS’s expanded interpretation of what “health-related” housing services are, who is eligible, and how they achieve the objectives of Medicaid reflect a growing evidence base.14–16 One major influence on the original waiver design was tying housing and utility cost-mitigation services to transitions from inpatient and institutionalized settings.2 The Healthy Opportunities Pilots broadened these services beyond medical transitions, although NCDHHS only requested one-time, prospective rent coverage for one month and required pairing it with a housing stability plan. Based on new precedent and stakeholder feedback, North Carolina now proposes extending housing and utility cost-mitigation services to cover six months, including payments of arrears, and adding mortgage assistance.2 Similarly, in 2018, CMS only approved health-related social needs services for chronically ill populations.2 Moving beyond precedent, North Carolina now proposes extending Healthy Opportunities Pilots eligibility to include people at risk for chronic disease. Finally, in 2018, CMS emphasized per unit prices of social needs services, influencing North Carolina’s fee schedule approach while also requiring value-based payment components.34

Participants in our study suggested modifying Healthy Opportunities Pilots housing services to better meet members’ needs (for example, emergency and short-term housing assistance, assistance with overdue rent, foreclosure prevention assistance, and expanded legal supports); some of these suggestions were included in North Carolina’s waiver renewal request, as described above. Exemplifying how the scope of the Pilots’ legal supports service could be expanded, New Jersey’s Section 1115 waiver allows service providers to assist “in resolving disputes with landlords” as part of housing tenancy–sustaining services.35 In addition, several participants in our study noted that adding a Healthy Opportunities Pilots service domain focused on economic insecurity could more efficiently address root causes of housing problems, but this lacks precedent.

Moving Toward Accountable Payment And Delivery Models

Alternative financial models are necessary to sustain the capacity to address housing-related needs.

Alternative financial models are necessary to sustain the capacity to address housing-related needs. Value-based payment models, such as prospective payment or budgets with ties to quality, could provide up-front capital, flexibility, and sustainable funding so that community-based organizations could provide services without billing burden.36 However, this would be challenging for certain Healthy Opportunities Pilots housing services for which an outcome of success is individually contextualized and difficult to predict. Designing a bundled payment for multiple housing services (suggested by interviewees) could provide flexibility and encourage coordination of services, as long as supports are provided to not disadvantage smaller or specialized community-based organizations. A future financial model might involve two payment mechanisms: prospective funds for more predictable and quantifiable services that can be tied to an outcome and fees for more ad hoc, unpredictable services. It is critical that the flexibility of any such financial arrangements be paired with mechanisms to protect community-based organizations from financial risk. For example, Network Leads and equivalent organizations in other states could manage prospective funding for their contracted community-based organizations’ service delivery (similar to New York’s proposal in its recently approved Section 1115 waiver amendment) to reduce managed care reimbursement delays without placing risk on community-based organizations.37

Value-based payment models incorporating social needs are novel, with incentives for screening being most common, but they have made limited progress toward measuring or paying for the quality of health-related social needs services.19 The National Committee for Quality Assurance recently introduced a Healthcare Effectiveness Data and Information Set measure to assess health plans’ performance on housing, food, and transportation screening and intervention, which could increase accountability.38 Early success could be rewarded through financial incentives to community-based organizations and Network Leads for milestone achievement and process measures (for example, the rate of referrals resulting in service delivery), which North Carolina employed in its current waiver. Transitioning to value-based payment models for social services at scale will require additional evidence to determine true costs and effective “doses” of social services and what constitutes high-quality services at different levels of administration (for example, health plans, community care hubs, clinicians, and community-based organizations).

Opportunities To Improve Cross-Sectoral Collaboration

Advancing broader partnerships and braiding funding with the housing sector is critical to more comprehensively and sustainably addressing housing-related needs.39 Entrenched silos for health care and housing providers are a common challenge to implementing Medicaid programs that address housing needs.40 In November 2023, the Department of Health and Human Services and HUD announced the Housing and Services Partnership Accelerator, which aims to support states in improving collaborations to expand access to housing-related supports through Medicaid.41 As Medicaid programs implement housing-related programs through new flexibilities and partnerships, continued technical assistance from federal policy makers would be useful for addressing common implementation issues.

Conclusion

As states consider programs to address housing-related needs, our analysis of the lessons learned from North Carolina’s Healthy Opportunities Pilots offer actionable insights related to the following implementation considerations and their relations to Medicaid policy: facilitating and sustaining cross-sectoral collaborations to address housing-related needs, defining and pricing housing services, and streamlining and tailoring housing service delivery.

ACKNOWLEDGMENTS

The authors acknowledge grant support for this work from the Kate B. Reynolds Charitable Trust. The authors thank Matt Gawthrop for his assistance with data collection, Anna Casey for her assistance with data analysis, and both Emma Sandoe and Mark McClellan for their feedback. Nicholas Pylypiw was at Cape Fear Collective, in Wilmington, North Carolina, when this work was performed. The information in this article does not necessarily reflect the views of the North Carolina Department of Health and Human Services. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) license, which permits others to distribute this work provided the original work is properly cited, not altered, and not used for commercial purposes. See https://creativecommons.org/licenses/by-nc-nd/4.0/. To access the authors’ disclosures, click on the Details tab of the article online.

NOTES

   
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