4. Non-Medical Drivers of Health

4. Non-Medical

Drivers of Health

NC DHSS should increase resources in NCCARE360 and CBOs to ensure their ability to address non-medical drivers of health.

Implementation: • NC DHHS should increase advertising and communication to community-based organizations on NCCARE360.

• NC DHHS should invest in technical assistance and resources to communitybased organizations to incorporate NCCARE360 into their practice.

• NC DHHS should set a community reinvestment requirement for PHPs.

North Carolina Context

Many North Carolinians face conditions including food insecurity, housing instability, unmet transportation needs, and interpersonal violence, all of which impact their health and well-being. More specifically, over 1.2 million North Carolinians cannot find affordable housing; the state has the eighth highest rate of food insecurity; 47 percent of North Carolina women experience intimate partner violence; and nearly a quarter of North Carolina children have experienced adverse childhood experiences.138 Screening and identifying these unmet needs provide opportunities for intervention, to improve health outcomes and to generate cost savings. NC Medicaid is a leader in the country in its effort to integrate non-medical drivers of health into models of care. The state has taken several initiatives to address non-medical drivers, including creating a set of nine standard screening questions for providers to determine if Medicaid enrollees face barriers related to transportation, food, housing, or interpersonal safety and developing Healthy Opportunities to improve screening for social needs, care coordination, and the provision of non-medical services to its Medicaid population.139 Furthermore, the state has created a statewide platform called NCCARE360, where providers can refer and connect patients to community-based organizations (CBOs). The coordinated care network was launched in 2019 and now boasts over 1,000 CBOs that connect people to resources they need in all 100 counties.140 However, one challenge has been a lack of widespread use of NCCARE360 by health care providers and community-based organizations.141 Stakeholder interviews indicated a need for greater awareness of NCCARE360 across provider networks as well as greater organizational capacity to implement it. CBOs cited a lack sufficient staff and technical training to implement NCCARE360 at a larger scale.

The effectiveness of these programs to connect people to local services depends heavily on CBOs’ resources and ability address people’s needs. The COVID-19 pandemic has impacted nonprofits in the state; 87 percent of nonprofits report lower than usual revenue and 77 percent report higher demand than usual for services.142

Evidence

Non-medical drivers of health are particularly important for people with SCD, who are more likely to experience structural barriers and racial disparities that exacerbate the physical and behavioral health challenges associated with SCD and result in worse health outcomes.143 A study examining universal screening for social determinants in patients with SCD in a pediatric hematology clinic at the Boston Medical Center found that 66 percent of patients screened positive for at least one unmet socioeconomic need with an average of 2.1 unmet needs per patient (among patients with unmet needs). The most common unmet need was food insecurity, followed by difficulty paying utilities, a desire for more education, unemployment, transportation, housing, and childcare.144 The same study found that patients were proactive after being referred

to community organizations, with 45 percent reaching out to resources within two weeks, demonstrating the benefits of a screening and referral program for people with SCD. Similarly, for pregnant and postpartum women with Medicaid, non-medical drivers of health can affect health outcomes. A study found that attending fewer than 10 prenatal appointments and having preexisting conditions, such as obesity or diabetes, were significantly associated with maternal mortality.145 Non-medical factors, such as lack of transportation or lack of healthy foods, inhibit access to prenatal care and contribute to adverse risk factors such as obesity and diabetes. Screenings and referrals have shown promise in improving health outcomes for pregnant and postpartum women. For example, women referred to and participating in the Supplemental Nutrition Assistance Program (SNAP) benefits have a reduced likelihood of pregnancy-related ED and lower rates of preterm births.146 Additionally, screening for domestic violence among pregnant women increased identification of and interventions for domestic violence.147

Additional Considerations

In the short-term, NC DHHS should increase funding to increase resources and technical assistance to CBOs to adequately implement NCCARE360. Additionally, there is still a lack of wide-spread awareness of NCCARE360, which inhibits its uptake. Potential avenues to increase engagement include web conferences, print material in newspapers and flyers, and social media posts. In the medium-term, NC DHHS can increase the capacity of CBOs to address non-medical needs through community reinvestment requirements, which require PHPs to spend a portion of profits or reserves on local communities. Currently, NC DHHS requires PHPs to engage with community organizations and incentivizes (but not mandates) PHPs to invest in communities; PHPs can include voluntary contributions to “health-related resources and initiatives that advance public health and Health Equity” towards their medical loss ratio, including “support for community-based organizations that provide meals, transportation or other essential services.”148 NC DHHS should set a community reinvestment requirement for PHPs, which can be modeled after Arizona’s MCO contracts. Arizona mandates its MCOs to re-invest six percent of their profits towards community reinvestment.149 PHPs have leeway to determine where to invest, which can include investing in CBOs or generally tackling non-medical drivers of health.150