Keep Up On the Partnership’s Activities

Each year the Centers for Medicare and Medicaid Services (CMS) reviews payment practices and policy changes under fee-for-service, or traditional, Medicare. The CY2024 PFS included important coding and payment changes for services to address health-related social needs (HRSNs) through separate payments for Community Health Integration (CHI), SDOH Risk Assessment, and Principal Illness Navigation (PIN) services.

In July 2024, CMS released its annual draft proposed updates for next year’s rules (CY2025 Medicare Physician Fee Schedule), which includes a request for information (RFI) regarding barriers to implementation for services to address HRSNs. 

The draft rule also includes proposed updates to:

• Caregiver Training Services;
• ACO quality measures re: screening for HRSNs; and
• the Advanced Primary Care Model (APCM)

All of these proposed changes could affect services to address HRSNs. 

On September 9, 20204 the Partnership submitted two letters to CMS on behalf of Partnership Co-Chairs and undersigned organizations. Sixty-five organizations signed on to the response to the request for information (RFI) regarding current barriers to implementing services to address HRSNs (CHI/PIN). Fifty-three organizations signed on to the letter regarding changes needed and proposed updates for telehealth, caregiver training services, ACO quality measures, and the Advanced Primary Care Model. Agency officials will review and document the more than 12,000 comments submitted as they finalize the rule.

Stay tuned for updates once we see the final rule published—likely in early November 2024. We will also be in touch with stakeholders regarding implementation resources that we plan to create and promote
once we see the final rule.

The Partnership to Align Social Care and Camden Coalition will host our eighth Coffee and Contracts session focused on compliance and risk management. Jennifer Raymond, Chief Strategy Officer at AgeSpan, and Mark Humowiecki, General Counsel & Senior Director of National Initiatives at Camden Coalition, will share their organizations' journeys with compliance and discuss what their compliance committees looks like, the policies and procedures in place, and how they meet healthcare standards. Participants will then break into groups for facilitated discussions to learn from their peers about compliance and risk management.

Register for the upcoming event here: https://bit.ly/4cY9BzY

Each year the Centers for Medicare and Medicaid Services (CMS) reviews payment practices and policy changes under fee-for-service, or traditional, Medicare. The CY2024 PFS included important coding and payment changes for services to address health-related social needs (HRSNs) through separate payments for Community Health Integration (CHI), SDOH Risk Assessment, and Principal Illness Navigation (PIN) services.

In July 2024, CMS released its annual draft proposed updates for next year’s rules (CY2025 Medicare Physician Fee Schedule), which includes a request for information (RFI) regarding barriers to implementation for services to address HRSNs. 

The draft rule also includes proposed updates to:

• Caregiver Training Services;
• ACO quality measures re: screening for HRSNs; and
• the Advanced Primary Care Model (APCM)

All of these proposed changes could affect services to address HRSNs. 

SIGN-ON REQUEST:
Please consider joining the Partnership to Align Social Care Co-Chairs and other organizational stakeholders on TWO sign-on letters offering comments. You may sign on to one or both letters: 

1. Sign-on letter responding to the RFI re: barriers to implementing services to address HRSNs
2. Sign-on letter responding changes needed and proposed updates for telehealth, caregiver training services, ACO quality measures, and the Advanced Primary Care Model

We also encourage you to download template language covering all of these issues and incorporate as applicable into your organization's response . As a reminder, comments are due by 5:00 p.m. ET on September 9, 2024, and can be submitted online.  

RESOURCES:

• SIGN-ON Letters (combined) responding to CMS CY2025 PFS Proposed Rule (pdf)
• Template language provided by the Partnership (Word version available for download)
• CMS CY2025 PFS Proposed Rule: https://www.regulations.gov/document/CMS-2024-0256-0045 
• Additional information and resources from the Partnership about this proposed rule: https://www.partnership2asc.org/implementation-resources/ and Resources List

USAging’s Aging and Disability Business Institute has released valuable resources from the 2023 CBO-Health Care Contracting Survey. Explore the data brief from their research partner Scripps Gerontology Center and the infographic and toolkit slides to gain essential insights for your organization on health care contracting. https://bit.ly/4dF0LYr

Members of the Convergence Collaborative on Social Factors of Health agreed that improving collaboration across social and health sectors—and between private and public organizations—is essential for effective SDOH strategies. Read the Collaborative’s latest Blueprint for Action consensus solutions to learn why achieving the necessary level of collaboration requires improving system integration: https://convergencepolicy.org/wp-content/uploads/2024/07/Social-Factors-of-Health-Blueprint-for-Action.pdf

The Partnership to Align Social Care and Camden Coalition hosted our seventh Coffee and Contracts session that focused on the process of vetting social care contracts from a CCH perspective. Ester Sefilyan, VP Network Services, and Anne Ly, MPH, Senior Director of Network Contracts & Systems Management, at Partners in Care Foundation discussed how their organization uses contract templates, the relationship between the CCH operations staff and the contracting officer, and how their team works with outside legal counsel. Participants broke into groups for facilitated discussions to learn from their peers about vetting social care contracts.

Link to recording

Meeting Slides (PDF)

Resource: Partners in Care Foundation Contract Terms worksheet (pdf)

Meeting summary and notes (pending)

The Partnership to Align Social Care hosted a webinar, What Does the CY 2025 Medicare Physician Fee Schedule Proposed Rule Mean for Addressing HRSNs? on Tuesday, July 30.

Attendees heard an overview and discussion of these updates and learned about relevant CMS requests for information, and additional opportunities to inform the public comment process. CBOs and community care hubs, health plans, health systems, Federally Qualified and Rural Health Centers (FQHCs and RHCs), other healthcare providers, and caregiver advocate attendees learned about how the proposed coding and payment changes could impact efforts to align health and social care ecosystems.

This session focused on the intersection of data security, compliance, and quality improvement from a Community Care Hub perspective. Abigail Morgan, President & CEO of Direction Home Akron Canton Area Agency on Aging & Disabilities, discussed the milestones in her organization's journey to develop their data security infrastructure and shared lessons learned. Participants broke out into groups for facilitated discussions to learn from their peers about data security experiences and opportunities.

Link to recording

Meeting Slides (PDF)

Meeting Summary and Notes (PDF)

The session focused on data sharing experiences from health plan, CBO, and CCH partnerships. Jolene Tanner, Senior Director of Health and Social Programs at United Healthcare, and Amy Fynmore, Housing and Health Program Manager at United Health Group, provided an overview of various data sharing arrangements including through community investment and direct vendor relationships. Attendees also had the opportunity to break into moderated group discussions with their peers.

Link to Recording

Meeting Slides (PDF)

Meeting Summary and Notes (PDF)

This session focused on what to expect from negotiations with a health plan when developing a contracted partnership. Nikki Kmicinski, Executive Director at Western New York Integrated Care Collaborative, Inc., shared her experiences in negotiating with healthcare organizations and discussed strategies to achieve a mutually beneficial contract for both parties. Attendees also had the opportunity to break into moderated group discussions with their peers.

Link to Recording

Meeting slides (PDF)

Meeting Summary and Notes

The Partnership to Align Social Care hosted a lunch and learn event on April 3, which was the first in a series of upcoming resources, A Primer: Understanding the Medicare Physician Fee Schedule Billing Codes for Community Health Integration (CHI), Principal Illness Navigation (PIN), and Principal Illness Navigation - Peer Support (PIN-PS) Services.

This webinar aimed to build upon previous Partnership events detailing opportunities to address HRSNs through fee-for-service Medicare. Attendees will have an opportunity to ask questions to help inform planning for, and implementation of, CHI and PIN services.

This month’s Gravity Implementation Affinity Group featured Timothy McNeill, RN, MPH from the Partnership to discuss the new calendar year 2024 social needs HCPCS codes. Implementers learned how Gravity SNOMED-CT intervention codes align with and support additional documentation aligned with regulatory and policy drivers.

Thank you to Civitas Networks for Health for your support of the Gravity Implementation Affinity Group meetings.

Our Partnership to Align Social Care co-chair, Timothy McNeill, RN, MPH, spoke at USAging's Aging Policy Briefing with colleagues from around the nation about the 2024 Medicare Physician Fee Schedule and how to implement changes in billing codes to better align care between CBOs, health entities, and Area Agencies on Aging.

Tim was joined by Kelly Cronin, Deputy Administrator, Center for Innovation and Partnership, U.S. Administration for Community Living; Doug Jacobs, MD, MPH, Chief Transformation Officer, Center for Medicare & Medicaid Services; and Christine Vanlandingham, CEO, Region IV AAA in St. Joseph Michigan.

We encourage you to learn more about these changes in the Medicare Physician Fee Schedule here: https://go.cms.gov/4c5f090

Join the Partnership to Align Social Care and Camden Coalition for a monthly peer learning series that provides an opportunity for presenters and participants to go deeper into specific topics related to contracting between CBOs/CCHs and healthcare organizations.

Sessions will allow participants to:

• Participate in peer-to-peer learning about contracting between CBOs, CCHs, and healthcare organizations;
• Learn about and engage with stakeholders and leaders of the Partnership to Align Social Care;
• Find opportunities to support new CCHs and get involved in ongoing national initiatives;
  Generate new learning which can be packaged into future resources and leading practices.

Register for the series and learn more at www.partnership2asc.org/coffee-and-contracts!

The recording and materials are available for the February 27, 2024 Partnership to Align Social Care event, Meeting the Administration’s Call-to-Action: Leading Practices to Address Health-Related Social Needs in Communities Across the Nation, featuring a discussion with officials from the U.S. Department of Health and Human Services (HHS) and key community and health care leaders on opportunities to address health-related social needs (HRSNs) through community partnerships.

Healthcare entities and social services providers are increasingly recognizing the importance of partnerships among historically siloed sectors to address health-related social needs (HRSNs). While the number of community-based organizations (CBOs) and community care hubs (CCHs) pursuing contracting relationships with healthcare organizations is increasing, CBOs and CCHs can experience challenges entering into contracting arrangements with the healthcare sector.

The Partnership to Align Social Care, the Aging and Disability Business Institute, and Camden Coalition created a Healthcare Guide to Contracting with CBOs. This toolkit offers a deep dive into leading contracting practices to effectively and efficiently address HRSNs. Each module focuses on the essential elements of contracting between health care and community partners and features leading practices from the field.

Healthcare entities and social services providers are increasingly recognizing the importance of partnerships among historically siloed sectors to address health-related social needs (HRSNs). While the number of community-based organizations (CBOs) and community care hubs (CCHs) pursuing contracting relationships with healthcare organizations is increasing, CBOs and CCHs can experience challenges entering into contracting arrangements with the healthcare sector.

Join the Partnership to Align Social Care, the Aging and Disability Business Institute, and Camden Coalition for a webinar series offering a deep dive into leading contracting practices to effectively and efficiently address HRSNs. In each webinar, we will focus on the essential elements of contracting between health care and community partners and feature leading practices from the field. Each event will also highlight key findings from a four-part toolkit, Healthcare Guide to Contracting with CBOs, developed with extensive input from CBOs, health plans, and health systems. While these resources were developed for a healthcare audience, CBOs, CCHs, and other health and social care ecosystem stakeholders will benefit from understanding how healthcare organizations approach the contracting process.

Attendees will gain:

• Guidance on designing a payment structure/model that aligns contracting parties around shared goals and produces value for each party (Oct. 10 @ 2 ET);
• Recommendations on how to develop an effective Scope of Work, based on insights from healthcare organizations and CBOs with extensive cross-sector contracting experience (Nov. 14 @ Noon ET);
• Insight on how payers can improve collaboration with CBOs and strategies to anticipate, avoid, and respond to common challenges that arise when CBOs, CCHs, and payers set out to work together (Dec. 12 @ Noon ET); and
• Perspective from CBO and healthcare leaders highlighting leading practices from community and health care partners that have effectively contracted to address HRSNs for multiple populations.

Registrants will receive access to all three webinars. All registrants will receive the recordings and follow-up resources. Register here: https://us06web.zoom.us/webinar/register/WN_GInAyGusSbSsqe0985JjAA

The Partnership to Align Social Care is a cross-sector effort to co-design a multi-faceted strategy to enable successful partnerships between healthcare organizations and networks of CBOs, or Community Care Hubs (CCHs). 

But, what is a Community Care Hub? Why is this model part of an important evolution toward achieving an equitable health and social care ecosystem? The Partnership and health and social care sector leaders recently hosted a series of webinars that dive into these and other important topics. All recordings and presentations are available from those events, and we encourage you to catch up and share this information with interested colleagues!

• Webinar 1: Cultivating Community Care Hubs: An Evolving Model to Improve Alignment between Health and Social Care Services outlines the important role of a CCH and provides examples from the field. (Recording and slides)

• Webinar 2: Integrating Community Care Hubs into Efforts to Address SDOH: A Playbook for State Medicaid Agencies, details the recent collaboration between Manatt Health and the Partnership to Align Social Care to create a resource for state Medicaid agencies and others seeking to partner with Community Care Hubs (CCHs) to integrate community-based organizations (CBOs) more effectively into their social drivers of health (SDOH) initiatives. The full playbook is available to download at https://www.partnership2asc.org/medicaidplaybook2022/ along with the webinar recording and slides.

• Webinar 3: Leveraging Multi-Payer Partnerships with Community Care Hubs to Build Equitable Health and Social Care Ecosystems, highlights opportunities to blend and braid multiple funding sources to support Community Care Hub capacity and service delivery and make the business case for the CCH model. (Recording and slides)

A recently released Health Affairs article, Improving Health And Well-Being Through Community Care Hubs, authored by a cohort of federal agency employees, details the importance of developing, supporting, and investing in multistakeholder collaborations to address social drivers of health. In particular, the authors point to the Partnership to Align Social Care, a national learning and action network, and its role to convene leaders across CBOs, health plans and systems, national associations, philanthropy, and federal agencies to co-design a multifaceted strategy to enable successful partnerships among health care organizations and hubs. Read the blog and more resources about Community Care Hubs at www.partnership2asc.org/cch-resources.

A new one-of-a-kind resource—prepared by Manatt Health in collaboration with the Partnership to Align Social Care, and with support from The SCAN Foundation—intends to help state Medicaid agencies seeking to partner with CBO networks and Community Care Hubs in the design and implementation of SDOH initiatives.

Working with Community Care Hubs to Address Social Drivers of Health: A Playbook for State Medicaid Agencies aims to help state Medicaid leaders and other stakeholders:

• Identify opportunities for state Medicaid agencies to partner with networks of community-based organizations (CBOs) and Community Care Hubs (CCHs) to address SDOH;
• Introduce state Medicaid leaders to the key functions of CCHs, and provide practical advice on how state Medicaid agencies can collaborate with CCHs;
• Highlight strategies to overcome existing challenges around establishing and building sustainable relationships between CBOs and health care organizations; and
• Feature practical examples, tips and links to materials used to support SDOH and CCH efforts in communities across the country.

View the full Playbook

Read the Executive Summary

Watch the Playbook webinar and download slides

During the conversation, Partnership Co-Chairs and healthcare thought leaders discussing integrating social care into healthcare delivery and the need for the organized delivery of social care services along with care coordination through a multi-stakeholder health and social care ecosystem, as part of a whole-person approach to health.

The full video recording is available on YouTube: https://www.youtube.com/watch?v=LInsgUc8wxM&t=21s

Featured Panelists and Partnership to Align Social Care Members:

• Sherry Novick, Community Health Lead, Social Health Practice, Kaiser Permanente
• Ji Im, Senior Director for Community and Population Health, CommonSpirit Health
• June Simmons, CEO and President, Partners in Care Foundation
• Tim McNeill, COO, Freedmen’s Health

CommonSpirit has also provided the partnership with a $100,000 grant, according to a July 25 press release. The partnership will use these funds and other resources to connect health organizations with social care delivery, including childcare, jobs and housing resources as a way to improve population health and health equity. 

"As one of the nation's largest providers of Medicaid services, CommonSpirit works with community-based organizations in more than 21 states because we believe it's critical to the health of the communities we serve," said Ji Im, senior director for community and population health for CommonSpirit. "Through our participation in the Partnership, we are bringing decades of best practices to help create a blueprint for the integration of health care and social services."

View Original Article

“As one of the nation’s largest providers of Medicaid services, CommonSpirit works with community-based organizations in more than 21 states because we believe it’s critical to the health of the communities we serve,” said

Ji Im, MPH, senior director for community and population health for CommonSpirit and leader of one of the Partnership to Align Social Care’s work groups.     “Through our participation in the Partnership, we are bringing decades of best practices to help create a blueprint for the integration of health care and social services.”

Research shows that aligning health care with organizations that connect people to community resources–childcare, jobs, housing, nutrition, and transportation–measurably improves the overall health of the population and can impact

up to 80 percent of health outcomes.^[1] The Partnership to Align Social Care was established to help create efficient networks that share information, are owned by the community, and supported by all the agencies, institutions, and businesses that are involved in improving health.

“CommonSpirit has been foundational to forming our Partnership and helping define its mission,” said June Simmons, MSW, Partnership to Align Social Careco-chair and Partners in Care Foundation CEO. “As a leader of one of our key workgroups, CommonSpirit is helping to convene diverse stakeholder groups to co-design a model that can be implemented across the country to create healthier communities.”

Founding organizations include health plans such as Aetna CVS Health, Elevance Health, Humana and United Healthcare; integrated delivery networks such as Kaiser Permanente; health systems including CommonSpirit and Rush University Medical Center; community-based organization (CBO) networks including the Detroit Agency on Aging, Partners in Care Foundation, and the Camden Coalition of Healthcare Providers. Liaisons from several federal agencies including the Administration for Community Living (ACL), the Center for Medicare & Medicaid Innovation (CMMI), and the Office of the National Coordinator for Health Information Technology (ONC) advise this effort.

Through the Partnership, organizations that may not typically work together have established a forum to create a framework that will build and sustain the capacity of CBO networks to provide social services. The Partnership will focus on priority issues including:

• Co-designing common standards for effective and sustainable partnerships of CBO networks, health plans, and health systems
• Identifying core attributes and competencies for CBO network credentialing
• Identifying/encouraging widespread use of existing billing codes and essential elements for a streamlined contracting process between health systems, health plans, and CBOs
• Making recommendations for infrastructure capabilities and financing for more sustainable CBO networks

CommonSpirit’s participation in the Partnership leverages its work in initiating and advancing models to close the gap between medical and non-medical providers and create a continuum of care so that patients receive the services they need to reach their greatest health potential. These include the Connected Community Network (CCN) model, which has been implemented in more than 20 different markets, to bring together diverse stakeholders to create an infrastructure for connecting underserved populations with the community resources they need. CCNs include shared governance and an innovative “community bank” concept, which creates a sustainable funding mechanism: funding partners contribute to the community bank and share in community infrastructure costs. Similarly, CommonSpirit has partnered with Pathways Community HUB Institute (PCHI) on a collaborative, outcome-based payment model for community health workers that complements the CCN and involves many of the same types of organizations and institutions.

About CommonSpirit Health
CommonSpirit Health is a nonprofit, Catholic health system dedicated to advancing health for all people. It was created in February 2019 by Catholic Health Initiatives and Dignity Health. With its national office in Chicago and a team of over 150,000 employees and 25,000 physicians and advanced practice clinicians, CommonSpirit operates 140 hospitals and more than 1,500 care sites across 21 states. In FY 2021, CommonSpirit had revenues of $33.3 billion and provided $5.1 billion in charity care, community benefit, and unreimbursed government programs. Learn more at www.commonspirit.org.

About Partnership to Align Social Care

The Partnership to Align Social Care—A National Learning and Action Network (Partnership), is a unique collective commitment to achieve meaningful alignment of health care and social care systems. The Partnership includes leaders among community-based organizations, health plans and systems, national associations and advocacy organizations, philanthropic organizations, foundation, academic institutions, federal agencies, and other key participants collaborating to co-design a strategy to enable successful partnerships between health care organizations and networks of community-based organizations (CBOs) delivering social care services delivering health-impacting social care. The Partnership aims to align with the CMS Innovation Center Strategy Refresh and aspires to support health and social care delivery system transformation that enables value-based care. Core components include shared governance, sustainable financing, multi-stakeholder accountability, and policy changes at the federal, state, and local levels. Learn more at www.partnership2asc.org.

^[1] https://www.rwjf.org/en/library/research/2019/02/medicaid-s-role-in-addressing-social-determinants-of-health.html

Members of the Partnership are collaborating to co-design a plan to build the full capacity of community based organizations (CBOs) to deliver health-impacting social care.The Partners in Care Foundation has received a one-year, $350,000 award from the Robert Wood Johnson Foundation to support a multi-disciplinary group known as the Partnership to Align Social Care – A National Learning and Action Network (Partnership).

Members of the Partnership are collaborating to co-design a plan to build the full capacity of communitybased organizations (CBOs) to deliver health-impacting social care.

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