In the midst of the pandemic, many states are continuing to advance their health system transformation efforts. Rhode Island’s Medicaid Accountable Entities (AE) Program, for example, is shifting to a pay-for-performance model for several screening measures. Under this model, there is an additional financial incentive to screen children and their families for health and social needs, which have taken on new importance due to the added stressors of COVID-19.
The state developed SDOH screening requirements for the AEs. Screening tools must be approved by the Rhode Island Executive Office of Health and Human Services (EOHHS), and they must include information on the following domains: housing insecurity, food insecurity, transportation, interpersonal violence, and utility assistance.
Screening for a child’s needs can offer insights about what kinds of services, referrals, or wrap-around care are needed to ensure healthy development. Because the ongoing pandemic has required children and families to stay home and spend additional time together, a safe and supportive home environment is especially crucial for children’s health and well-being. The SDOH screening domains that are required by EOHHS overlap with adverse childhood experiences (ACEs), such as poverty, food and/or housing insecurity, neglect, and mental illness — all of which contribute to poor health outcomes for children.
Rhode Island’s AE program takes into account the benefit of a two-generation (2Gen) approach to these issues. Under a 2Gen framework, services are provided to both children and the adults in their lives simultaneously to help families live healthy and productive lives. When screening children under age 12, Rhode Island’s SDOH screening measure can be applied to an entire household instead of to only the individual child. This can provide a better understanding of how to target interventions for the whole family going forward.
This year, a key change is happening within the AE program that may increase the number of children and families served by the program. The state is shifting to pay-for-performance (P4P) for the SDOH screening requirement. Beginning in Project Year 4 (PY4), there is a financial incentive for the AEs to increase their SDOH screening rates among their attributed populations. AEs needed time to develop their screening tools and build capacity around screening for SDOH before shifting the AE incentive metric to P4P. Other measures, including documented developmental screening for children younger than age 3, will also transition to P4P in PY4.
Though the SDOH screening requirements are specific to Medicaid AEs in Rhode Island, state officials expect the screening requirements to have a ripple effect. In primary care settings, for example, if a provider is administering the SDOH to AE-attributed patients, officials expect they are likely integrating the screening into their workflows and administering it to all of their patients. This has proven to be the case with other well-child practices. For example, the AE Coastal Medical, has implemented universal screenings across all of its practices to assess and identify needs around depression, anxiety, and SDOH.
Screening is only the first step in improving health-related social needs for children and families. One of the goals of the AE program is to use screening results and the improved understanding of its members’ circumstances to improve their overall health. Rhode Island is leveraging its Quality Report System (QRS), a tool for data collection, to calculate performance on the quality measure. This tool enables providers to drill down to the patient level to identify patients still in need of screening.
An upcoming strategy to help AEs coordinate better with community partners is the procurement of a community referral system that would help connect individuals to necessary resources. Such a referral network could be linked with the QRS in the future, making data collection, analysis, and referral a centralized process. Ultimately, this initiative may drive a broader conversation about how the state collects screening data across both public and private payers, and how this data can be used to improve the health outcomes of Rhode Island residents.