Health Starts

Health Starts is TennCare’s approach to improving the health of Tennesseans by focusing on the conditions where they live, work, and play. TennCare’s vision for Health Starts is that all TennCare members are screened for Social Determinants of Health (SDOH) with a unified screening tool and identified needs are met by community resources, resulting in the improved health of each TennCare member. Examples of SDOH include safe housing, access to nutritious foods and transportation, education, and job opportunities. TennCare has identified three interconnected workstreams to achieve this vision: Provider Partnerships, Technology Supports, and Workforce Development.

If you have any questions related to Health Starts, please email health.starts@tn.gov.

Provider Partnerships

SDOH, or non-medical risk factors, that go unaddressed can contribute to negative health outcomes for individuals and increased health care expenditures for the State. The purpose of the Provider Partnerships is to address social needs and improve health outcomes of TennCare members through the providers they see for health care. TennCare’s Managed Care Organizations partner with health care providers across the state to screen for non-medical risk factors, refer members to appropriate community-based organizations (CBOs), and close the loop on referrals to ensure needs have been met. The partnerships established between the MCOs, providers, and CBOs expand the capabilities of different provider groups and increase the reach of CBOs within the community.

The Provider Partnerships also aim to gather data regarding best practices related to screening, referring, and closing the loop. This data will help determine a pathway to address the social needs of TennCare members through scalable and sustainable solutions.

To learn more about this effort, please read the issue brief about Tennessee Medicaid’s Health Starts Provider Partnerships.

If you're a provider, and you want to address social needs in your community, please reach out to the contact for your Managed Care Organization.

Closed-Loop Referral System

TennCare selected a Closed Loop Referral System (CLRS) vendor, Findhelp, through a competitive procurement process. The TennCare CLRS has been branded as “Tennessee Community Compass”. The primary components of Tennessee Community Compass include:

1. Health-Related Social Needs (HRSN) Assessment – Embedded in MCO case management systems and key provider partner EHRs to identify Health-Related Social Needs (HRSN) of TennCare members.
2. Community Resource Directory – Available now! This public directory houses free and reduced cost services categorized by domain that can help meet identified HRSN. This is a free resource for all Tennesseans, and it can be accessed by going to the Tennessee Community Compass website.
3. Referrals to Community Based Organizations (CBOs) – CBOs are being onboarded across the state in partnership with MCOs, Findhelp, and the Rural Health Association to accept and respond to HRSN referrals.
4. Track Social Needs Outcomes - The system will serve as a repository of data for TennCare to assess HRSN across providers and MCOs over time.

TennCare’s Vision for Tennessee Community Compass

1. Strengthened Community Based Organization Relationships
2. Connect members to Health-Related Social Needs (HRSN) resources
3. Unified approach to address HRSN for members and their care teams enabled by one single system
4. Collect meaningful data and develop an integrated database to measure impact of addressing

Workforce Development

The Workforce Development workstream invests in the development of evidence-based models of care incorporating non-traditional providers to either directly address a member's health needs or to improve navigation through community resources and the health care system.