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.
Health Starts Success Story: Matthew
A TennCare member and his family have a new lease on life thanks to our Provider Partnerships program with Catalyst Health Solutions. Provider Partnerships is part of Health Starts, which is TennCare’s approach to improving the lives of Tennesseans by focusing on the conditions where they live, work, and play. The goal of Provider Partnerships is to address social needs and improve member health outcomes through the providers they see for health care. Through this program, Managed Care Organizations partner with providers to screen members for non-medical needs and refer community resources to help them.
Before receiving individualized treatment for substance abuse through Catalyst Health Solutions, Matthew says “Life was rough trying to juggle life, children, and addiction.” The 36-year-old, his wife, and their three children all receive medical, behavioral health, and support services through TennCare. According to Matthew, the resources provided through Catalyst and BlueCare —including gas, food vouchers , and medications—have made all difference. At one point, Matthew had difficulty finding work and food vouchers helped him keep his family fed. Once he did find employment, gas vouches empowered him to get to work, see his care team, and make sure his kids got to their appointments, too. “Before I was never able to go to the doctor. Now I’m able to get the help I needed. I have a family doctor […] I’m also able to go to urgent care when I need to.”
More specifically, the member’s provider Dr. Seaton oversees his medication and health referrals, while his counselor Lauren Graham helps offers resources and guidance on parenting. With their support, Matthew’s able to focus on what really matters: “I am working on finding full time employment so I can provide better for my family,” he says. He’s also found time for fun and trying new hobbies, “like fishing and playing video games.”
For those in his situation, Matthew says “Don’t be scared, I was at first. I was afraid of getting in trouble with the Department of Children’s Services. But Catalyst really wants to help, and they have. I wanted to do it earlier than I did but was afraid. I’m so glad I did.”
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.
UnitedHealthcare Community Plan |
April Blair Social Drivers of Health Director april_a_blair@uhc.com |
Wellpoint (formerly known as Amerigroup) |
Emily Goolsby, LMSW Health Starts Program Manager emily.goolsby@wellpoint.com |
BlueCare |
Trish Olivier, M.Ed, M.S. Manager, Innovative Partnerships & Strategic Improvement Trish_Olivier@BCBST.com |
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:
- 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.
- 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.
- 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.
- 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
- Strengthened Community Based Organization Relationships
- Connect members to Health-Related Social Needs (HRSN) resources
- Unified approach to address HRSN for members and their care teams enabled by one single system
- 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.
Definition
According to the American Public Health Association1, a community health worker (CHW) is “a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served.” CHWs serve as links between the community and health/social services to expand access to care and improve health outcomes. CHWs have been shown to improve health outcomes, lower healthcare costs, and reduce health disparities when integrated into communities in a coordinated, intentional model of care
Infrastructure
TennCare is investing in CHW infrastructure through grant opportunities to increase continuity, capacity, and sustainability of the CHW workforce. The TennCare CHW Grant Opportunity was created to support the CHW infrastructure and assist CHWs in meeting CHW program standards and best practices by:
1. Supporting organizations employing CHWs to make key investments in organizational infrastructure and overhead costs
2. Providing technical assistance to organizations employing CHWs to implement evidence-based best practices and integrate evidence-based CHW models
3. Developing CHW program standards and establishing an accreditation entity to develop pathways for CHW sustainability
The grantees will create CHW organizational infrastructure and utilize technical assistance to implement CHW models that strengthen the CHW workforce and improve the lives of TennCare members across the state.
2023 TennCare CHW Infrastructure Grant Awardees
- BCBST Sanitas
- Darsalud (Lifedoc Health)
- Matter Healthcare
- Methodist LeBonheur Healthcare
- Regional One Health
- Senior (IHCM) Solutions
- Siloam Health
2024 TennCare Infrastructure Grant Awardees
- Ascension Saint Thomas Health
- Ballad Health
- ConnectUS Health
- Family Care Wellness
- Homeland Heart Birth & Wellness Collective
- Interfaith Dental Clinic of Nashville Inc.
- Matthew Walker Comprehensive Health Center, Inc.
Detailed information about the CHW Infrastructure Grant can be found in the attachments below:
- CHW Infrastructure Sample Grant
- CHW Infrastructure Year 2 Sample Grant
- TennCare CHW Infrastructure Grant Kick-Off Slides
Accreditation
TennCare aims to establish program standards for CHW organizations that reflect evidence-based practices and align expectations between CHW organizations, TennCare, and TennCare MCOs. TennCare is partnering with Tennessee Community Health Worker Association (TNCHWA), a statewide CHW association, to develop statewide CHW program standards and a pathway to establishing an accreditation entity. Through this initiative, TennCare will invest in key statewide efforts to establish a training or certification program to train for core competencies.
By the end of Year Two, grantees must meet requirements for successful submission of application or attainment of Program Accreditation as outlined by TNCHWA. TNCHWA will lead the implementation of this accreditation program while collaborating with TennCare and the National Committee Quality Assurance (NCQA).
References:
Overview
The State has committed to understanding the doula workforce and its role within Tennessee to support women and babies. This commitment includes implementing doula pilot projects, facilitated by the state’s Managed Care Organizations (MCO), to increase understanding around the barriers, challenges, and opportunities specific to Tennessee regarding doula services and programs for individuals covered by Medicaid.