The Alliance for Rights and Recovery’s Waiver Community Connection Initiative
Beginning in January 2025, community-based agencies (CBOs) and providers will begin conducting “health-related social needs” assessments of all Medicaid members.
Based on the results of the assessments, referrals can be made to services and supports that match each person’s needs.
For Medicaid members in managed care programs, health related social need services can be offered to assist with housing, food, transportation, and case management. For example, healthy packaged meals delivered may be delivered to people who have food insecurities.
Social Care Networks, groups of service providers who are connected through and working under a lead agency to coordinate and provide services to eligible people, will manage the overall system to document every assessment and referral. The goal is to measure outcomes to determine how social supports can improve health care.
The Waiver Community Connection Initiative, a project of the Alliance for Rights and Recovery, is dedicated to supporting the goals of the New York Health Equity Reform 1115 Medicaid Waiver to reduce health disparities among New Yorkers and ensure eligible Medicaid Members have access to the new services available through the waiver. Health disparities refer to differences in health outcomes among different groups of people, such as higher rates of diabetes or lower life expectancies for racial groups. These disparities are often linked to social, economic, and environmental disadvantages, as well as systemic inequalities in access to health services and resources.
As New York State’s Medicaid program increasingly focuses on Social Determinants of Health (SDOH), the conditions in which people live, learn, work, and play, the 1115 Medicaid Waiver introduces a long-sought shift from only funding medical services to addressing the health-related social needs (HSRNs). HRSNs refer to the immediate, individual-level social and economic factors that impact a person’s health and well-being. These needs are often tied to the broader Social Determinants of Health (SDOH) but focus specifically on addressing an individual’s immediate, tangible barriers to achieving optimal health. These efforts reflect a critical shift toward holistic, community-driven health solutions, recognizing that physical and mental health are deeply influenced by social factors.
Under the guiding principle that personally engaging people who are directly impacted by Medicaid services leads to better health outcomes, the Waiver Community Connection Initiative prioritizes education, empowerment, and direct feedback. By educating Medicaid members and Community Based Organizations about the waiver and supporting connections within SCNs, the initiative forges a knowledgeable, community-based force for change. Participants are equipped to shape local mental health and social care systems through peer-led meetings, webinars, open forums, and accessible policy bulletins that clarify complex policy topics.
Through this initiative, we aim to foster informed involvement, ensuring that the people receive the services needed to improve their health and lives. This collaborative approach not only strengthens local service systems but also amplifies the voices of Medicaid members and providers in our shared mission to improve health equity and overall community wellness.
More Information on the Waiver
The NYHER 1115 Medicaid Demonstration Waiver represents a transformative effort by New York State, in partnership with the Centers for Medicare & Medicaid Services (CMS), to advance health equity, reduce health disparities, and address social determinants of health (SDOH). This initiative will leverage $7.5 billion in funding over three years to implement innovative programs aimed at improving health outcomes for Medicaid recipients.
Key goals of the waiver include:
1. Addressing Health-Related Social Needs (HRSNs):
- Establishing Social Care Networks (SCNs), which are groups of local providers who are connected within a system to coordinate and provide needed health services for such as housing support, nutrition assistance, and transportation for Medicaid members.
- Integrating behavioral health, primary care, and social services to ensure holistic care delivery for underserved communities.
2. Advancing Health Equity:
- Reducing disparities in care for children, pregnant and postpartum people, and high-risk adults by expanding access to culturally appropriate and community-driven services. Examples of health disparities include less access to healthy foods among people in low income communities or less access to effective mental health supports for communities of color.
- Supporting safety net hospitals that serve populations with the greatest health needs by ensuring sustainable funding and transitioning to value-based payment models.
3. Expanding Behavioral Health Services:
- Enhancing access to comprehensive, coordinated treatment for substance use disorders (SUDs).
- Improving integration between behavioral health and primary care providers to better serve Medicaid populations.
4. Strengthening the Healthcare Workforce:
- Addressing critical workforce shortages by creating career pathways training programs for frontline health and social care professionals.
- Launching a loan repayment program to incentivize clinicians, including dentists and psychiatrists, to work in underserved areas.
- Supporting peer-led workforce development to integrate individuals with lived experiences into the delivery of recovery services for mental health and substance use care.
5. Investing in Primary Care:
- Developing a “Making Primary Care Primary” initiative to strengthen primary care infrastructure.
- Aligning Medicaid and Medicare value-based payment strategies to improve population health outcomes.
- Facilitating Community-Based Organization (CBO) Integration:
- Allocating $500 million to SCNs to build infrastructure and empower CBOs to deliver Health-Related Social Need (HRSN) services.
- Ensuring CBOs have the necessary support and resources to partner effectively with SCN leads, emphasizing their critical role in community service delivery.
6. Promoting Value-Based Care:
- Advancing the transition to value-based contracting to prioritize quality over quantity in care delivery.
The waiver reflects New York’s commitment to creating a more equitable and integrated healthcare system that prioritizes prevention, holistic care, and sustainable solutions to long-standing health disparities. Continued advocacy and support for community-based providers and individuals with lived experiences will be critical to ensuring the success of these ambitious goals.
Contact
The Social Care Networks (SCNs) are still organizing their systems. CBOs, providers and members can learn more by connecting with the Alliance and attending our three upcoming webinars and in person events. Email the contacts below to be added to a mailing list to receive more information and updates.
Brett A. Scudder
Bretts@rightsandrecovery.org
Luke Sikinyi
LukeS@rightsandreovery.org