High angle view of thoughtful man lying on bed in hospital

Two government agencies are prodding states and providers to pioneer innovative ways to address communities’ social needs with the help of home- and community-based services (HCBS) and community-based organizations (CBOs). 

The Department of Health and Human Services and the Centers for Medicare & Medicaid Services recently released a series of documents with new strategies to address social determinants of health. One, the new “Playbook to Address Social Determinants of Health,” includes ways for states to leverage federal dollars for HCBS to address beneficiaries’ social determinants of health.

State Medicaid programs, it said, should deploy funds to help HCBS providers address beneficiaries’ nutritional needs. These providers’ tools, like medically-tailored meals for people with chronic conditions, for example, can reduce beneficiaries’ risk of hospitalization and promote healthier living. But the playbook noted that nutrition programs are not offered by every state Medicaid program or health plan, so HHS recommended exploring an alternate route to address this social need.

“States can use in lieu of services and settings (ILOS) through Medicaid managed care programs to offer optional alternatives to State plan covered services to address health-related social needs,” HHS said in the playbook released Thursday. “Medically appropriate and cost effective ILOSs… could improve health outcomes and facilitate greater access to home and community-based services, thereby preventing or delaying the need for nursing facility care or acute hospitalization.”

The playbook also included action items for providers themselves. HHS recommended cooperation with CBOs, which typically understand the needs of the communities they serve, and can advise ways to best address beneficiaries’ social needs. 

“Local CBOs, such as area agencies on aging, aging and disability resource centers, centers for independent living, community mental health centers,” HHS said, “Are often trusted organizations within communities that can convene key partners across sectors to develop a shared vision that includes expanded reach and responsibility for the health and well-being of the community.”