Bridging State, Health Care, and Community Systems to Amplify Impact of Food is Medicine

The North Carolina Department of Health and Human Services (NC DHHS) is a government entity that helps to advance Food is Medicine (FIM) efforts through their Healthy Opportunities Pilots (HOP) program. Key to NC DHHS’s success are the partnerships they have leveraged partnerships with community-based organizations (CBOs) and the use of their existing statewide health care technology platform (NCCARE360). NC DHHS is featured in the Bright Spot series as an exemplar of state agencies creating systemic FIM approaches. Notably, HOP is the nation’s first comprehensive program to test and evaluate the impact of providing select evidence-based, non-medical interventions related to housing, food, transportation, and interpersonal safety and toxic stress to high-needs Medicaid enrollees. This Bright Spot serves as a model to other FIM implementers on how they can leverage partnerships with community-based organizations to identify community-specific needs and increase participation in their FIM programs.

Impetus for establishing HOP

Research has shown that 80 percent of health care outcomes are driven by factors outside of clinical care settings (Magnan, 2017); however, 90 percent of halth care expenditures are used for clinical care. To address this discrepancy, NC DHHS developed a series of initiatives and a statewide infrastructure to connect health and human services and address whole person needs. They leveraged this existing infrastructure to implement the HOP program. Through HOP, North Carolina uses Medicaid dollars to pay for services that address individuals’ health-related social needs (HRSN) with the aim of improving access to food, housing, and transportation, while also promoting interpersonal safety.  

HOP implementation framework

NC DHHS began designing and implementing the Healthy Opportunities portfolio in 2017, including design of HOP as a Medicaid 1115 demonstration program which was approved by the Centers for Medicare and Medicaid Services (CMS) in 2018 for a demonstration period from 2019 to 2024. Through a request for proposal, HOP procured three Network Leads entities to develop and oversee a network of community-based organizations (CBOs), referred to as Human Services Organizations or HSOs, that provide 28 federally approved HOP services. The Network Leads—Access East, Inc., Community Care of the Lower Cape Fear, and Impact Health—provide three regions of North Carolina with access to HOP services, consisting of 33 predominantly rural counties. HOP participants are Medicaid beneficiaries who meet the program’s eligibility criteria and live in one of the 33 counties covered by the Network Leads. To meet eligibility criteria for HOP, participants must have at least one physical or behavioral health risk factor and one social risk factor.  

As of April 2024, over 15,000 North Carolinians have used HOP services with 200,000 services delivered by 147 CBOs. Food services are the most common service type, representing more than 85 percent of all services delivered. The Interim Evaluation Report states that HOP participants have benefited in the following ways:  

• Reduced emergency department use  
• Reduced inpatient hospitalizations for non-pregnant adults by two admissions per month per 1,000 beneficiaries
• Reduction in the total number of social needs and services used across housing, food, and transportation domains
• Monthly health care cost savings of $85 per participant, with greater reductions in direct service spending observed in those who participated in HOP for longer periods of time 

Statewide infrastructure

NC DHHS built a statewide infrastructure that aimed to provide shared assets that could be used in all populations and Medicaid managed care plans. This infrastructure was leveraged and modified to create HOP. To build this infrastructure, NC DHHS developed a technical advisory group of health and human services providers to standardize a set of social needs screening questions that could be used by providers for all populations and would be contractually required by Medicaid.  

NCCARE360

Through a public-private partnership, the private, non-profit Foundation for Health Leadership & Innovation issued a request for proposals to find a vendor for a data sharing technology platform known as NCCARE360, which serves as a statewide closed-loop referral system that can be used for all populations and connects North Carolinians with the community resources required to meet their social needs. Afterwards, NC DHHS began designing their 1115 waiver, which would be the vehicle for moving to Medicaid Managed Care in NC and would authorize North Carolina Medicaid to implement HOP.  

Obtaining stakeholder feedback

Throughout the HOP design process, NC DHHS continued to convene stakeholder meetings and identify the best methods to use when implementing HOP. This process included leveraging the Commonwealth Fund to convene stakeholders and develop the fee schedule. NC DHHS also issued a request for information, targeting stakeholders who were unable to attend in-person meetings. NC DHHS used a phase-in approach for HOP service delivery. The phase-in approach indicated that food, housing, transportation, toxic stress, and sensitive (e.g., interpersonal violence) services would become available across all participating regions at different times; services in the food domain were the first available. Advanced functionalities specific to HOP requirements were built upon the existing statewide NCCARE360 platform. 

NC DHHS leveraged funding from a variety of sources to implement HOP. Below are the major milestones in NC DHHS’s journey to funding HOP:  

• NCCARE360 was primarily funded through private philanthropic dollars in the first few years of implementation.  
• During the pandemic when health-related social needs rose, NC DHHS leveraged the Coronavirus Relief Fund (U.S. Department of Treasury, 2024) to provide funding to Foundation for Health Leadership & Innovation to expand the NCCARE360 system and support social service pilots.  
• NC DHHS was also able to leverage funding from federal grants, including the CDC Health Disparities Grant, to increase the capacity of CBOs to use NCCARE360 and deliver social services.  
• Through Medicaid Managed Care, NC DHHS developed financial levers for Managed Care Plans to be able to invest in social needs. These include allowing social services to be included as value-added services, in lieu of services, and as clinical services, as part of the Medical Loss Ratio.  
• HOP services and infrastructure are supported by funding authority from the CMS 1115 Medicaid demonstration waiver. The 1115 waiver permitted a capacity building period for HOP so that participating CBOs would have time to receive funding from NC DHHS, hire qualified personnel, and train staff to provide HOP services.  

NC DHHS partners with CBOs such as food banks, food pantries, and churches to leverage CBO knowledge of community-specific needs while providing financial support in their overall strategy to address social needs and deliver HOP services. Throughout the HOP design and implementation processes, NC DHHS also partnered with local grassroots organizations to obtain their input. Partnerships with CBOs and local grassroots organizations have allowed NC DHHS to invest in local capacity and create a program that is rooted in local community.   

The primary reason NC DHHS developed the strategy to address health related social needs was to reduce health disparities statewide. To promote improved health for all people within HOP, NC DHHS ensured that the governing bodies of the Network Leads responsible for onboarding CBOs were representative of the populations that would be served in their region. NC DHHS also directed their health care plans to prioritize high-need populations when promoting enrollment in HOP. 

Statewide infrastructure

NC DHHS attributes their success in addressing health related social needs and developing and implementing HOP to the creation and accessibility of a statewide multi-component shared infrastructure, commitment to investing in local communities, continuous communication with partners, attention to detail, creativity, and humility. The statewide multi-component infrastructure facilitates the sharing of assets and targeted initiatives that can be used to build the evidence base and bridge health care and human services across diverse populations and geographies. Access to this infrastructure was essential for NC DHHS because it facilitated the rapid scaling and delivery of HOP.  

Investing in local communities

Choosing to invest in local communities helped NC DHHS leverage the expertise in communities, ensure the sustainability of HOP, and invest in the economic growth of communities. For example, FIM is an important framework for HOP food services and helps North Carolina establish relationships with local care teams. NC DHHS developed operational focused meetings with their local partner networks, which allowed for rapid identification and resolution of problems with HOP service delivery. 

Investing in CBOs

Investing in locally-based CBOs to deliver HOP services provided a key pathway to success because CBOs can leverage their connections with community members to encourage participation. To establish CBO capacity for service provision, NC DHHS leveraged the 1115 waiver to allow for upfront capacity building dollars through Medicaid prior to service delivery. This was an essential task because most CBOs are under resourced, resulting in an inability to readily provide HOP services up front and then seek reimbursement from payors later.  

Longer time horizons

While implementing HOP, NC DHHS learned that food facilitates human connections, addresses social isolation, and helps to build a sense of community. Participants who received HOP services for longer periods saw greater reduction in health-related social needs and health care costs than those who were enrolled in HOP for a short time.