“American Compassion”: Partnering with The LBJ School on the Safety Net Podcast

As part of our mission to build a better social safety net, Findhelp fosters conversations about the state of modern social care and what can be done to improve it. As we recently announced, we’re collaborating with The LBJ School of Public Affairs at the University of Texas-Austin to co-host a LIVE speaker series for the latest season of American Compassion: The Safety Net Podcast.

American Compassion: The Safety Net Podcast

Season 3 of American Compassion will kick off with four video podcast episodes – two this fall and two next spring – filmed in front of a live audience at The LBJ School’s historic Bass Lecture Hall. The series will be free and open to the public, featuring experts from academia, the public and private sectors, and practitioners who are innovating America’s social safety net.

“As an alum of The LBJ School of Public Affairs (Class of ‘04), this initiative has special meaning. LBJ always knew that the Great Society legislation wasn’t perfect. With the benefit of time, and advances in technology, we hope ideas debated here can be implemented to improve the lives of others.”
– Erine Gray, Founder & CEO of Findhelp

Register to attend the live filming of American Compassion season 3 episodes.

Season 3: Looking ahead

What will the outcome of the 2024 presidential election mean for the safety net? How can technology improve outcomes for Americans? What does the gold standard for social care look like? These are some of the questions we’ll explore in this innovative series.

Episode 1 | September 18, 2024

Titled “The Broken U.S. Safety Net”, the first episode will be filmed on Sept. 18, 2024, from noon to 1:30pm Central. The episode will take a big picture look at the modern safety — how did we get here, what’s broken, and what are the biggest challenges standing in the way of Americans who need help?

Erine Gray, Founder & CEO of Findhelp, will join a panel featuring:

Maninder “Mini” Kahlon, Ph.D., Dept. of Population Health at Dell Medical School
Isha Deselle, Founder of Turning Point Center
Dr. Pritesh Gandhi, Chief Community Health Officer for Walmart

Register for free to attend the September 18 recording of the American Compassion podcast.

Future Episodes

New episodes of American Compassion will be available on Findhelp’s YouTube channel, Spotify, and Apple Podcasts shortly after the live events. The recorded episodes will also air on KUT, Austin’s Public Radio station.

Nov. 13, 2024 | “What Happens Now?” After the results of the US presidential election, we explore what the outcome means for social care and the future of the safety net — for the next four years, at least.
Feb. 12, 2025 | “Social Care in the Digital Age.” Given the flaws in the safety net and the political realities that exist, we explore how to modernize the system. Discussion topics include the roles played by AI, health insurance companies, and social determinants of health tech.
March 26, 2025 | “Who’s Doing It Best?” In this episode, look for those who are innovating the safety net to create modern solutions.

Seasons 1 & 2: Looking back at where we started

In the first two seasons of American Compassion, we dove into the history behind the safety net. From FDR’s New Deal to LBJ’s Great Society, host Rebecca McInroy spoke with prominent historians like Robert Caro, H.W. Brands, and Mark Updegrove. They explored the origins of some foundational government programs that still exist today. Rebecca will return to the series as host and moderator for season 3, bringing more than 20 years of experience in journalism and public radio.

“I’m thrilled to discuss the shaping of a robust, comprehensive safety net for the 21st century with some of the most thoughtful, innovative, energetic minds in America. From librarians, nurses, and data scientists to tech giants, policymakers, and business leaders, these are the voices that will help us imagine a future where all Americans thrive.”
– Rebecca McInroy, Executive Producer & Host

Listen to the first two seasons of the American Compassion podcast.

A Texas Team-up: Partnering with The LBJ School of Public Affairs

Founded in 1970, The LBJ School is America’s preeminent educational institute for training leaders and improving the quality of public service in the United States and abroad at all levels of governance and civic engagement.

“As UT’s hub for policy leadership, The LBJ School has a powerful tradition of convening both the UT and greater Austin communities together for dialogue on issues of policy importance. I’m delighted that Erine Gray, one of our very own LBJ graduates, has chosen to partner with the school to bring our community important programing on social policy.”
– JR DeShazo, Dean of The LBJ School

Findhelp is honored to collaborate with The LBJ School of Public Affairs on this endeavor, and we look forward to welcoming their esteemed students and faculty to the conversation.

“In a world where people have become so divided about so many things, we hope to broaden our understanding and provide solutions,” Erine said. “We want people to learn something new and leave feeling good about the future.”

Learn more about the American Compassion podcast.

Join the conversation!

You’re invited to join the live recording session of American Compassion on UT-Austin’s campus. Claim your free spot by registering today. Hear directly from our featured experts and innovators and enjoy a light lunch following the discussion.

Register to attend the live recordings of the American Compassion podcast.

CMS SDoH Regulations for Hospitals are Finalized

Healthcare providers have increasing social determinants of health (SDoH) responsibilities as the Centers for Medicare & Medicaid Services (CMS) continues adding SDoH provisions in its annual rulemaking. In this week’s blog, we review what’s new for hospitals in 2025 under CMS’s Inpatient Prospective Payment System (IPPS) final rule.

Over the past several years, CMS SDoH provisions include the addition of screening measures, increased inpatient reimbursement for patients with certain needs, and introduced payment for SDoH assessment and community navigation. Findhelp is here to help you advance your health equity strategies. Use our platform and network to ensure that discharged patients are connected to the community resources they need.

To support our healthcare customers, Findhelp’s policy team closely monitors regulatory developments that impact your SDoH and health equity strategies. This also helps our community-based organization (CBO) network understand partnership opportunities and value propositions for the healthcare providers in their communities. Read on to learn more about the new IPPS provisions for 2025.

CMS SDoH Changes for Hospital Inpatient Settings

CMS’s Inpatient Prospective Payment System (IPPS) rule establishes hospital inpatient payment methodology, updates quality measures, and institutes other hospital programs. The 2025 final rule includes several new provisions that will further engage hospitals in SDoH work.

Increased reimbursement for services provided to people with housing insecurity

CMS increased the severity level designation for inpatient encounters with SDoH Z codes describing housing insecurity and inadequate housing.

Inpatient claims with these codes will have increased reimbursement to account for the increased costs of caring for people with housing concerns.
This change expands on the 2024 IPPS provision that increased the severity level designation for inpatient encounters with Z codes for homelessness.
Hospitals must ensure that the appropriate Z codes are included as a secondary diagnosis.

In the final rule, CMS encourages hospitals to include all SDoH-related Z codes on claims so that the agency can analyze whether social conditions affect the cost of care. Understanding this impact may prompt CMS to change severity levels for other SDoH-related Z codes, if appropriate. Staff can identify and document all SDoH concerns through screening discussions, and can use Findhelp to track post-discharge referrals. This creates safe and effective care transitions and can prevent readmissions penalties.

Age-Friendly Hospital measure added to quality reporting

CMS added an Age-Friendly Hospital structural measure to the hospital inpatient quality reporting (IQR). This means that hospitals will need to attest to having certain infrastructure and processes to meet the goals of the measure.

This measure assesses hospital commitment to improving care for patients older than 65.
Hospitals must attest that they have processes in place to assess for social vulnerability, including social isolation, economic insecurity, elder abuse, caregiver stress, and inadequate access to healthcare.
Positive screens should result in interventions and appropriate referrals.

Hospitals must begin reporting on this structural measure in calendar year 2025, which will impact fiscal year 2027 payments. Hospitals using Findhelp can easily attest to meeting this measure with embedded screening questions, tailored referrals, and a Trusted Network of CBO partners that is configured to meet the needs of older adults.

Mandatory payment model to incentivize quality improvement and care coordination

CMS finalized the Transforming Episode Accountability Model (TEAM), a five-year, mandatory payment model for hospitals in 188 geographic areas. The model begins in January 2026.

TEAM is a bundled payment model for certain joint, extremity, bowel, and heart procedures.
The model incentivizes the participating hospitals to reduce fragmentation and improve the transition from hospital to community for patients who undergo the relevant procedures.
TEAM includes health equity components like social risk adjustment in the payment methodology, health equity plans, and social needs screening.

CMS estimates that TEAM will save the Medicare program approximately $481M over five years. Participating hospitals can leverage Findhelp for social needs requirements and subsequent referrals.

SDoH items on long-term care hospital standardized patient assessment

CMS finalized the addition of SDoH questions on the standardized patient assessment required in Long Term Care Hospitals (LTCHs).

The LTCH standardized patient assessment must include the housing, food, utility, and transportation questions from the Accountable Health Communities tool.
This requirement is consistent with standardized patient assessment requirements in inpatient rehabilitation facilities. It also aligns with hospital IQR and inpatient psychiatric facility quality reporting requirements.

While CMS SDoH provisions fall short of requiring referrals for identified needs, the agency recommends referral pathways. Integrate Findhelp’s screening and referral processes into your LTCH EHRs to support simple workflows for closed-loop referrals.

CBOs Can Work with Hospitals to Offer SDoH Services

CBOs are essential partners, and well positioned to offer valuable services to hospitals that are required to identify and address patient social needs. As hospitals increasingly screen for SDoH, they’re identifying more needs and hospital staff often don’t know where to send patients for help. CBOs can build awareness of their services by:

Claiming your programs in the Findhelp network to ensure you receive referrals and connect with hospital partners.
Attending a virtual training to make the most of free Findhelp tools.
Partnering with Findhelp to establish contractual partnerships with hospitals that are looking to invest in SDoH interventions.

Partner With Us to Meet your Regulatory Requirements

Regulatory changes and requirements can become overwhelming, but Findhelp makes SDoH screening and referral workflows easy for customers. Connect with us to learn more about how we can partner to ensure people receive the SDoH services they need. Partnering with Findhelp will bring value to your patients and cost savings to your facility.

Social Care Networks Announced Under New York’s HRSN Waiver

New York State has announced its 9 Social Care Networks (SCNs), new entities tasked with managing social care delivery for people with Medicaid under the state’s Section 1115 health-related social needs (HRSN) waiver demonstration. Findhelp is proud to partner with several New York SCNs, providing interoperable and integrated technology that will fundamentally change HRSN service delivery in New York.

The SCNs will be a major part of the state’s HRSN service delivery infrastructure, implementing screening and navigation for the state’s Medicaid population, building CBO networks to deliver approved services, and paying their contracted partners for services.

About New York’s 1115 HRSN waiver

New York’s waiver, New York Health Equity Reform (NYHER), authorizes up to $3.16 billion for HRSN services and $500 million for HRSN infrastructure. The SCNs and Findhelp will be integral to the state’s infrastructure that is intended to integrate health and social care, and most closely knit the social safety net.

The HRSN demonstration requires the SCNs to:

Findhelp's New York network by the Numbers - New York's 1115 HRSN waiver

NYHER places a particular emphasis on HRSN screening for Medicaid members and coordinated service delivery. As such, interoperability is a cornerstone of this work. On behalf of our SCN partners, we will establish direct connectivity with New York’s health information exchange infrastructure and data warehouse to provide screening, referral, and service data for people who have consented to sharing. All data will be transmitted using HRSN data standards, enabling timely data exchange, reporting, and analysis.

“We are honored to have a role in New York’s transformational waiver program, and we applaud Governor Hochul, the New York State Department of Health, and the New York State Medicaid program for this investment. Findhelp is excited to move forward with our SCN partners and the CBOs in their networks to launch new models of social care that will improve the lives of New Yorkers with Medicaid.”
Carla Nelson
Sr. Director of Healthcare & Public Policy at Findhelp

Proud to partner with SOMOS Community Care, SCN for the Bronx

SOMOS Community Care is a network of over 2,600 culturally competent healthcare professionals who provide care to over 1 million patients in New York’s underserved neighborhoods—particularly Asian, African-American and Latino communities. Their network comprises primary care physicians, specialists, behavioral health providers, pharmacies, community-based organizations.

Their providers establish genuine relationships with their patients, getting to know their family circumstances, along with the social and environmental factors that impact their health. In a great many cases, SOMOS doctors work and live in the same neighborhoods as their patients, often sharing their linguistic and ethnic background.

As the designated SCN covering the Bronx for New York’s 1115 HRSN waiver, SOMOS will partner with Findhelp to further empower their CBO partners, create additional capacity around social needs screening, and deliver the state’s enhanced HRSN services to eligible populations.

Somos is excited to partner with FindHelp in this historic program to help New York’s most vulnerable populations. We have decades of experience working in underserved communities in a person-centered manner. This has allowed us to identify the barriers to wellbeing and inequitable situations our communities experience. We have for years strived to bring greater access to care and services, but our reach has been limited. This program, and working closely with FindHelp, will allow us to increase our reach, scale our efforts and more efficiently deliver care and services to those in need.
Lidia Virgil
Chief Operation Officer, SOMOS

A long history of supporting Bronx residents

Findhelp has been partnering with New York-serving organizations since 2015. We work with customers across the City, including many that provide services to the Bronx: Montefiore, the Institute for Family Health, Union Community Health Center, United Way of New York City, Mount Sinai, and more.

Over the past two years, the number of searches made by Bronx residents on the Findhelp platform has almost tripled, showing a growing need for community resources. Top needs in the Bronx are related to food and housing, with diapers & formula also high on the list.

Findhelp supports waiver programs across the country

Is your state preparing for a waiver to be approved? We’re ready to help. We have a history of successfully supporting 1115 programs. Connect with one of our expert team members to explore how Findhelp can support your implementation.

Medicaid Waivers by State: Findhelp and New York

More than 30 healthcare, health plan, nonprofit, and other organizations across New York have already implemented social care coordination platforms using Findhelp and are ready to hit the ground running with New York’s Medicaid 1115 waiver program, Medicaid Redesign.

Read on to discover how we can partner with you on your Medicaid Redesign lead entity application and browse some of our successful 1115 waiver program partnerships from around the country. Together, we can ensure a seamless delivery of goods and services to Medicaid members while tracking claims to report back to the State.

What Are Medicaid 1115 Waiver Programs?

Section 1115 of the Social Security Act gives states flexibility to update and improve their Medicaid programs by providing waivers authorizing experimental, pilot, or demonstration projects. Many states focus their 1115 waiver program projects on improving health outcomes by addressing Medicaid enrollees’ unmet health related social needs.

At Findhelp, we have both a history of successful Medicaid 1115 waiver program support (example: California) and deep relationships across the state of New York and beyond.

Our technology supports:

Capturing eligibility and authorization needs for 1115 waiver programs
Reporting on services rendered, codes, and data needed for invoicing and claims
Invoicing paying entities and facilitating payment to community organizations and vendors

New York’s 1115 Waiver Program: Medicaid Redesign

On January 9, 2024, CMS approved New York State’s section 1115 Waiver Amendment Request through March 27, 2024 – providing $6.7B in funding to improve the health of New Yorkers. The Medicaid Redesign program will award up to 13 social care network (SCN) lead entities.

Given our singular experience creating these programs, Findhelp is here to support your NY 1115 waiver program initiatives, from application to implementation.

Partnering to Support New Yorkers

From housing and food security to transportation, employment, education, and more, Findhelp has the tools and expertise to build your trusted network and empower informed decision-making. As lead entities begin to apply for the NYS 1115 waiver program, they’ll need to outline their plans for reliable networks of contracted community-based organizations (CBOs) to better enable HRSN screening and the delivery of social care services.

Leverage Findhelp’s expertise in designing successful waiver programs, honed through collaborations with state leaders nationwide. Our proven workflows simplify complex regulations, maximizing your program’s impact.

We’re here to assist you with your NYS 1115 waiver program lead entity applications to ensure greater coordination of social care services for NY Medicaid members. Our products and services support every aspect of the program, from eligibility checking to claims generation and reimbursement.

Medicaid Waivers by State

Since 2019, we’ve been partnering with our customers and trusted community partners to support Medicaid 1115 waiver programs across multiple states. We collaborate with payers, managed care organizations, accountable care organizations, and community-based organizations to configure workflows and payment processes to fit the requirements of each state’s program.

Massachusetts: Flexible Services

Under Flexible Services, MassHealth pays for health-related nutrition and housing supports for certain members enrolled in an Accountable Care Organization (ACO). These ACOs pilot evidence-based approaches that address a member’s health-related social needs with the goal of improving health outcomes and reducing the total cost of health care for the member.

Starting in 2020, Findhelp partnered with Mass General and Brigham and Women’s Health to launch Flexible Services pilots with 10 community-based organizations.
Midway through 2020 we expanded our partnerships to include Boston Medical Center and SouthCoast Health and trained 7 additional community organizations to improve food and housing outcomes across the state.
Today, we are partnering with several Flexible Service ACOs to support navigation assistance for areas with higher volumes of eligible patients. In the first year of Flexible Services, 99% of patients reported that their participation improved their overall health.

California: CalAIM

On January 1, 2022, the California Department of Health Care Services launched the California Advancing and Innovating Medi-Cal (CalAIM) program, an 1115 waiver program to make Medi-Cal more equitable, coordinated, and person-centered. The program covers one-third of Californians and perinatal care for half of annual births and will impact the lives of over 14 million Californians.

CalAIM expands community-based approaches to addressing complex care for high-needs populations, such as individuals experiencing homelessness, serious mental illness, or substance use disorders, or children involved in the child welfare system. Designated navigators coordinate members’ physical and behavioral care, as well as access to critical social services.
Through 14 services such as Asthma Remediation and Housing Navigation Support, CalAIM encourages Medi-Cal managed care plans to address social determinants of health (SDoH) and offer preventative upstream interventions.
Findhelp partners with MCPs across the state like Aetna Better Health, Health Net (Centene), and Alameda Alliance for Health to support CalAIM. We enable MCP staff and ECM to order more than 445 different social services from community partners.

Looking Ahead

Findhelp has experience partnering with customers across the country to address needs like food, housing, transportation, and more, whether it’s via our fulfillment program, Marketplace, by establishing Trusted Networks of community service providers, or by collaborating with organizations like Uber Health.

We look forward to joining forces with our existing customers and community partners to advance the work of the New York State Department of Health and the goals of the upcoming NYS Medicaid 1115 waiver to connect people in need to the programs and services that can help them.

Partnering for Success

You don’t have to start from scratch with your pilot demonstrations; chat with one of our team members to learn how we can collaborate with your organization to successfully implement New York’s 1115 waiver program, using established best practices and our proven strategies.

Prospective Customers: connect with our Director of Enterprise Sales, Rachel Harris ([email protected]).
Community Organizations & Customers: reach out to our Director of Customer & Community Success, Geoff Gamm ([email protected]).
Policymakers: connect with our Regional Director for Government Relations, CG Niquette ([email protected]).

“American Compassion” Podcast: LBJ and the American Social Safety Net

On January 8, 1964 (60 years ago today!) President Lyndon Baines Johnson (LBJ) gave the State of the Union address to the United States Congress. During his speech, LBJ proposed legislation as “an all-out war on human poverty” in response to a national poverty rate of around nineteen percent: “This administration today, here and now, declares unconditional war on poverty in America”.

In honor of this declaration and LBJ’s progressive legacy, we’re launching season two of American Compassion, our podcast about the history of the social safety net in America.

From the New Deal to the Great Society

In season 1 of American Compassion we went back in time to the turn of the 20th century to explore poverty and wealth, philanthropy and charity, work, health and politics, and policy at a time when the idea of a safety net was just a dream, and we dove deep into what and who it took to make those dreams a reality. From workplace safety, fair labor standards, and child labor laws to the New Deal, we scratched the surface of the complex history of the social safety net in America.

In season 2, we explore not only what programs and legislation President Johnson created to build the safety net we have today, but we also delve into why LBJ was so committed to civil rights, education, economic opportunity, and so much more. We do this through both archived recordings and speeches and interviews with Pulitzer Prize-winning biographer Robert Caro. Other guests on the podcast include biographers, economists, policy advisors, and historians, H.W. Brands, Julian Zelizer, Guian Mckee, Mark Updegrove, Martha Baily, Andrew R. Smith, Melody Barnes, and Erine Gray.

Episode 1: Taking The Reins and Passage of The Civil Rights Act

In May of 1964, six months before he would be elected president of the United States in a landslide victory, President Johnson laid out his vision for The Great Society in a speech at the University of Michigan: “The Great Society rests on abundance and liberty for all. It demands an end to poverty and racial injustice, to which we are totally committed in our time.” It was there that he was to begin his life’s work, with “liberty for all”. Passing the civil rights bill was crucial for Johnson, not only because he was continuing Kennedy’s legacy, but because it was a foundational piece of his Great Society and the American Safety Net.

In this episode we explore Lyndon Baines Johnson the man and the president with Pulitzer Prize-winning biographer Robert Caro, we hear conversations between LBJ with Martin Luther King Jr. and we get a better understanding of the context and the consequences of this monumental moment in American history.

Episode 2: The (Revolutionary) Economic Opportunity Act

It’s the summer of 1964 and Lyndon Johnson has just signed the most sweeping civil rights legislation since Reconstruction, but when it came to the safety net Johnson’s vision encompassed far greater legislation. President Johnson was willing to wager his presidency on the War on Poverty – but why?

In this episode, we will pull apart the fine details of the Economic Opportunity Act and hear some conversations that illustrate the tension and the stakes of creating some of the most revolutionary safety net programs of the 20th century. We’ll talk about why the War on Poverty and programs like Community Action, Job Corps, and Head Start were so important to LBJ as a person and as president, and we’ll talk about the compromises it took to create and pass this legislation. In addition, we’ll explore the impact of programs like the Job Corps through the experiences of George Foreman.

Episode 3: The Road to Realization for Medicare and Medicaid

By passing the Civil Rights Act on July 2, 1964, and The Economic Opportunity Act on August 20, 1964, President Lyndon Johnson continued the work of Franklin Roosevelt as an interim president before he was elected in his own right in November of 1964. However, there was a significant element of the safety net that no president before LBJ was able to conquer, and that was healthcare. In this episode, we explore Medicare’s tenuous, little-known road to realization and the masterminds behind its conception.

Episode 4: The Legacy of The War on Poverty

In his State of the Union address on January 8, 1964, Johnson says, “This administration here and now declares unconditional war on poverty in America.” But we still see poverty in America today; does that mean the War on Poverty failed? In this episode, we’ll look at the legacies of the Great Society, the War on Poverty, and LBJ’s presidency. What did the policies that came out of his administration mean for the American Safety Net, and why aren‘t more people aware of LBJ’s social policy legacy?

Partner With Us to Rebuild the Safety Net

If you’d like to learn more about how we partner with more than 600 customers nationwide to rebuild the social safety net, connect with us.

Health Equity Quality Measures: Supporting Accreditations, Regulations, & Policy

Social care and health equity quality measures exist to ensure healthcare organizations are providing high-quality services that relate to one or more goals including effective, safe, efficient, patient-centered, equitable, and timely care.

In late 2022 and early 2023 the Joint Commission, National Committee for Quality Assurance (NCQA), and Centers for Medicare & Medicaid (CMS) introduced new requirements to advance health equity. Healthcare and health plan organizations will now be required to report on their efforts to reduce health disparities and screen patients for social determinants of health (SDoH) needs.

Read on to learn how Findhelp is here to support you and your organization across these various policies, accreditations, certifications, and requirements into 2024.

NCQA: Health Equity Accreditations

The National Committee for Quality Assurance (NCQA) provides 2 accreditation options: the Health Equity and Health Equity Plus. Each provide health care organizations with an actionable framework for improving health equity; these accreditations are starting to be required by state Medicaid agencies in order to be considered for contracts.

Findhelp software helps customers earn these accreditations via closed-loop referral tracking (married with the customer’s system-of-record data) and Community Engagement activities (outreach, partnerships, and trusted networks), as well as supporting the discovery / confirmation of non-discriminatory practices at community-based organizations.

The Health Equity Accreditation adds new requirements to NCQA’s Multicultural Health Care standards that focus on organizational diversity, equity, inclusion, and reducing bias; collecting gender identity and sexual orientation data; and reporting race/ethnicity stratified HEDIS measures.
The voluntary Health Equity Accreditation Plus option includes standards for assessing and addressing social determinants of health and will be available for public comment this fall. In 2022, eight of the nine organizations that earned the first Plus accreditation are Findhelp customers and included Findhelp data in their applications.

The mission of The Joint Commission is to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.

They do this by setting quality standards, evaluating an organization’s performance, and providing an interactive educative experience that provides innovative solutions and resources to support continuous improvement.

Requirements to Reduce Health Care Disparities

These Joint Commission’s requirements to reduce disparities took effect on January 1, 2023, and apply to organizations in accreditation programs for ambulatory, behavioral and human services, critical access hospitals, and hospitals.

Findhelp’s product and services support all of the Joint Commission’s new requirements to Reduce Health Care Disparities:

(Req. 1) Our Community Engagement & Customer Success teams can guide your organization to develop an internal position to lead your activities to reduce health care disparities or augment that work for you.
(Req. 2 & 3) You can report on aggregate and individual needs identified via our configurable social care assessments; these can be integrated with your Epic EHR, and our SQL data delivery tool allows for additional risk stratification.
(Req. 4) Our Customer Success team can guide your organization to develop an action plan with specific deliverables to address health disparities; our Marketplace delivery program makes it easy to order, track, invoice, and deliver social goods directly to the people who need them.
(Req. 5) Our Customer Success team can help your organization pivot when disparity reduction goals are not met, and help guide the creation of a revised action plan to address barriers and challenges to increase your impact.
(Req. 6) Using our progress reports and executive reviews as starting points, we can help you identify the appropriate channels to share your progress and plans with relevant stakeholders.

Health Care Equity Certification

In July 2023 the Joint Commission started accepting applications for a new Health Care Equity Certification to recognize organizations that go beyond the basic accreditation requirements and strive for excellence. It’s a voluntary program for hospitals, separate from accreditation, with a focus on health care equity. Certification requirements build upon long-standing and recently-released health care equity accreditation requirements.

The Centers for Medicare & Medicaid Service (CMS): Health Equity Framework

CMS is the federal agency that provides health coverage to more than 160 million through Medicare, Medicaid, the Children’s Health Insurance Program, and the Health Insurance Marketplace. CMS works in partnership with the entire health care community to improve quality, equity and outcomes in the health care system.

CMS updated their framework for health equity to highlight Five Health Equity Priorities for Reducing Healthcare Disparities:

Priority 1: Expand the Collection, Reporting, and Analysis of Standardized Data
Priority 2: Assess Causes of Disparities Within CMS Programs and Address Inequities in Policies and Operations to Close Gaps
Priority 3: Build Capacity of Health Care Organizations and the Workforce to Reduce Health and Health Care Disparities
Priority 4: Advance Language Access, Health Literacy, and the Provision of Culturally Tailored Services
Priority 5: Increase All Forms of Accessibility to Health Care Services and Coverage

Unique Ways Findhelp Supports Health Equity Quality

Social care and health equity quality measures, whether legally required or voluntary, are an important differentiator for healthcare organizations. At Findhelp, our policy team closely monitors updates regulatory changes so that we’re ready to support and advise you.

Here are some of the services we provide:

Alignment of internal goals and workflows to meet quality measures with an emphasis on a health equity strategy to drive frontline workflows
Advice on the health needs assessment process and using Findhelp data to support creating action plans and monitoring & evaluation strategy
Action plan creation to meet measurable goals for closed-loop referrals, engagement and adoption of platform, connections, and activated community partners
Framework development for enterprise-level work that includes tailored, scalable processes for regional communities
Creation of data plan to identify Findhelp data points to combine with system of record data to measure outcomes (clinical, health equity-related, utilization / cost-saving)

Quality Support for Quality Measures

Connect with our team to see how we can help your organization acheive health equity accreditation and support your social care requirements and regulations.

Supporting Colorado’s Drug User Health Hub

We are proud to announce that we have been awarded a contract with the Colorado Department of Public Health and the Environment (CDPHE) to build a Drug User Health Hub. This project, funded in part by the Centers for Disease Control and Prevention, will help reduce transmission of viral hepatitis and promote the prevention, diagnosis, and treatment of the infectious disease consequences of drug use.

Addressing Substance Use in Colorado

In Colorado, intravenous drug use is the most common risk factor associated with acquiring hepatitis A and C. At the same time, overdose deaths in Colorado have risen sharply since 2019, in line with national trends. In 2020, the state suffered a historic high of 1,477 fatal overdoses; in 2022, that number rose to 1,799 (source: CDPHE).

Substance use disorder programs often focus on treating addiction and preventing overdoses, to the detriment of addressing the infectious diseases associated with injected drug use. People who inject drugs are at high risk for viral hepatitis, HIV, and bacterial or fungal infections, which require costly and prolonged medical care. Despite these acknowledged risks, there are many barriers to accessing longer-term medical and social care services.

Findhelp’s Network in Colorado

One of the reasons CDPHE chose Findhelp is because we have an engaged network that’s already in place. Our network spans the entire Centennial State and Coloradans across the state are using our platform to find and connect to needed services and support.

558,152 users statewide
1,740,226 searches conducted statewide
6,109 listed programs serving Colorado
1,645 claimed programs serving Colorado

Findhelp’s data and analytic tools can identify gaps in services and provide actionable insights to inform public policy. For example, over the past two years, monthly users and searches on Findhelp’s network in Colorado jumped 252% and 167% respectively, reflecting our important (and growing) role in connecting Coloradans to local social assistance.

Partnering for Success in Colorado

As of October 2022 we partner with more than 18 customers through the state to connect their patients, members, students, constituents, and clients to local resources. Here are some highlights of how these organizations successfully partner and innovate with us to lift up their communities.

Based in Colorado, Denver Health is known for emergency medicine and trauma care; as Colorado’s primary safety-net institution, Denver Health has provided billions of dollars in uncompensated care and serves as a model for other safety net institutions across the nation.

In 2021, Denver Health launched their Community Resources platform (powered by Findhelp); their staff conduct health-related social needs screening for medically-complex patients and care navigators follow up to address identified needs.
Denver Health staff have made nearly 3,000 referrals to social care programs and have integrated their Findhelp platform with Epic’s MyChart application to make it easy for their patients to self-navigate to needed social care services.

UCHealth strives to promote individual and community health and leaves no question unanswered along the way. Their network of nationally-recognized hospitals, clinic locations, and health care providers extends throughout Colorado, southern Wyoming and western Nebraska.

Since launching their UCHealth platform (powered by Findhelp) in 2019 to provide a standardized and centralized resource tool to address patients’ social needs, UCHealth has made over 14,000 connections to resources on behalf of their patients.
In partnership with Findhelp, Denver Health, Intermountain, Children’s Hospital Colorado, and others, UCHealth is collaborating locally in the Denver metro area to build a trusted network of community referral partners who are trained on the Findhelp platform.

Early Childhood Partnership of Adams County (ECPAC) is made up of over 80 Adams County, Colorado organizations and family partners building a system of early childhood education, health, mental health and family support so every child is ready for school and can read well by 3rd grade.

ECPAC launched their Adams County (CO) Resources platform (powered by Findhelp) to connect their community partners with families who need help, and to provide a safe and secure way for Adams County residents to self-navigate anonymously if they aren’t ready to reach out for assistance.
Since launching their platform in August 2022, ECPAC has made over 17,000 searches and 2,000 connections and trained more than 100 community referral partners.

Next Steps for the Drug User Health Hub Project

The health hub will focus on the surveillance of viral hepatitis, increased stakeholder engagement in viral hepatitis treatment planning and elimination, as well as improved access to prevention, diagnosis, and treatment among populations at risk. In addition, the project aims to deliver comprehensive, outcome-focused approaches to preventing infections associated with injection drug use, reducing overdose deaths, and linking people to substance use disorder (SUD) treatment.

Phase 1 is focused on creating a resource directory in the Pueblo area later this year / early 2024.

Supporting Your Community

Schedule a demo with one of our team members to learn more about how our platform can meet the needs of the individuals you serve.

Meet the Social Care Needs of Medicaid Beneficiaries

There’s been a lot of commentary and discussion recently about Medicaid enrollment and redetermination. What does it mean for your organization and the people you serve? Read on to learn more about the challenges facing healthcare organizations, and the technology solutions that can help you meet the social care needs of Medicaid beneficiaries.

Medicaid: Supporting Vulnerable Populations

Medicaid is a federal program managed by the Centers for Medicare and Medicaid Services (CMS) and implemented by individual states that provides health coverage to low-income people. In the wake of the COVID-19 pandemic and the end of the federal public health emergency, state Medicaid agencies are undergoing a process of redetermination, updating the eligibility status of millions of Americans.

Many people will end up losing their coverage, exacerbating already tenuous situations and increasing the need for community and social services to fill in the gap.

Addressing Social Needs via 1115 Waiver Programs

Section 1115 of the Social Security Act gives states flexibility to design and improve their Medicaid programs by providing waivers authorizing experimental, pilot, or demonstration projects. 1115 waivers are initially approved for five years and can be extended for three to five more years. Many states focus their projects on addressing Medicaid enrollees’ unmet health related social needs and the downstream health impacts.

At Findhelp, we have a history of successful 1115 waiver program support:

California

Massachusetts

In response to increasing needs surrounding food, housing, and behavioral health, Massachusetts’ department of health, MassHealth, launched their 1115 demonstration waiver program, Flexible Services, in 2019. Today, we partner with several ACOs to support navigation assistance; in the first year of the Flexible Services initiative, 99% of patients reported that their participation improved their overall health.

New York

The Empire State is awaiting approval on a several billion dollar New York 1115 waiver proposal to invest in creating major social care network structures. We look forward to collaborating with our existing customers and community partners to advance the work of the New York State Department of Health to connect people in need to the programs and services that can help them.

Meeting Immediate Needs: Findhelp’s Marketplace

Even if your state isn’t currently implementing an 1115 waiver, you have options to address your population’s health-related social needs. Our Marketplace program allows you to order goods and services from a vetted vendor, deliver them to an individual in need, track outcomes, and manage invoicing and payment – all from your Findhelp platform.

Healthcare organizations and health plans are looking beyond medical needs to improve health outcomes by either paying directly for social care services or reimbursing healthcare groups for arranging them. The government is supportive of these measures, providing grants and allowing Medicare to begin reimbursing plans for “non-medical” services as part of the 2020 CHRONIC Care Act.

With Marketplace, we’re shifting the paradigm beyond search and referral to order and delivery. We support eligibility and/or authorization of services, order and fulfillment, invoicing, and payment. You can ensure that people who need transportation can order an Uber Health ride to their appointment, or someone who is identified as food insecure gets a food box delivered right to their door.

Navigating the Medicaid Landscape

To learn more about how we support healthcare organizations, health plans, government agencies, and community organizations grappling with the changing Medicaid landscape, connect with us.

NY 1115 Waiver Program: Meeting the Needs of New Yorkers

More than 30 healthcare, health plan, nonprofit, and other organizations across New York have already implemented social care coordination platforms with Findhelp and are ready to hit the ground running when the NY 1115 waiver program is approved later this year. Read on to learn about proven strategies from some of our current New York customers and successful 1115 waiver programs across the country.

Innovating Medicaid Delivery to Address Social Needs

Why are folks talking about 1115 waivers, and what are they? Section 1115 of the Social Security Act gives states flexibility to design and improve their Medicaid programs by providing waivers authorizing experimental, pilot, or demonstration projects.

1115 waivers are initially approved for five years and can be extended for three to five more years. Many states focus their projects on addressing Medicaid enrollees’ unmet health related social needs and the downstream health impacts.

At Findhelp, we have both a history of successful Medicaid 1115 waiver support and deep relationships across the state of New York and beyond. Our technology supports:

Capturing eligibility and authorization needs
Reporting on services rendered, codes, and data needed for invoicing and claims
Facilitating invoices and payment to community organizations and vendors

Our Network in New York

One of the reasons our customers across industries choose Findhelp is because we have an engaged network that’s already in place. Our network spans the entire Empire State and New Yorkers are already using our platform to find and connect to needed services and support.

1,530,721 users statewide
4,905,024 searches statewide
13,710 listed programs serving New York
2,034 claimed programs serving New York

Findhelp’s data and analytic tools can identify gaps in services and provide actionable insights to inform public policy. For example, over the past two years, monthly users and searches on Findhelp’s network in New York jumped 452% and 153% respectively, reflecting our important (and growing) role in connecting Empire Staters to local social assistance.

Partnering to Help New Yorkers

As of September 2023 we partner with more than 30 customers throughout the state to connect their patients, members, students, constituents, and clients to local resources. Our customers know that they can trust us to help them connect their most vulnerable populations to resources and services that can help them, as shown by our Best in KLAS rating for 2023.

A few of the organizations we partner with in New York.

These highlights show how some of our customers successfully partner and innovate with us to lift up their communities.

New York City’s Institute for Family Health (IFH) is a federally qualified health center (FQHC) that launched their IFH Findhelp platform in August 2019 to foster meaningful connections between their patients and CBOs like A-Med Supplies, God’s Love We Deliver, Preferred Home Care, and many more. By partnering with Findhelp to build this trusted network of community partners, 94% of IFH referrals receive a response from the referred-to CBO.

In 2021, IFH deepened our partnership by leading an innovative collaboration between Findhelp and UberHealth to provide 2,396 free rides for patients to and from vaccination centers during the COVID-19 pandemic. IFH continues to explore additional innovative approaches to proactive social care and plans to launch additional Findhelp-UberHealth transportation assistance programs in 2024 to ensure patients can attend routine medical care appointments.

Value Network LLC, IPA is a behavioral health care collaborative in Western New York that advances healthy equity, innovation, and transformational strategies. They launched the Value Network Community Connector platform (powered by Findhelp) in December 2021 to facilitate stronger coordination between helping professionals, patients, and the greater Western NY community.

Value Network has used their vast network of providers to strengthen the safety net to address member’s social needs and has led the way with innovative work to create efficiencies in provider workflows by integrating multiple electronic health record (EHR) systems with Findhelp.

Mount Sinai Health System uses their Community Resources Guide (powered by Findhelp) to support all their patients in need and connect them to free or reduced-cost social services with dignity and ease.

Since launching the platform in December 2019, more than 85,000 patients and staff have visited the platform to search the 13,000+ programs available in Findhelp’s New York network. Mount Sinai continues to build robust community relationships and generate social care referrals with an array of partners to holistically support the social needs of their patients.

A Legacy of Support for Medicaid 1115 Waivers

We’ve been partnering with our customers and trusted community partners to support Medicaid 1115 waiver programs since 2019 in Massachusetts and California, and are uniquely positioned and ready to support New York’s Medicaid 1115 waiver. We collaborate with health plans, managed care organizations, accountable care organizations, and community-based organizations to configure workflows and payment processes to fit the requirements of each state’s program.

Massachusetts: Flexible Services

Starting in 2020, Findhelp partnered with Mass General and Brigham and Women’s Health to launch Flexible Services pilots with 10 community-based organizations.
Midway through 2020 we expanded our partnerships to include Boston Medical Center and SouthCoast Health and trained 7 additional community organizations to improve food and housing outcomes across the state.
Today, we are partnering with several Flexible Service ACOs to support navigation assistance for areas with higher volumes of eligible patients. In the first year of Flexible Services, 99% of patients reported that their participation improved their overall health.

California: CalAIM

CalAIM expands community-based approaches to addressing complex care for high-needs populations, such as individuals experiencing homelessness, serious mental illness, or substance use disorders, or children involved in the child welfare system. Designated navigators coordinate members’ physical and behavioral care, as well as access to critical social services.

Through 14 services such as Asthma Remediation and Housing Navigation Support, CalAIM encourages Medi-Cal managed care plans to address social determinants of health (SDoH) and offer preventative upstream interventions.
Findhelp partners with managed care plans across the state like Aetna Better Health, Health Net (Centene), and Alameda Alliance for Health to support CalAIM. We enable their staff to order more than 445 different social services from community partners.
As we continue to onboard new community organizations and train managed care plan staff on use of the platform, we’ve seen a 40% increase in the number of referrals sent on CalAIM Findhelp sites from July to August 2023.

Looking Ahead to 2024

Our robust data and analytics show what New Yorkers have searched for over the last two years, painting a picture of how needs have changed over time and what gaps currently exist in New York communities.

As you can see, food, housing, and transportation-related needs are among the most common for New Yorkers over the past couple of years. Findhelp has experience partnering with customers across the country to address needs like these, whether it’s via our fulfillment program, Marketplace, by establishing trusted networks of community service providers, or by collaborating with organizations like Uber Health.

When the New York Medicaid 1115 waiver is approved later this year, we’re ready to partner with our existing and future New York-based customers to help them connect their patients, members, students, and clients to helpful resources.

We look forward to collaborating with our existing customers and community partners to advance the work of the New York State Department of Health to connect people in need to the programs and services that can help them; we’re ready to support New York’s Medicaid 1115 waiver.

Partnering for Success

Prospective Customers: connect with our Director of Enterprise Sales, Rachel Harris ([email protected]).
Community Organizations: reach out to our New York Community Engagement Manager, Colton Navel ([email protected]).
Policymakers: connect with our Regional Director for Government Relations, CG Niquette ([email protected]).

Medicaid Waivers by State: Findhelp and California

Section 1115 of the Social Security Act gives states flexibility to design and improve their Medicaid programs by providing waivers authorizing experimental, pilot, or demonstration projects. 1115 waiver programs are initially approved for five years and can be extended for to three to five more years.

Many states focus their projects on addressing Medicaid enrollees’ unmet health related social needs and the downstream health impacts. Findhelp has extensive experience supporting 1115 programs in states like Massachusetts and California, where managed care organizations (MCOs) and accountable care organizations (ACOs) use our platform to place orders for their Medicaid members for reimbursable goods and services. Our technology supports:

Capturing eligibility and authorization needs
Reporting on services rendered, codes, and data needed for invoicing and claims
Invoicing paying entities and facilitating payment to community organizations and vendors

Medicaid 1115 Waivers in California: CalAIM

On January 1, 2022, the California Department of Health Care Services launched the California Advancing and Innovating Medi-Cal (CalAIM) program, an 1115 waiver program to make Medi-Cal more equitable, coordinated, and person-centered. The program covers one-third of Californians and perinatal care for half of annual births and will impact the lives of over 14 million Californians.

Through 14 services such as Asthma Remediation and Housing Navigation Support, CalAIM encourages Medi-Cal managed care plans to address social determinants of health (SDoH) and offer preventative upstream interventions.

Our Network in California

Our California network spans the entire Golden State and Californians, community-based organizations (CBOs), and more than 71 customers across the state are already using our platform to find and connect to needed services and support.

3,005,249 users statewide
9,498,815 searches statewide
26,378 listed programs serving California
4,937 claimed programs serving California

Over the past two years, monthly users and searches on Findhelp’s network in California jumped 453% and 204% respectively, reflecting our important (and growing) role in connecting Golden Staters to local social assistance.

Collaborating to Support CalAIM

We partner with managed care plans throughout the state to support the CalAIM initiatives. Our technology provides both the platform to connect with contracted partners and support for billing, invoicing, and reporting. Throughout the CalAIM process, our Customer Success team works with the managed care plan staff to onboard them to the Findhelp CalAIM platforms, including detailed training sessions, office hours, in-person support, and more.

At the same time, our Community Engagement team works with the contracted service providers to onboard them to the platform. This includes in-person and virtual support to claim their programs, turn on referrals, set up screeners, and submit data for billing purposes.

Typical CalAIM Workflow

Managed care plan navigators complete a required eligibility check to confirm the person being helped is qualified for CalAIM; this can occur in either Findhelp or the managed care plan’s provider portal or care management system.
A navigator completes the CalAIM Assessment in Findhelp to collect member information and indicate the member’s needs across the 14 service categories.
Available services are displayed in Findhelp based on the member’s assessment responses. The navigator then chooses the appropriate program and makes a referral to the service provider.
The managed care plan will authorize the service; the authorization can be accessed either in Findhelp or the plan’s provider portal.
After completion of the eligibility check and authorization for services, the referral is updated via the Findhelp platform to the service provider, indicating the member can now receive services.
After addressing the member’s need, the service provider closes the loop on the referral, then fills out the data form in Findhelp to facilitate simple billing.
Findhelp creates and sends an invoice to the managed care plan on behalf of the service provider.

Supporting California Customers & Seekers

Findhelp collaborates with managed care plans across the state to connect Californians to resources via CalAIM. We enable their staff to order more than 445 different social services from community partners. Through the Findhelp platform, navigators can assess members and order services based on state-mandated eligibility criteria, and service providers can bill for and receive payments. Furthermore, Findhelp’s data and analytic tools can be used by our customers and partners to identify gaps in services and provide actionable insights to inform public policy and prioritize initiatives.

Here are just a few examples of how we’re partnering with California organizations to support their CalAIM programs.

Founded in California more than 40 years ago, Health Net believes every person deserves a safety net for their health regardless of age, income, employment status, or current state of health. Health Net provides quality affordable health plans for individuals, families, Medi-Cal members, Medicare and businesses. Health Net launched their CalAIM platform Community Supports (powered by Findhelp) in 2021.

Health Net works with Findhelp to manage their CalAIM-related referrals and workflows. Our platform allows for end-to-end referrals in tandem with existing workflows in Health Net’s internal care management system and provider portal. Health Net has a mixed workflow: navigators check the provider portal for eligibility and service providers use the Findhelp platform.
We partner with Health Net to onboard service providers to Findhelp’s invoicing process. Our Community Engagement team has worked extensively with more than 100 of Health Net’s contracted community providers to onboard them to the platform and ensure they claim and accept referrals. Our Customer Success team works ongoing with Health Net’s staff to provide training, office hours, and general support of the platform.

As a local, public, not-for-profit managed care health plan, Alameda Alliance for Health is committed to making high-quality health care services accessible and affordable to Alameda County residents. The Alliance staff and provider network reflect the county’s cultural and linguistic diversity; they launched their Findhelp platform in 2023 to provide social care support for county residents.

The Alliance works with us to manage their CalAIM referrals and internal staff workflows. Similar to Health Net, the Alliance has a mixed workflow, with staff checking internal Alliance systems for eligibility and authorization and navigating for services via the Findhelp platform.
After authorization of the service occurs through internal systems, Alliance staff use the Findhelp platform to send referrals to service providers via our marketplace functionality. Service providers also identify eligible members and make referrals to Alliance’s internal Community Supports and Case Management teams, via Findhelp program listings.

Supporting communities for over 30 years, Aetna Better Health of California brings national experience to the local level, ensuring members have the resources and tools to stay well; they launched their CalAIM platform (powered by Findhelp) in 2021 to connect members to community resources.

Aetna has collaborated with Findhelp to build automation into their end-to-end referrals workflow. Their staff navigators can identify at the start if a person is eligible for services, and shared demographic data helps to avoid double-documentation.
Additionally, we created data collection forms for each service provider to add information from a pre-made list, such as Healthcare Common Procedure Coding System (HCPCS) codes, modifiers, and more. This allows service providers to generate and send invoices to Health Net, via the Findhelp platform.

The Future of the Findhelp’s Support for CalAIM

We continue to expand and adapt our CalAIM support in partnership with our customers, to reflect ongoing changes in the state policy landscape. Recent updates and improvements include:

Outcome Tracking Improvements
- Service providers can document services rendered on multiple outcome tracking forms to allow for a more frequent billing cadence or separation of data collected for different uses.
- Users can save outcome tracking forms as a draft without having to enter required fields.

Integrations & APIs
- We’re implementing additional integrations with nonprofit care management systems.
- We completed integrations with HarmonyHealth, a company that provides text messages for seeker outreach, to directly engage with those who need additional help and to support the closure of more referral loops.
- We’re making ongoing improvements to eligibility file ingestion with the capability to support member eligibility APIs.

Authorization Workflows
- Findhelp is working with managed care plans to support their authorization workflows in deeper ways, ensuring ease of use for contracted providers and staff.

CalAIM Success Story

Want to Learn More?

Schedule a demo with us to see how we can partner with your organization to support your members via CalAIM (or other Medicaid 1115 waiver programs).