Catalyzing Medicaid Progress on Health-Related Social Needs: The Role of Collaboratives in Policy Development and Implementation

Across the United States, Medicaid programs are recognizing the value of addressing health-related social needs (HRSN) while meeting ambitious health equity goals. Recent evaluations from Massachusetts and North Carolina reinforce the value of investing in HRSN services. In Massachusetts, participants in the Flexible Services Program experienced a 23% reduction in hospitalizations and a 13% drop in emergency department visits, with net savings achieved. North Carolina’s Healthy Opportunities Pilot showed that nutrition and housing supports yielded net savings within eight months. These results underscore the importance of continuing to explore and invest in HRSN strategies that align with state priorities and infrastructure as the availability of federal authorities to fund these strategies shifts. 

As states recalibrate following the rescission of federal Health-Related Social Needs (HRSN) waiver guidance and navigate H.R.1 policy changes, the impact of the sunsetting of pandemic-era enhanced supports, and rising costs, they face a pivotal question: how can state Medicaid agencies continue to move from intent to impact in addressing social drivers of health? 

New Jersey Model

The Social Determinants of Health Learning Collaborative (SDOHLC), a component of the Quality Improvement Program – New Jersey (QIP-NJ), offers a roadmap for action. QIP-NJ, launched in 2020, is a Medicaid Managed Care pay-for-performance state directed payment initiative for acute care hospitals with performance measures targeting improvements for the Behavioral Health and Maternal Health populations. The program measure portfolio includes some pay-for-reporting measures, including SDOH screening in emergency, ambulatory, and inpatient settings. Through three Breakthrough Series Learning Collaboratives, the QIP-NJ program accelerated improvement in key outcomes. In 2024, the state launched a collaborative to help hospitals improve community referrals and connection to services after a positive social needs screen, as many of the pay-for-performance clinical measures can be improved by closing gaps in social service needs of patients in the target population. The 9-month SDOHLC delivered results:  

• • All program respondents reported making progress towards their team goal, with 67% noting that they met or exceeded their goal of improving successful connections to community based social services in meal, transportation or housing supports.  

• • Meal support was the most identified need and posed the most challenging for data relay and closed loop communication, compared to housing and tenancy supports and transportation supports.  

• • The majority – 78% (n=22/28) – of hospital teams reached at least the relationship building milestone of conducting regular meetings between key contacts at a new community-based organization providing services in meal, transportation or housing supports. Thirteen hospitals reached the subsequent milestone of establishing workflows for closed loop referral processes, with two teams achieving the final relationship building step of establishing memoranda of understanding (MOU) and business associate agreement (BAA) data sharing agreements. 
  • The cohort of 28 participating hospital teams successfully reported social risk screening data, integrated community referrals into their workflows, contacted 430 patients to assess their experience, and improved their readiness to meet future equity-focused benchmarks.  

The Role of Stakeholder Collaboratives

HRSN are a pressing community need that challenge hospitals daily in their effort to serve their patients, so leveraging existing quality programs that include a collaborative to address those needs is a practical and scalable approach. 

As states respond to shifting federal guidance and funding mechanisms for HRSN, establishing this sort of collaborative grounds program design in stakeholder input and delivery system realities. Hospitals are actively working to find ways to better address the social needs of their patients. New Jersey’s experience with the Social Determinants of Health Learning Collaborative (SDOHLC) highlights how learning collaboratives can support Medicaid agencies in translating intent into impact by engaging delivery system providers who are eager to find solutions for their patients’ complex challenges. The SDOHLC demonstrated that provider collaboratives can help build relationships with community-based organizations, strengthen referral workflows, and improve data infrastructure, all without requiring significant new funding to launch or sustain. 

State Considerations

When considering an approach to invest in HRSNs, states may consider: 

• • Aligning HRSN initiatives with existing Medicaid performance programs, such as QIP-NJ. 

• • Supporting practices for data integration and workforce development for non-traditional partners, including peer specialists, doulas, and community health workers. 

• • Evaluating HRSN program impact on both utilization and equity to inform future investment. 

• • Embedding Breakthrough Series Collaboratives into policy programs to accelerate implementation and elevate the voices of community-based organizations and Medicaid members. 

New Jersey’s experience shows that strategic convening and collaborative learning can drive impactful changes in the delivery system. As states look ahead to the next chapter of Medicaid transformation, they must draw on existing lessons and infrastructure to guide their approach in ways that reflect community needs, policy goals, and the realities and motivation of the delivery system.