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  • Writer's pictureericjcarrig

Using non-profits to build the health-support network white people take for granted? Let's do better

Updated: Jun 11, 2023

Guest: Laurie Stradley, Executive Director of Impact Health and leader of The Healthy Opportunities Pilot

Connecting the neediest with physical and mental health care and non-clinical services to improve life quality and reduce emergency department visits and hospital readmissions

Healthy Opportunities Pilot Overview

  • $650 million, five-year program in North Carolina, focused on improving the living conditions that influence eligible Medicaid members’ health, like access to food and transportation along with physical and mental health.

  • It aims to show the Centers for Medicare and Medicaid Services (CMS) and state and local governments that using healthcare dollars on community resources improves health and reduces costs, especially related to emergency department visits and hospital readmissions.

Examples from 29 service categories:

  • Food: Healthy food boxes; Fruit and vegetable prescription; Medically tailored, home-delivered meals; Group nutrition classes; Diabetes prevention program

  • Housing: One-time security deposit and first month’s rent; Inspection for housing safety and quality; Home remediation services; Home accessibility and safety modifications; Short-term post-hospitalization housing; Linkages to legal support services

  • Transportation: Transportation to support health needs like the grocery store or fitness center; Taxi and ride-sharing credits where public transportation is unavailable; Reimbursement for gas mileage; Vehicle repairs

  • Toxic Stress: Evidence-based parenting curriculum; Home visiting services; Dyadic therapy (form of therapy in which child and parent are treated together)


  • Members must live in one of the pilot’s three regions, have at least two chronic conditions or repeat emergency department or hospital visits, and have an additional risk factor like food or housing insecurity.

  • If one person in the family is eligible, the entire family is eligible, so, for example, HEPA filters can be brought in for one asthmatic child or food boxes can be delivered to serve the entire family.

How it works

  • Members can enter the program through a healthcare provider, whatever social service they need, or self-refer into the program by going to the Impact Health site or calling Impact Health or the number on their Medicaid Managed Care card.

  • Impact Health coordinates private insurers, physician practices, care management organizations, and local community groups like food banks and housing remediates, which do things like remove moldy carpet so people have better air quality in their homes.

  • A care manager assesses their need for services and then connects them with community organizations that can help.


  • A diabetic repeatedly visits the emergency department despite having access to insulin.

  • During an interview with the patient, a social worker finds out that they don’t have a refrigerator, which is required to keep insulin active.

  • By paying $300 to get a refrigerator into that person’s apartment, the program can keep them from multiple visits to the ER because they are able to manage diabetes.

  • Further, the person can put food in the refrigerator.

Should a program like this be so difficult to implement?

To succeed, we need more care managers and coordinators, who tend to be nurses or social workers, when there is a shortage of them, and the jobs don’t pay that well.

  • They are responsible for reaching our to members, getting to know them, assessing their needs and helping them navigate care after a diagnosis.

  • They typically have a clinical license, so are not trained nor inclined to play the role of coordinator, especially for Medicaid members — who tend to be more difficult to reach and reluctant to enter the healthcare system.

Delicate process of outreach and enrollment

  • Many individuals are wary of enrolling because they doubt the system will support them because someone in their family has had a bad experience or they are concerned because they have mixed immigration status, for example.

  • Outreach must come from someone the member trusts because health information is supposed to be private, e.g. a doctor or representative of an organization they already know.

  • Privacy rules can make getting eligibility lists for outreach from state enrollee logs or providers difficult.

Building a network of services is uncharted territory

  • There is no network of community services in a single database like there is for medical providers. For example, there is no connection from a primary car physician for a referral to a food pantry or feedback loop to tell the physician whether the patient got food.

  • While urban areas tend to have more social services in concentrated areas, rural areas have fewer and less connected resources.

Adding red tape?

  • Each community service bills for each service separately, like paying for a refrigerator or a navigation consultation, so that creates more paperwork and administrative burden, which can lead to frustration.

Patience for performance?

  • Short-term measures are fewer emergency department visits and lower hospital readmission rates.

  • Whether the program leads to better quality of life could take years to measure. Will governments have patience?

Too many of us don’t understand what it is like to have to prove you are poor enough to deserve help

  • When you have money and insurance, you show your card at the doctor’s office or pay your bill. You may have foundational health, like the ability to get food, pay your bills, drive to get wherever you need to be, and have a decent place to live. You don’t rely on public transportation.

  • When you can’t afford the deductible and copays, lack food, gas for the car, and struggle with rent, and don’t have a social network with the means to help you, you don’t go to the doctor.

  • If you are on Medicaid, you need to prove your are eligible for benefits — that you are poor enough to deserve help, unemployed, don’t have a car, can’t pay your bills, and your home is unlivable. Every day is a trade-off of barely-met needs.

  • Why would you enter the health system unless you had to go to the emergency department, which is what poor people do?

  • Example

    • Let’s say you need to take your car to the shop. You pay the cost of the repair, maybe work from home, and have a friend or spouse to your kids to school.

    • If you have to go to work and don’t have a social network, that all changes. You can’t get to work. The kids don’t go to school. If the car breaks down during the day, you can’t pick up kids from school, so pay a penalty for care/being late.

Simple actions and a little thinking

Provide direct financial support local community groups because we need stable health services organizations and non-profits.

Look for ideas like Healthy Opportunities and organizations like Impact Health in your state to support.

A broader perspective

  • Broaden the definition of healthcare to include not only nutrition and exercise and physical and mental health care but also the foundational elements of health support networks we take for granted like transportation, housing and a living wage.

  • Consider that we have a model of care that wealthy people use, which seems to work.

    • They use their income to pay for their health insurance premium and deductible, surgery copayment, drugs, car, food, and housing.

    • They apply their education and social network to know what to do, navigate the system, and get the support they need in a pinch.

    • Why are we making people prove that they deserve access to healthcare and social services when we know that doing so would improve health and reduce costs based on our experience with wealthy people

  • For everyone else, do we want to build the same model we have in physical health

    • Will we succeed by asking nurses, social workers and physicians to do more non-clinical work related to a new universe of services that creates more administrative burden when they are already burned out and leaving the profession?

    • Will it work to ask community service organizations to file a claim for anything from giving away food, to paying a utility bill, to offering guidance, which also adds to the administrative burden and discussions about what is covered that we have today?

  • What if we all had the same access to care and prices for it were capped?

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