Delivering Social Care

Authority to cover social needs is necessary but not sufficient. The hard part is delivery, and delivery runs through organizations that sit outside healthcare entirely. Medicaid’s social-needs ambitions succeed or fail on whether that hand-off works.

The delivery chain and where it leaks

The standard model is screen, refer, resolve: screen enrollees for social needs, refer those who screen positive to a community organization, and track whether the need was met. Each step leaks. Screening is done inconsistently. Referrals land on food banks and housing agencies that may already have waiting lists. And closed-loop tracking, actually confirming the need was resolved, is the exception rather than the rule.

Worth remembering: the pipeline works when the receiving end is funded. A plan can screen every enrollee and refer every need, but if the community organizations have no capacity, screening is diagnosis without treatment.

Community organizations as paid partners

The serious version of this work is a payment relationship, not a referral list. Medicaid’s coverage authorities let plans contract with community-based organizations, food banks, housing agencies, area agencies on aging, and pay them per service or per member to deliver. That turns a nonprofit’s goodwill into fundable, accountable capacity.

Community health workers deserve specific mention. Hired for lived experience and community trust rather than clinical credentials, they show some of the strongest evidence in the field for reaching Medicaid enrollees the system otherwise misses, the same finding the intro course reported, and a natural fit for a program whose members face the most barriers.

The realistic view

Medicaid has done more than any payer to make social care fundable. Whether it improves outcomes depends on execution: targeting the enrollees for whom a social barrier is truly the binding constraint, funding real community capacity, and closing the loop. The authority is a tool, not a result.

Key takeaways

• Social-needs programs run through community organizations, and the screen-refer-resolve chain leaks at every step.
• The pipeline works only when the receiving organizations are funded to deliver.
• Contracted community organizations and community health workers are the strongest delivery vehicles; execution, not authority, decides impact.

Sources

• CMS, Coverage of Services and Supports to Address Health-Related Social Needs in Medicaid (November 2023) (opens in a new tab)
• Medicaid.gov, In Lieu of Services and Settings (opens in a new tab)