Funding and Sustainability Strategies for Rural SDOH Programs

Funding and reimbursement are key sustainability strategies for rural programs that address social determinants of health (SDOH). Rural programs are also exploring alternative payment models and strategies to unite disparate funding streams. For general information on program sustainability, see the Sustainability Strategies section of the Rural Community Health Toolkit.

Key funding strategies used by rural programs addressing SDOH include:

Grant funding, including securing grants from a range of federal agencies and state-level government programs, as outlined on the next page of this module
Local support, including contributions from local government, local business, and community leaders
Partnerships, such as with healthcare providers and organizations, who may provide financial contributions to support SDOH programs
Philanthropic funding, which includes support from national, regional, and local foundations and philanthropies
User fees from program participants (applicable in some cases, such as transportation-focused programs)

Reimbursement and billing is another key funding strategy for rural programs seeking to maintain services over the long term. While reimbursement policies vary by state, examples of services programs may seek reimbursement for include:

Care management services
Interdisciplinary care teams
Home visiting services
Services provided through school-based health centers
Telehealth services
Transportation services, especially through Medicaid Non-Emergency Medical Transit

Some programs may experience challenges with reimbursement. For example, reimbursement structures typically do not allow for community health worker (CHW) payment codes, despite CHWs and patient navigators being essential in connecting people to services to address SDOH. Identifying alternative funding sources is crucial to maintaining CHW and patient navigator services. The Rural Community Health Workers Toolkit compiles funding considerations to sustain these types of programs. For additional funding information, see Funding & Opportunities in the Social Determinants of Health for Rural People topic guide.

Alternative Payment Models

Rural communities addressing SDOH in healthcare should explore alternative payment models. These programs may fund services that address upstream factors affecting health, such as food access or housing, to achieve improved healthcare outcomes.

Payment reform is a complex topic. As healthcare costs increase, interest is moving from fee-for-service care to value-based payment (VBP) models of care. Healthcare organizations have been piloting VBP models to evaluate impacts on cost, patient experience, and population health. Healthcare organizations are still in the early stages of determining how to design these models and the impact they may have on SDOH.

The Centers for Medicare & Medicaid Services (CMS) funds several demonstration programs that address payment and service delivery models through the Innovation Center. Demonstration models focus on incentivizing healthcare providers to provide high-quality care, improving access to primary care, and integrating cost-effective systems of care, including Medicaid managed care plans that address social needs.

States are also using federal funding to transform their own state Medicaid programs, often focusing on addressing SDOH and promoting health across populations. Oregon is one among several states that are testing out these new models. In Oregon, Coordinated Care Organizations (CCOs) receive a global budget to provide all integrated physical and behavioral health services to patients in their region. As part of the global budget, CCOs can fund flexible services that address SDOH, ranging from housing and transportation to food access and educational opportunities. For example, the Eastern Oregon Coordinated Care Organization, which serves 12 of Oregon's rural counties, is funding the Frontier Veggie Rx Program to provide eligible patients with prescriptions to buy healthy fruits and vegetables.

Uniting Funding Streams for SDOH

Many healthcare programs addressing SDOH operate and are funded in silos, which can be a challenge. Funding opportunities for programs looking to address SDOH often focus on one type of social determinant and prevent resource allocation for competing problems. Additionally, funding may come with varying requirements and eligibility requirements, creating barriers to data integration and program coordination efforts. For example, a rural program seeking to connect community members to health insurance, housing assistance, childcare support, and transportation access could be managing 4 different federal and state funding sources. Rural communities could explore the option of using flexible funding approaches, including blending or braiding siloed funding sources, to streamline payment and reimbursement of services. Blending refers to pooling two or more funding sources to fund a program or initiative, whereas braiding protects each funding stream's connections to its original source.

The Rural Services Integration Toolkit provides examples of one-stop shop rural programs that are seeking to blend or braid different programs and funding streams.

Resources to Learn More

Braiding and Blending Funds to Promote Social Determinants of Health
Video/Multimedia
Describes challenges to and strategies for combining different funds from different sources to support community health and economic development.
Organization(s): Brookings Institution
Date: 5/2019

Guidance for Structuring Team-Based Incentives in Health Care
Document
Describes teamwork in healthcare settings and how each team member impacts the outcome of work performed by others. Discusses the shared accountability for health outcomes and healthcare spending. Identifies the challenges associated with designing and implementing team-based incentives and performance measures.
Author(s): Blumenthal, D.M., Song, Z., Anupam, B.J., & Ferris, T.
Citation: American Journal of Managed Care, 19(2), e64-e70
Date: 2/2013