CHCF Closing the Gap in California's Health Data Exchange: Necessary Investments and Funding Opportunities JUNE 2022 AUTHORS Lauren Block, MPA; and Kate Ricker-Kiefert, MS About the Authors Lauren Block, MPA, is a managing princi- pal for Medicaid Policy and Programs at Aurrera Health Group, a mission-driven national health policy and communications firm based in Sacramento. Kate Ricker-Kiefert, MS, is CEO of Amelia Mayme Consulting, LLC, a firm that provides health policy, operations, and technology consulting services for public and private sector clients. About the Foundation The California Health Care Foundation is dedicated to advancing meaningful, measurable improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford. CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemakers to create a more responsive, patient-centered health care system. DESIGN BY DANA KAY DESIGN Contents 19 21 22 32 Introduction Methodology and Scope Key Findings Onetime Technical Capabilities and Infrastructure Maintaining New Technical Capabilities and Infrastructure Policy and Implementation Support Staffing and Workforce IT Needs by Delivery System Federal Funding That Supports Information Technology Investments Examples of Other States Pursuing Similar Goals Conclusion Appendices A. Data Exchange Framework Timeline B. Interviewees C. Constraints on Federal Funding D. Type of Federal Funding Available to States E. Strategies for Leveraging Medicaid Dollars F. Components of CalAIM That Could Support AB 133 Priorities for Data Exchange G. Glossary of Abbreviations Endnotes Introduction Electronic data exchange within health care and across sectors is an essential component of effec- tive care delivery and critical to address health and social needs, reduce health disparities, and improve outcomes. This year California is implement- ing multiple major initiatives that will necessitate robust cross-sector data sharing, including the Data Exchange Framework. Electronic data exchange within health care and across sectors is an essential component of effective care delivery and critical to address health and social needs, reduce health disparities, and improve outcomes. In July of 2021, Governor Newsom signed into law AB 133 (Chapter 143, enacted Health and Safety Code § 130290), the Omnibus Health Trailer bill, which among other things, calls for development and implementation of a statewide Health and Human Services Data Exchange Framework.' The law envisions a state in which "every Californian, and the health and human service providers and organizations that care for them, will have timely and secure access to usable electronic information that is needed to address their health and social needs and enable the effective and equitable delivery of services to improve their lives and wellbeing."" The 2021-22 state budget allocated $2.5 mil- lion for health information exchange leadership in the state.' In addition, the May Revision adds two important grant and technical assistance programs to the 2022-23 budget: >» Technical assistance grants. A $50 million two-year grant program "to provide technical assistance to small or underresourced providers, particularly small physician practices, rural hospi- tals, and community-based organizations, as well as education and technical assistance for entities new to health information exchange." > Equity and practice transformation payments. Two hundred million dollars for "grants and tech- nical assistance to allow small physician practices to upgrade their clinical infrastructure, such as electronic health record systems, data collection and reporting capabilities, implementation of care management systems, and other activities that will allow the adoption of value-based and other payment models that improve health care quality while reducing costs."* Hospitals, physician organizations, medical groups, clinical labs, skilled nursing facilities (SNFs), health service plans, and acute psychiatric hospitals must execute the data sharing agreement framework by January 31, 2023, with real-time data shar ing phased in from January 31, 2024, through January 31, 2026. The state must also engage counties, including health, public health, and social services agencies, to encourage participation by January 31, 2023. See Appendix A for a complete implementation timeline. California has a local and decentralized approach to governance with distributed authority at the county level, so regions, counties, and communi- ties have developed and procured systems and tools to meet their specific needs without a coor dinated state-level approach.° As a result, different regions of the state have variable levels of health Closing the Gap in California's Health Data Exchange: Necessary Investments and Funding Opportunities 3 and social services information exchange infrastruc- ture, though public health is largely excluded from most clinical health information exchange. The goal of this paper is to outline the technological capacity and funding needs of delivery system pro- viders who must comply with AB 133. The authors identified four categories of investments necessary to achieve robust interoperability based on stake- holder engagement: > Onetime technical system and infrastructure investment > Technical system and infrastructure maintenance and operations > Policy and implementation support > Staffing/workforce The paper also outlines existing federal funding streams that, if leveraged, could support interop- erable data exchange, as well as anticipated remaining funding needs that will require targeted investments to close the gap in data exchange capabilities. Methodology and Scope This report was produced by conducting a litera- ture review of funding sources and investments at the federal and state levels and through interviews with association and county level representatives from organizations identified in AB 133 as well as consultants and vendors serving associations and counties. Aurrera Health Group and Amelia Mayme Consulting conducted interviews with 36 staff across 24 organizations. A complete list of those interviewed is included in Appendix B. Of note, interviews were conducted before the May Revision of the 2022-23 budget was released. Therefore, needs identified did not take into consideration the potential availability of $250 million in grant and technical assistance for small and underresourced providers. The report focuses on functional and funding needs to support interoperable data exchange for entities named in AB 133. Research on funding sources was limited to federal resources and not private sector contributions. Also, the paper focuses on funding sources available on an ongoing basis rather than short-term or onetime funding. Consideration of specific technological architecture solutions or the merits of different approaches and potential needs of vendors and organizations that might implement such solutions are outside the scope of the paper. Further, the paper does not address the extent to which certain potentially shared technology ser- vices such as consent management and identity management might be implemented or financed. Federal funding announcements known as Notifications of Funding Opportunities can be found at www.grants.gov.° Specific regulatory and program requirements including allowable uses of funds can be found in the Federal Register and Federal Policy Guidance resources, such as the State Medicaid Director letters.' Key Findings Across delivery system providers, there are a range of technical service and support needs to facili- tate interoperable data exchange. Delivery system providers who historically received funding and implementation support have the fewest needs, while those historically excluded from such pro- grams will require the greatest resources to meet the expectations of the Data Exchange Framework. Table 1 shows a summary of four categories of need identified by interviewed stakeholders to promote adoption and maintenance of systems that support interoperable data exchange. California Health Care Foundation www.chcf.org 4 Table 1. Categories of Functional Need by Delivery System Stakeholders to Support Information Exchange Onetime Technical Capabilities and Infrastructure » Electronic data capture » Electronic data standards » Data systems interoperability » Adapting single use and legacy systems » Data aggregation and analytics Maintaining New Technical Capabilities and Infrastructure » Ongoing operations and sustainability » Scale and extended functionality Policy and Implementation Support » Initial and ongoing outreach and education » Privacy and security » Informed data analysis and decisionmaking Staffing and Workforce » Technical, operational, and strategic roles Below is more detail on these categories of func- tional need for delivery system providers. Onetime Technical Capabilities and Infrastructure Electronic Data Capture At the most basic level, to engage in electronic data exchange, information must be digitized. Most clin- ical health care providers outside of public health in California use an electronic health record (EHR) system, with larger and more sophisticated pro- viders using certified EHR technology. Some also have care coordination systems, screening tools, customer relationship management platforms, and referral tools that may be integrated with an EHR platform. However, some health care providers and many public health and social service providers use paper-based systems or tools like Excel databases to capture patient/client information, make referrals via phone or fax, and fax information like lab results between providers. Electronic Data Standards Many organizations without certified EHRs have rudimentary systems that support electronic data entry but do not adhere to a common data model such as the United States Core Data for Interoperability (USCDI) to capture information.® They may use systems that allow entry of narrative text, notes fields, or scanned documentation. While these practices can work within an organization or system, not using common discrete data elements precludes meaningful cross-sector data sharing and more sophisticated functionality like data aggrega- tion for population health analysis. Adhering to the same data standard allows health care stakeholders to exchange health information, including nonclinical data like claims and encoun- ters, across organizations. This increased data flow allows stakeholders to track admission and discharge information, coordinate care, and iden- tify health patterns and opportunities for quality improvement. Additionally, reporting clinical data to public health in a standardized format improves data quality and administrative efficiency for care teams in public health departments. Of note, the standards used in one sector do not always translate to standards used in another. Therefore, it is critical to invest up-front time identify- ing shared data definitions and agreeing on semantic and transport standards, especially for common use cases within and across sectors. Further, while all health care providers benefit from robust and interoperable EHRs, social service providers, such as organizations that support people experiencing homelessness or that facilitate access to food, may have different information technology priorities.' Staff time and effort is required to reconcile all these differences, meet the needs of multiple data users, Closing the Gap in California's Health Data Exchange: Necessary Investments and Funding Opportunities 5 and maximize the benefits of data exchange (see Staffing and Workforce on page 8). Data Systems Interoperability Beyond the ability to capture data in a standard- ized way, systems must be able to both send and receive data through bidirectional data exchange. In a mature environment, unique data systems are interoperable. This means that data flow seamlessly between EHRs and other data platforms; users remain in their workflow rather than using multiple systems and integrating data across each unique system. Unfortunately, interoperability is still absent in cer- tain parts of the health care system. For instance, health systems are required to report notifiable conditions for infectious disease surveillance, but public health systems have inconsistent capacity to receive the data electronically or to report back individual information. Similarly, Homeless Management Information Systems (HMIS) used by counties and commu- nity-based organizations (CBOs) support limited data reporting to the US Department of Housing and Urban Development (HUD) on performance measures but often lack functionality to ingest information or customize information sharing with partners outside the homeless system of care. This can stymie efforts toward bidirectional cross-sector data sharing. Within health care, admission, discharge, and trans- fer (ADT) feeds represent an example of the standard alerts and notifications to make providers aware of their patients' status. In addition, adherence to widely recognized data exchange standards, such as Health Language 7 (HL7) transport standards and Fast Healthcare Interoperability Resources (FHIR), can facilitate connections across systems to reduce duplicative data entry, which is time-consuming and contributes to inconsistencies and errors. To accomplish meaningful bidirectional information exchange, organizational leaders must make early concerted effort across sectors and with vendors to articulate system requirements. If the health care sector works independently on technical and policy solutions without collaborating with other sectors, the technical and policy approaches likely will not meet the needs of all stakeholders. At a minimum, some level of data mapping and data normaliz- ing must occur to facilitate data translation and harmonization. In some instances, providers procure the same tech- nology platforms with their desired data sharing partners, such as a specific EHR, care coordination, or referral platform. However, unless organizations collaborate with one another and the vendor or align standards early in the process, use of the same platform does not automatically result in interoper- ability across users of the same system. Absent interoperability, some organizations inter- viewed allow external users customized access (e.g., read-only vs. edit functionality) to one another's sys- tems. This does not allow sharing across platforms, but it provides insights about individual client infor- mation. Alternatively, technical systems can be connected to one another for directed and pulled data transfer though point-to-point connections, though these are difficult and costly to maintain. Adapting Single Use and Legacy Systems Many existing systems used by public health pro- grams, homeless systems of care, jails, and smaller physician offices were built or procured with nar- rowly defined functionality in mind. Systems built with limited scope often lack the capacity to adapt in functionality and reuse systems architecture for new purposes. Performing one-to-one systems integrations to incorporate new features or partner- ships in less agile systems can be complex, time intensive, and costly, as is ongoing maintenance to sustain these connections. Even within seemingly California Health Care Foundation www.chcf.org 6 similar sectors such as housing and homelessness, systems vary widely and do not support data shar- ing with one another. In some cases, delivery systems may be able to leverage application programming interfaces (APIs) to support data sharing. However, some legacy sys- tems are too antiquated to support upgrades or enhancements, and organizations are faced with determining whether investments in more sophis- ticated scalable infrastructure built with integration and data harmonization in mind is necessary. In the short term, migrating data and procuring reusable architecture solutions will be time intensive and complicated, but if funding is available to support the upgrade, it can reduce manual labor, work- arounds, and duplicative data entry. Data Aggregation and Analytics To engage in population health management, data analysts require a platform for storing and inte- grating data and tools that support analytics and reporting. As one 2019 CHCF publication stated, "Many providers use capabilities native to their EHRs to exchange individual patient information with other health systems. These are important func- tions that can support episodic care coordination but are insufficient to manage population health, which requires analytics and the ability to aggregate data across providers, payers, and human services organizations.""° Maintaining New Technical Capabilities and Infrastructure Ongoing Operations and Sustainability Every technology investment requires maintenance to sustain high levels of performance and relevance over time. Assuming the state adheres to federal and industry standards (e.g., USCDI, FHIR, and HL7), needs of health care delivery system providers who received prior funds will likely be limited to minor systems updates and maintenance as technol- ogy evolves to add new features and capabilities. Organizations newer to interoperable technology may need to more time and resources to main- tain their systems and train staff on infrastructure enhancements. Organizations may also have to pay ongoing fees for subscription services for vendor- owned and vendor-operated technology services, like referral platforms or membership for informa- tion sharing networks. Scale and Extended Functionality As networks of data sharing partners grow within sectors (e.g., new hospitals or health systems), orga- nizations will need resources to integrate with new partners and data systems and maintain those inte- grations. This scalability requires staffing or vendor support to complete the technical updates, inte- gration, and testing. Similarly, as networks expand to new types of partners, such as data sharing with new sectors, additional resources may be necessary to develop data sharing agreements, establish new privacy controls, and align processes. Policy and Implementation Support Initial and Ongoing Outreach and Education When new state policies and program requirements are released, state, association, and community leaders need resources to develop "call to action" messaging and educational materials so that stakeholders understand who is impacted, how to comply, what the timelines are, how policies devi- ate from historical regulations, and how to align with federal regulations. This information can help facilitate a coordinated rollout and inform delivery system providers before they make technology pro- curement decisions. Ongoing federal and state policies changes may necessitate additional stakeholder work on techni- cal systems, organizational policies, staff training, Closing the Gap in California's Health Data Exchange: Necessary Investments and Funding Opportunities 7 and clinical and administrative workflows at the local level. Establishing a forum and cadence for information sharing and practical guidance related to new legislation and regulations can facilitate meaningful adoption and compliance. Proactive and early stakeholder engagement enables these organizations to build in the means to measure and evaluate their new capabilities over time. All these efforts require additional funding and resources to deliver. Privacy and Security The most-identified need addressed by _ inter- viewees for this report was help with the practical application of privacy laws related to cross-sector information sharing. Smaller providers or commu- nities often lack dedicated in-house staff or access to consultants with expertise in how to organize and operate to exchange data while also protect- ing privacy and complying with state and federal law. Without a strong understanding and buy-in for policy objectives, fear and lack of knowledge may trump policy goals, and some organizations may interpret data sharing permissions narrowly to reduce risk. This is a particularly acute issue when considering the new terrain of cross-sector data sharing and different rules that apply across sec- tors. Both robust state-level resources that provide practical and accessible guidance and custom- ized individual policy support can help facilitate adoption. Informed Data Analysis and Decisionmaking Participants in data exchange networks need to understand how to interpret and use the data they receive. Training users about the right information to share, the meaning of specific data elements, and how to look at information holistically across service providers and over time is essential to ensuring effec- tive decisionmaking at the individual and population levels. Without relevant training, providers could easily misinterpret or misuse information, creating more harm than benefit for patients and clients. Staffing and Workforce A wide range of staff is necessary to support health information exchange _ infrastructure, including technical, operational, and strategic roles. Most organizations use vendors to procure interoperable technology systems. Large organizations typically have the most financial resource to support staff- ing for technical implementations, compliance, and ongoing operations. Small to midsized entities, like counties, often lack consistent funding to meet human resource needs and use consultants to sup- plement internal staff. Small CBOs dependent on grant funding, which can be unpredictable, often face challenges sustaining staff positions and may struggle to support technical services procurement. Activities that support data exchange and may require new in-house staff or contract resources include: > Implementing processes that previously did not exist or were underdeveloped. > Entering and validating data that facilitate chang- ing business and clinical operations. > Maintaining technical infrastructure and support- ing advanced data and analytics capabilities. > Building and coordinating relationships across organizations to establish contracts, memoranda of understanding, or other legal agreements that facilitate exchange. > Monitoring and complying with federal and state privacy and data security laws. > Researching, applying for, and managing federal and state funding opportunities that may sup- port expanded data exchange activities. Nearly all the delivery system providers interviewed for this report indicated that their organizations lack sufficient capacity to secure funding necessary to delivery on AB 133's promise and potential. California Health Care Foundation www.chcf.org 8 IT Needs by Delivery System Tables 2-4 outline the historical investments and anticipated funding needs of delivery system providers subject to AB 133. Funding needs are characterized by current level of technical sophis- tication as well as the ability of an entity to pay the costs to become compliant with anticipated requirements and expectations. General acute care hospitals, physician orga- nizations and medical groups, SNFs, clinical laboratories, and acute psychiatric hospitals. Until recently, acute care and critical access providers and hospitals serving Medicare enrollees, Medicaid enrollees, or both were the primary recipients of federal and state funds that supported electronic data documentation and exchange. The federal Medicare and Medicaid EHR Incentive Program (formerly known as "Meaningful Use," now known as "Promoting Interoperability") supported the adoption, implementation, and demonstration of meaningful use of certified EHR technology." Almost all acute care hospitals now have EHRs. Table 2. Current Funding Needs, by Level of Need Rehabilitation hospitals, inpatient psychiatric hos- pitals, long-term care hospitals, correctional health facilities, most mental health providers, and pub- lic health were ineligible for the early programs that financed health information technology and exchange. In addition, small independent physi- cian practices have historically lacked the resources and technical expertise to adopt more advanced technologies. Further, delivery system stakeholders who do not participate in Medicaid or Medicare, including some pediatricians and mental health providers, have been excluded from many incentive programs. These disparities have resulted in signifi- cant variation in implementation of technologies that support advanced electronic data collection and interoperability across the health care sector, with those entities that have had the least historical investments requiring the greatest support. @ Minimal © Average ® Significant ONGOING POLICY AND STAFFING ONETIME TECHNICAL IMPLEMENTATION AND TECHNOLOGY INFRASTRUCTURE SUPPORT WORKFORCE Acute Care Hospitals e e e e Physician Organizations e e e e and Medical Groups" SNFs¥ e e e e Clinical Laboratories Unknown Unknown Unknown Unknown Acute Psychiatric Hospitals e e e e Closing the Gap in California's Health Data Exchange: Necessary Investments and Funding Opportunities Health service plans and disability insurers, Medi- Cal managed care plans (MCPs). Health plan associations indicated sufficient capacity among their members to comply with AB 133. For health plans exclusively offering commercial products, competition and market forces have provided adequate incentives to adopt advanced technol- ogy and to leverage provider participation in data collection, reporting, and exchange. Therefore, if the state adheres to commonly recognized stan- dards, and plans do not have to reinvest resources, mature health plans will not have issues with com- pliance. Further, CalAIM (California Advancing and Innovating Medi-Cal) is providing incentive pay- ments through MCPs as well as other supports. See Appendix F. In addition to the AB 133 requirements, qualified health plans must meet the CMS Patient Access and Interoperability Final Rule requirements for payer-to-payer exchange, patient access through APIs, and other data interoperability requirements. Greatest concerns raised by health plan associa- tions were the capacity for health care providers operating on legacy health information technology systems. Table 3. Current Funding Gaps, by Level of Need Counties. Throughout California, counties' vary widely in how they organize their agency structures and service delivery systems. For example, some counties house health care, public health, and social services under one umbrella agency, some sepa- rate the functions across different departments, and others leverage CBOs to perform key roles. Initiatives like the Whole Person Care pilots and Health Homes supported technology investments to facilitate cross-sector data sharing and referrals, but these pilots were implemented in silos - some through counties, others through health care part- ners or nonprofit organizations - each of which structured its service delivery differently." The structural variations and diverse approaches to technology adoption have led to a prolifera- tion of fragmented approaches to data sharing. Some communities built strong health or commu- nity information exchange systems while others have limited if any electronic infrastructure or data. CalAIM presents a potential source of funding to support technology adoption for data exchange, but without centralized coordination at the state level, a panoply of approaches may continue with- out statewide interoperability. For more information about how CalAIM could potentially serve as a funding source to support AB 133 objectives, see Appendix F. ®@ Minimal @ Average ® Significant ONGOING POLICY AND STAFFING ONETIME TECHNICAL IMPLEMENTATION AND TECHNOLOGY INFRASTRUCTURE SUPPORT WORKFORCE Health Service Plans e ® e e Disability Insurers e e © e Medi-Cal Managed Care Plans e e e e California Health Care Foundation www.chcf.org 10 >» Homelessness. Homelessness data are typi- cally managed at the county level by CBOs, or by cities on behalf of the county, through the local HMIS. HMIS provides functionality for data management and reporting to HUD, which funds basic IT functionality systems maintenance. Service providers must adhere to HMIS data reporting requirements, which change annually. In many instances, HMIS cannot support signifi- cant technological platform enhancements or modifications beyond HUD requirements, as the funding to support HMIS is limited to the key data elements necessary to meet HUD reporting requirements (e.g., point-in-time count, housing inventory count, and system performance mea- sures). Often HMIS users are asked to share their data, which is easier to do than ingesting infor- mation, though it limits bidirectional program impact. As one expert described it, HMIS is more like a dirt road than an information highway as a mode to share data. Public health. Public health data systems largely lack technical maturity. In many counties, public health relies on faxes and paper documenta- tion or maintains very basic systems that do not support interoperability. Most public health departments do not have access to EHR sys- tems or health plan data about information like vaccinations. All public health departments par- ticipate in centralized reporting to state registries (e.g., immunization and reportable conditions registries). According to the executive director for the County Health Executives of California, a significant opportunity exists to think holistically about the needs of public health data modern- ization at the state and county level and to work collaboratively to develop a comprehensive strat- egy that will address data collection, exchange, reporting, and population health management. Jails. Most health care services in the jail system in California are provided by entities contracted through counties, though some counties provide mental health services directly. Jails maintain EHR platforms for physical and behavioral health data. In most counties, there is no data exchange with external partners, electronic discharge planning, or referrals. In some cases, non-jail employees are given access to the EHR for auditing or for documentation, particularly in cases where men- tal health is provided outside of the jail setting. Jails also maintain Jail Management Information Systems, which are the source of release infor- mation, but the jail system, probation, and EHR systems are not interoperable. Any information sharing that happens is based on manual report- ing or direct systems access. Table 4, Current Funding Gaps in County Services, by Level of Need @ Minimal e Average © Significant ONGOING POLICY AND STAFFING ONETIME TECHNICAL IMPLEMENTATION AND TECHNOLOGY INFRASTRUCTURE SUPPORT WORKFORCE Jails e e e e Homelessness e e e e Public Health e e e e Closing the Gap in California's Health Data Exchange: Necessary Investments and Funding Opportunities 11 Federal Funding That Supports Information Technology Investments This report focuses primarily on federal funding sources that typically fund the stakeholders required to comply with AB 133, focusing on the Department of Health and Human Services agencies. This report also identifies non-HHS agencies, such as HUD and the Bureau of Justice Administration to align with California's cross-sector priorities. States can coor- dinate data infrastructure and exchange efforts to maximize federal funds. If goals for data exchange align across state agencies and delivery system providers with centralized coordination in pursuit of funding, it is easier to apply for resources that can advance objectives across sectors. By collaborat- ing toward shared priorities, entities can braid and blend funding to build systems with reusable archi- tecture and adaptability. By investing in reusable technical architecture com- ponents, such as provider and resource directories or technical services, delivery systems can lower implementation costs and reduce use of one-off solutions. This approach also aligns with CMS's fed- eral funding requirements for enhanced Medicaid matching to "promote sharing, leveraging, and reuse of Medicaid technology systems.""" Sharing business or technical services and software, lim- iting use of proprietary solutions, and adapting current technology with minimal customization can also strengthen networks and reduce silos. See Appendix C for constraints on federal funding sources and Appendix D for types of federal fund- ing available to states and a funding flow for IT investments available to states. Table 5 summarizes funding needs for the Data Exchange Framework and where federal funding sources may support these needs. Tables 6-9 provide more detail on the HHS funding sources listed above for technical services, infra- structure, policy and implementation assistance, and workforce development. California Health Care Foundation www.chcf.org 12 Table 5. Potential Federal Funding Sources for Data Exchange Framework Needs AGENCY PROGRAM $ Allowable funding ONGOING ONETIME TECHNICAL TECHNOLOGY INFRASTRUCTURE POLICY AND IMPLEMENTATION SUPPORT $ Allowable funding with restrictions STAFFING AND WORKFORCE DIRECT TO STATE AGENCY FUNDING CMS Center for Medicaid CHIP Services Medicaid Enterprise System (MES) Managed care and provider payment incentives through 1115 and 1915 waivers State-Developed EHR Incentive Program Innovation Center Federal Behavioral Health Incentive Program Centers for Disease Control and Prevention Public Health and Health Services Scientific Services Block Grant Epidemiologic and Laboratory Capacity Cooperative Agreement Section 317 Vaccine Program Strengthening US Public Health Infrastructure, Workforce, and Data'® AH Substance Abuse and Mental Health Administration Mental Health Block Grant DIRECT TO DELIVERY SYSTEM FUNDING Health Resources and Services Administration Public Health Services Act for Community Health Centers Federal Communications Commission Healthcare Connect Fund Program Rural Health Care Program Department of Housing and Urban Development Homeless systems of care / Continuums of Care Administration for Community Living Aging and disability networks Bureau of Justice Administration (BJA) Harold Rogers Prescription Drug Monitoring Program (PDMP) grant Closing the Gap in California's Health Data Exchange: Necessary Investments and Funding Opportunities 13 CMS Center for Medicaid CHIP Services State Medicaid agencies can submit waivers and funding requests for enhanced Federal Funding Participation (FFP) for health data, technology, and infrastructure investments supporting Medicaid programs, providers, and administrative functions. Table 6 outlines the available authorities for federal funding. See Appendix E for more information about strategies for leveraging Medicaid dollars. Table 6. CMS Center for Medicaid CHIP Services, Available Authorities for Federal Funding ELIGIBLE ENTITIES FUNDING SOURCE ESTIMATED AMOUNTS FREQUENCY document Medicaid Enterprise California State proposed amount Annual Systems Section 1903{a)(3) | Department based on allowable FFP advanced of the Social Security Act - of Health Care and required matching _ planning allows states to receive Services (DHCS) funds: enhanced federal funding = with passthrough =. 99.49 Erp __ for activities related to funding available their Mechanized Claims to: Processing and Information > Other state Retrieval Systems, as well agencies as other technical modules, such as health information » Delivery system = > exchange services and providers (health, reusable infrastructure.'? social, behavioral) . and contracted technical service organizations and vendors (e.g., HIOs, vendor) INCENTIVE PAYMENTS Managed care provider DHCS payment incentives through design, devel- opment, and implementation, including planning 75-25 FFP - operations" 50-50 FFP - administrative costs and technology Up to 5% of the annual managed care plan updates No timeline, up to state's ALLOWABLE USES Agency staff costs supporting the services or critical infra- structure receiving funding Technology costs, includ- ing vendors, upgrades, and connections to technology hubs for interoperability (e.g., national networks, EHR interoperability hubs) Technical support and help desk support, including personnel time implementing new technology, data feeds, or both; assisting with technical steps required of participants (e.g., pulling a patient roster to get notifications); trouble- shooting; etc. Privacy and security costs directly related to services State example: Maryland leverages MES 75-25 opera- tions funds for statewide health information exchange (HIE) technical services to support care coordination, population health, and critical support infrastructure. The HIE services include core, reusable infrastructure with master patient index (MPI), PDMP, image exchange, and encoun- ter notification service." Up to state's discretion 1115 and 1915 waivers" capitation payments* - discretion State-Developed Electronic DHCS Up to state's Medicaid Notimeline, Up to state's discretion Health Record (EHR) Medicaid providers Federal Medical up to state's Incentive Program" Assistance Percentage discretion (FMAP) California Health Care Foundation 14 www.chcf.org CMS Centers for Medicare & Medicaid Innovation Section 6001 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act authorizes the testing of incentive payments for behavioral health providers for adoption and use of certified EHR technology to improve care quality and coordination through the electronic documentation and exchange of health information." Although the legislation passed in 2018, program details have not been released. Table 7. CMS Centers for Medicare & Medicaid Innovation, Authority for Federal Funding ELIGIBLE ENTITIES Federal Behavioral Health The legislation amends Section 1115A(b)(2)(B) of the Social Security Act (42 U.S.C. 1315a[b] Incentive Program" [2][B]). Several entities are eligible to participate in the program: » Psychiatric hospitals, as defined in Section 1861(f) >» Community mental health centers, as defined in Section 1861(ff)(3)(B) » Hospitals that participate in a state plan under Title XIX or a waiver of such plan » Treatment facilities that participate in such a state plan or such a waiver >» Mental health or substance use disorder providers that participate in such a state plan or such a waiver » Clinical psychologists, as defined in Section 1861(ii) » Nurse practitioners, as defined in Section 1861(aa)(5) with respect to the provision of psychiatric services » Clinical social workers, as defined in Section 1861(hh)(1) Centers for Disease Control and Prevention The CDC funds cooperative agreements and grants related to the 10 essential public health services. Although data, technical infrastructure, and technical assistance may be supported, funds are authorized under Public Health Services Act (Title 42 of U.S.C.). The CDC utilizes grants and cooperative agreements to assist other health-related and research organizations that contribute to the CDC's mission and to accomplish public health goals. The programs outlined in Table 8 provide technical funding directed to states to support public health preparedness and response. CDC funding awards can be made directly to health departments (at all levels), nonprofits, academia, busi- nesses, and community organizations. State-level entities may share awards with local entities, benefit the entire state, or both. Other awards to national organizations may include subawards to other entities."" Typically, CDC funding does not fund statewide system infrastructure modernization to advance data docu- mentation and exchange for transactional data exchange. Rather, CDC funds individual programs with specific eligible entities and program priorities. Therefore, when contemplating pursuing these funding streams as a potential mechanism to support interoperable HIE, it is important to recognize that these resources will fund a portion of a vision. This requires close coordination across entities to ensure alignment. Closing the Gap in California's Health Data Exchange: Necessary Investments and Funding Opportunities 15 Table 8. Centers for Disease Control and Prevention, Available Authorities for Federal Funding ELIGIBLE ENTITIES ESTIMATED IN CALIFORNIA ALLOWABLE USES FREQUENCY AMOUNTS Public Health Services California Department Recipients set their own goals Annual Formula Act (PHSA)"® of Public Health and program objectives and Public Health and Health (CDPH) implement local strategies to Services Scientific address national health priorities. Services Block Grant Epidemiologic and CDPH Financial support and technical Annual 2021 funding Laboratory Capacity for assistance to public health agencies awards totaling Prevention and Control approximately of Emerging Infectious $247 million to Diseases Cooperative 64 recipients Los Angeles County"? Flexible funding to eligible recipients to meet state and community needs Agreement Disease-specific projects Leadership and management for strategic planning Cross-cutting projects and programs to enhance collaboration between state epidemiology, lab, and local public health agencies Implementation and maintenance to support activities such as vector-borne disease surveillance, including data reporting Section 317 immunization CDPH Immunization Information Systems - Annual, CDC releases grants" (IIS) data exchange, security discretionary annual guidance Vaccine for Children standards, and enhanced funding based on current interfaces with EHRs.* CDC priorities program Vaccines for Adults IIS program support to assess (VFA)*" technology and data infrastructure gaps; enroll providers in IIS; improve data collection, exchange, maintenance, and analysis; and improve reporting by health care providers. Technical and financial support of children, adolescents, and adult immunization programs; provider and public education; and evaluation and research Data Modernization CDPH $500 million to support efforts Formula Initiative* Local or county to continue to modernize public Up to $500 health surveillance and data public health jurisdiction above certain population : : ; million, with collection nationwide and to $200 million forecast emerging biological distributed threats. These efforts build on ongoing investments in public health data modernization to support availability and use of real-time data at the federal, state, and local levels. to state, tribal, local, or territo- rial public health departments * Less than 50% of jurisdictions use local or state funding for IIS maintenance, operations, and enhancements, according to the American Immunization Registry Association. In addition to the funding mentioned above, the CDC has seven categories of discretionary spend- ing authority organized by mission for different priority programs with varying funding levels each year. As an example, in its 2021 annual report, the CDC reported spending $7.8 billion through its discretionary funding authority, which included significant resources for state, city, and county governments.*® While funding is provided for a wide range of purposes and specific eligible enti- ties, there is opportunity to align statewide data exchange goals with allowable funding uses to sup- port interoperability. Substance Abuse and Mental Health Services Administration SAMHSA funds noncompetitive Community Mental Health Services Block Grants (MHBG} to all 50 states and territories to provide community health services authorized under the Public Health Services Act (Title XIX, Part B, Subpart II).** Table 9 summarizes the funding opportunity. SAMHSA uses a weighted population-at-risk index formula calculation to fund priority treatment and support services, prevention activities, and data collection for performance and outcomes measurement." The block grant funding goes directly to each state's agency responsible for administering MHBG, which can distribute funds to local governmental agen- cies and nongovernmental organizations, such as intermediaries (e.g., administrative service orga- nizations).*° Typically, SAMHSA funding does not fund statewide system infrastructure. In 2021, the American Rescue Plan (ARP) autho- rized an enhanced FMAP up to 85% for three years to expand funding to cover "community-based mobile crisis intervention services" providing rapid response, individual assessment, and crisis resolu- tion by trained mental health and substance abuse treatment professionals and paraprofessionals.*" The crisis intervention services mobile teams need access to relevant health information and techni- cal infrastructure for system integration. States can request MES 75-25 FFP for ongoing operations of CMS-approved technical systems. Additionally, the Federal Communications Commission (FCC) adopted rules to establish a national 988 three-digit phone number for peo- ple in crisis to connect with suicide prevention and mental health counselors. Medicaid matching funds can support technical infrastructure, integra- tion, and planning and operationalization of 988. The ARP also allows a 5% set aside for the MHBG, allowing states to establish core crisis care ele- ments.*® Allowable costs in the 5% set aside also include technical infrastructure, such as EHRs and bed availability technology." Direct to Delivery System Funding Several agencies including HRSA, HUD, the Administration for Community Living (ACL), and BJA have funding to support technology and data for specific community services for targeted settings and populations. These funding sources can sup- port electronic data capture and technology uses. All funding requires data reporting for program Table 9. Substance Abuse and Mental Health Services Administration, Authority for Federal Funding ELIGIBLE ENTITIES ESTIMATED IN CALIFORNIA ALLOWABLE USES FREQUENCY AMOUNTS MHBG DHCS Community Mental Health Services Annual 5% set aside Crisis stabilization systems information technology implementation, EHRs for behav- ioral health providers, telehealth, electronic bed registries, and system integration 5% set aside available for California three years (2022-25) supplemental award - $108 million*® Closing the Gap in California's Health Data Exchange: Necessary Investments and Funding Opportunities 17 documentation and measurement. Most funding opportunities provide training and technical assis- tance to program awardees. Health Resources and Services Administration funds discretionary grant programs for research, training, and technical investments to enhance the delivery and improve access to high-quality care. Typically, HRSA funding is limited to specific, nar- rowly defined delivery system providers. The Public Health Services Act created and authorized the health center program authorizing HRSA grants to health centers."' Section 33 provides supplemental grants to expand capacity to previously unserved communities, to expand access to addiction treat- ment, and to enhance health IT (HIT) capabilities and integrations. This funding also provides training and technical assistance to the commu- nity health centers through the State and Regional Primary Care Associations and HRSA's HIT National Training and Technical Assistance Partners. Federal Communications Commission provides funding directly to providers and communities for broadband funding and telehealth services for health care. Broadband is a critical foundation for interoperable, cross-sector information sharing. To bridge the broadband digital divide, the FCC's Healthcare Connect Fund Program provides fund- ing through the Universal Services Administrative Company to eligible providers through an applica- tion process for broadband services and network equipment with a discounted rate at 65% on eli- gible expenses." The Rural Health Care Program provides funding to eligible health care providers for telecommunications and broadband services necessary for the provision of health care." Department of Housing and Urban Development provides annual discretionary funding directly to homeless systems of care (known as "Continuums of Care," or CoCs) promoting community-wide planning and strategic use of resources to address homelessness." The funds require data reporting for program components, but funding for tech- nical investments is limited to development and maintenance of HMIS for program measurement, documentation, and reporting to HUD." These funds cannot be applied to CoC program compo- nents or technical investments. Administration for Community Living provides funding for multiple programs that strengthen networks of CBOs. One example is the aging and disability networks, which includes national, state, and local organizations that support community living options for older adults and people with disabilities." ACL funds programs through man- datory formula grants, such as through the Older Americans Act, and discretionary funding to award- ees through a competitive grant process. Funding passes through state designated State Units on Aging and may be distributed in subgrants to Area Agencies on Aging responsible for city, single county, or multi-county districts to provide care and community services to older adults. Bureau of Justice Assistance (BJA) provides dis- cretionary funds and formula grants to eligible recipients supporting behavioral health and com- munity-based criminal initiatives. Examples include the Harold Rogers PDMP grant to support state and local governments in PDMP implementation and enhancement activities. Another example is the Justice and Mental Health Collaboration sup- porting cross-system collaboration to improve responses and outcomes for people with mental ill- ness or co-occurring mental health and substance use disorder who come in contact with the justice system." Anticipated BJA funding streams include training, technical assistance, and technology with cross-sector collaboration objectives. California Health Care Foundation www.chcf.org 18 Examples of Other States Pursuing Similar Goals Many states throughout the nation are pursuing similar objectives to California, both to align with federal requirements and to advance state-specific objectives. Table 10 presents objectives set forth by California's Data Exchange Framework legislative requirements and the stakeholder advisory group in the column on the left alongside priorities and funding sources established by the states of Washington, Maryland, and Nebraska on the right. Note that this is not an exhaustive list of all state HIT priorities. Table 10. Examples of HIT/E Priorities and Funding Sources in Other States CALIFORNIA HIT/E OBJECTIVES HIT PRIORITIES FUNDING SOURCE WASHINGTON'? Interoperability/Statewide HIE with Requirements for Participating Department of Health public health core services, integration engine, analytics, data visualization Prescription Monitoring Program HIE services and integration CDC Data Modernization funds CMS MES 90-10 FFP - planning public health CMS MES 75-25 FFP - operations awaiting certification HIT/E Technical Assistance Program Health Care Authority behavioral health and crisis stabilization services Behavioral health, rural, and long-term care providers EHR-as-a-service Washington State 988 Tax (E2SHB 1477)°° Shared Identity Management Solution MARYLAND Interoperability/Statewide HIE with Requirements for Participating MPI across five HHS Coalition agencies" Data exchange and integration PDMP Public health reporting Multi-state event notifications™ Reporting and analytics Social determinants of health tools (e.g., eReferral) CMS MES 90-10 FFP Annual subscription fees vary by HIE participant type BJA Harold Rogers PDMP funding*? CDC Overdose to Action funds" CMS MES 75-25 FFP - operations Hospital assessment as part of the global budget model® State PDMP funds HIT/E Technical Assistance Program Health Equity Pathways Technical Assistance™ Hospital Community Benefit Program (Health Service Cost Review Commission) (HSCRC) Shared Identity Management Solution Included in HIE core services CMS MES 75-25 FFP - operations Provider/Resource Directory Provider directory CMS MES 75-25 FFP - operations Closing the Gap in California's Health Data Exchange: Necessary Investments and Funding Opportunities 19 Table 10. Examples of HIT/E Priorities and Funding Sources in Other States, continued CALIFORNIA HIT/E OBJECTIVES HIT PRIORITIES FUNDING SOURCE NEBRASKA*" Interoperability/Statewide Prescription Monitoring Program HIE with Requirements for Participating Statewide integrator Single sign-on Direct secure messaging Public health reporting Multistate ADT alerting Social data exchange CDC PDMP Infrastructure funding and Opioid Crisis Response CMS MES 75-25 FFP - operations awaiting certification CDC 1815 - Chronic Disease CDC Data Modernization Funding COVID-19 public health funding Shared Identity Management Solution Patient identity management across health and social sectors CMS MES 75-25 - operations awaiting certification Provider/Resource Directory Included in core HIE services Included in social data exchange vendor services CMS SUPPORT Act enhanced FMAP CMS MES 75-25 - operations awaiting certification Other Investments? Workforce development Data-driven research and decisionmaking Population health and health care disparities Improving clinical quality and outcomes CyncHealth Foundation State appropriations, utilizing MLR and reinvest- ment funds to offset state match difference California Health Care Foundation www.chcef.org 20 Conclusion The Data Exchange Framework, as set forth in AB 133, presents an opportunity for the state of California to establish statewide standardized health information exchange and to create a level playing field for participation across delivery sys- tem providers. Because delivery system providers have different levels of technical maturity, necessary investments across industry will vary. Small health care providers who did not partici- pate in the Meaningful Use Program or Cal-HOP, smaller SNFs, inpatient rehabilitation facilities, and most county health, public health, and home- lessness systems of care lack infrastructure that supports interoperability and will need the greatest investments in technology adoption, technology maintenance, policy and program support, and staffing. Because some funding sources and the systems they support lack flexibility (e.g., HMIS and county public health), those limitations may thwart meaningful data exchange unless new investments are made. Hospitals and larger provider networks that received historical investments and maintain certified EHRs will require the least support assuming the state adheres to commonly accepted data sharing stan- dards. Health plans also indicated a high level of readiness consistent with messaging of the hospitals and larger provider networks regarding adherence to standards and data exchange capabilities. To effectively regulate, monitor, and enforce any new requirements, state government will require staffing or contracted resources. Assuming new funds are available to support compliance by deliv- ery system providers, there may also be grants or technical assistance administration responsibilities for the state. The state and delivery system providers may be able to leverage an array of federal and state fund- ing vehicles to advance AB 133 priorities. However, it will be necessary to braid and blend federal and state funding streams to achieve interoperability across programs and sectors. Apart from Medicaid investments, there is no enterprise funding source with the flexibility to drive statewide technical assis- tance and technical infrastructure. Federal funding sources directed to delivery system providers and partners typically rely on competitive discretionary funds that require resources to apply for and include program requirements that may differ from delivery system strategic priorities. State agencies, counties, and other delivery system providers can, by align- ing strategies and coordinating across government, pursue funding streams that will help close the gap between technically mature providers and those lacking interoperable infrastructure. Establishing a technology funding czar and a coor- dinated funding strategy across agencies and counties can address technology gaps, increase awareness, and facilitate coordination of funding requests. In addition, by coordinating across organi- zations and sectors and leveraging data standards, providers can direct future investments in scalable infrastructure that can support modularity and interoperability, which will increase reusability. For more sophisticated organizations, a smaller invest- ment to support reconfiguration and integration with new types of partners and enhanced function- ality may be possible. Because funding that supports technology often competes with other operational and program costs, for this process to be successful, investments must be made for operational, programmatic, and technology needs. Closing the Gap in California's Health Data Exchange: Necessary Investments and Funding Opportunities 21 Appendix A. Data Exchange Framework Timeline DATE (no later than) ACTIVITY September 1, 2021 CalHHS Data Exchange Framework stakeholder advisory group begins convening April 1, 2022 CHHS submits written update to the legislature based on input from the stakeholder advisory group July 1, 2022 Establishment of Data Exchange Framework July 31, 2022 CalHHS publishes a strategy for digital identities to support master patient indices January 31, 2023 Execution of data sharing agreement by statutorily named entities CalHHS works with the California State Association of Counties to encourage the inclusion of county health, public health, and social services agencies in the California Health and Human Services Data Exchange Framework January 31, 2024 General acute care hospitals, physician organizations and medical groups, SNFs (that currently maintain EHRs), health plans, clinical laboratories, and acute psychiatric hospitals must begin exchanging health information in real time January 31, 2026 Physician practices of fewer than 25 physicians, rehabilitation hospitals, long-term acute care hospi- tals, acute psychiatric hospitals, critical access hospitals, rural general acute care hospitals with fewer than 100 acute care beds, state-run acute psychiatric hospitals, and any nonprofit clinic with fewer than 10 health care providers must begin exchanging health information in real time California Health Care Foundation www.chcf.org 22 Appendix B. Interviewees ORGANIZATION INTERVIEWEES Alameda County Health Care Service Agency Aneeka Chaudhry, Assistant Agency Director, Health Care Services Agency Cristi lannuzzi, Interim Technology Strategy Director Kimia Pakdaman, Program Specialist, CalAIM Daphne Robert, Technical Services Director, Information Technology California Association of Health Facilities Joe Diaz, Regional Director California Association of Health Plans Charles Bacchi, Chief Executive Officer Anete Millers, Director of Regulatory Affairs California Association of Public Hospitals and Health Systems Amanda Clarke, Director, Programs California Department of Corrections and Rehabilitation Brenda Grealish, Executive Officer, California Council on Criminal Justice and Behavioral Health California Emergency Management Systems Authority Leslie Witten-Rood, Chief, Office of Health Information Exchange California Hospital Association Trina Gonzalez, Vice President, Policy California Medical Association David Ford, Vice President, Health Information Technology California Mental Health Services Authority Amie Miller, Executive Director Jeremy Wilson, Program Director and Public Information Officer California Primary Care Association DeeAnne McCallin, Director, Health Information Technology California State Sheriff Association Usha Mutschler, Legislative Representative Council of State Governments Justice Center Hallie Fader-Towe, Program Director, Behavioral Health Kevin O'Connell, Project Director, Data Driven Recovery Project County Health Executives Association of California Michelle Gibbons, Executive Director CRISP Lindsey Ferris, Senior Advisor CyncHealth Jaime Bland, CEO Homebase Julie Silas, Directing Attorney Local Health Plans of California Linnea Koopmans, Chief Executive Officer Marin County Charis Baz, Senior Department Analyst, Whole Person Care Monterey Coalition of Homeless Services Providers Roxanne Wilson, Executive Officer Orange County Health Care Agency Nicole LeMarie, Whole Person Care Program Manager Closing the Gap in California's Health Data Exchange: Necessary Investments and Funding Opportunities 23 ORGANIZATION INTERVIEWEES San Diego Regional Task Force on Homelessness = Tamera Kohler, Chief Executive Officer Lahela Mattox, Chief Operating Officer San Francisco Department of Public Health Eric Raffin, Chief Information Officer Santa Clara County Probation Holly Child, Director, Research and Development Santa Cruz County Tiffany Cantrell-Warren, Assistant Director Lynn Lauridsen, Whole Person Care Program Coordinator State of Washington Chris Baumgartner, Senior Data Exchange Manager, Department of Health; Jennifer Harvell, Senior Federal Project Consultant, Health Care Authority; Bryant Karras, Child Informatics Officer and Senior Epidemiologist, Department of Health; Kelly McPherson, HIT Program Manager, Health Care Authority; Christine Nolan, Deputy ClO, Health Care Authority; Shawn Roberts, Program Manager Medicaid Investments, Department of Health UCSF Center for Clinical Informatics and Julia Adler-Milstein, Project Manager Improvement Research Grace Krueger, Research Assistant Wellpath Health Bonnie Bernard, IT Director of Telehealth Carin Kottraba, Vice President, Mental Health Anthony Lopez, Director, IT Delivery Danielle Pierce, EHR Systems Administrator California Health Care Foundation www.chcf.org 24 Appendix C. Constraints on Federal Funding While federal funding can contribute significantly toward development and enhancements of health information exchange infrastructure, funding comes with constraints and requirements that can take significant resources to navigate and address. In addition, silos within the federal government funding streams can reinforce the fragmented investments that occur at the state level, thereby requiring significant coordination across state agen- cies to align resources. Program scope and goals. Federal funding streams are appropriated to specific agencies and programs and must meet specific requirements. These require- ments do not necessarily preclude support of data exchange, but it can take strategic and creative coordination across delivery systems and sectors to support it. For instance, public health long-term data modernization and infrastructure investments would ideally include a public-private strategy for improving data reporting between public health and health systems (e.g., vaccine administration data to health system or payers for closing immu- nization schedule gaps). CDC's Section 317 of the Public Health Services Act provides money in immunization program staff and technology to sup- port vaccine management and administration data reporting for children, adolescents, and adults. Investments can be used to improve connections to the health care delivery system, but state public health immunization programs must delegate fund- ing for external connections. As another example, Federal Emergency Management Administration funding can be used only for emergency preparedness, response, and recovery, which includes partnerships with the health and local sectors. By connecting community and statewide emergency preparedness and response with health and hospital partners, California can potentially enable access to electronic health infrastructure supporting emergency response across hospital and emergency service providers to support acute emergency situations and disaster response (e.g., acute care services, COVID-19 alter- nate care facilities, fire evacuations). Lead agencies. Certain federal funds may only be accessed by specific state agencies. Thus, the state agency must approve and administer the funding request on behalf of other state agencies and part- ners. Sharing a coordinated vision and continuous coordination is important. Identification and reuse. To ensure states are not duplicating investments, many federal funding sources require identification of other federal fund- ing used to build or enhance technical capabilities. Federal agencies may request documentation dem- onstrating that the investment is not duplicative. Matching funds. Many federal funding sources require a state matching fund contribution to off- set the costs of programs, technical investments, staff, and nonstaff costs. Matching funds cannot be leveraged from other federal funding sources (e.g., a public health grant awarded to the California Department of Public Health cannot serve as match- ing funds for CMS Federal Funding Participation requests). Closing the Gap in California's Health Data Exchange: Necessary Investments and Funding Opportunities 25 Appendix D. Type of Federal Funding Available to States Medicaid Financing CMS has multiple vehicles to support technology investments in the Medicaid program. >» State Medicaid plansor State Plan Amendments specify the types of services Medicaid covers in the state. States can apply for waivers to certain federal requirements under sections 1115 and 1915 of the Social Security Act to add flexibility in use of federal funds.© Through these waiv- ers, states can propose strategic investments, and incentive payment programs to support the agency, program, and population goals. >» Medicaid Federal Medical Assistance Percentage (FMAP) represents the federal contribution toward Medicaid expenditures in each state using a statutory formula based on a state per capita income. FMAPs vary from a floor of 50% to a high of 74%.°' CMS has made temporarily enhanced FMAP adjust- ments for specific state events (e.g., Louisiana following Hurricane Katrina) or declared pub- lic health emergencies (e.g., COVID-19). In 2018, the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act §§ 5041-42 allowed states to receive 100% FMAP for fiscal years 2019 and 2020 for PDMP implementations." > Medicaid FFP is federal funding provided to states for their share of expenditures for pro- viding Medicaid services and administering the Medicaid program and certain other human ser- vices programs. FFP sets the percentages for federal and state contributions known as "state matching funds" from nonfederal dollars. State Medicaid agencies can submit planning, imple- mentation, and operations advanced planning documents (APDs) to describe the funding needs, funding sources, programs, and investments needed to plan and implement the program. FFP has requirements for allowable matching funds (i.e., not using other federal funds), cost alloca- tion formulas calculating Medicaid's fair share of the investments, and allowable program costs. Examples for FFP are detailed in Table 6. > Incentive payment programs, such as the Medicare and Medicaid Meaningful Use EHR Incentive Program provided 100% FFP to adopt, implement, and meaningfully use certified EHR technology. Federal Medicaid provides 90% FFP for state administrative expenses related to the program with 10% state matching funds. States have flexibility to establish incentive payment programs for technical investments that may be up to FMAP or at a set FFP rate. Additional avail- able FFP options can be found in Table 6. As one example, New Jersey's Substance Use Disorder Promoting Interoperability Program is funded by state dollars and pays substance use disorder providers to adopt EHRs." Grants Several federal agencies award grants to states and delivery system providers. Grants can serve as a mechanism to pursue opportunities that might not otherwise be funded. Formula grants are awarded to predetermined entities, based on a distribution formula. Formula grants are noncompetitive (e.g., block grants) and typically fund continuing activities without constraints to a specific project. Common formula elements include population, proportion of population below the poverty line, and other demographic information. Mandatory grants are awarded under a program where the authorizing statute requires an agency or designees to make an award to each eligible entity under the conditions and amount (or based on a formula) specified in the statute. California Health Care Foundation www.chcf.org 26 Discretionary grants are often funded from federal agencies based on merit and eligibility through a competitive application process. Agencies deter- mine the awarded amounts. Passthrough funding may be issued by federal agen- cies to a state agency or institution, where funds are transferred to other state agencies, units of local government, or other eligible groups per the award eligibility terms. States have the option to distrib- ute funds as competitive or noncompetitive grants, based on terms and legislation authorizing of the primary award. This gives state governments flex- ibility and autonomy over the use of federal grant funds.° Cooperative agreements are similar to competi- tive, discretionary grants in the award process, but are used where there is substantial agency involve- ment in the direction of the work beyond normal oversight and monitoring activities. Other factors influencing federal funding flow include congres- sional authorizations and directed appropriation with eligibility varying by funding opportunity, and limited numbers of recipients for competitive or merit-based processes. Also, some funding is allo- cated according to a preset formula, which may be specified in law." Figure D1 outlines federal agency funding sources that typically support HIT-related activities and examples of pathways to distribute funds. Figure D1. Funding Flow for Health Information Technology Investments e Technology and Infrastructure Investment e Technology and Infrastructure Maintenance Federal cDC CMS SAMHSA eecoe0e @ @ GF MHSA eco State DPH DHCS ' @ o Delivery System e eceee e e Counties MH Public Health Social Services Jails Health Plans e Policy and Implementation Assistance e Workforce and Staffing e Operations HRSA ACL BJA HUD boc Health Providers Hospitals FQHCs AAAs Homeless Systems of Care Note: AAA is Area Agencies on Aging; ACL is Administration for Community Living; BJA is Bureau of Justice Assistance; CBO is community-based organiza- tion; CDC is Centers for Disease Control and Prevention; CMS is Centers for Medicare & Medicaid Services; DHCS is California Department of Health Care Services; DOC is Department of Corrections; DPH is Department of Public Health; FOHC is Federally Qualified Health Center; GF is general fund; HRSA is Health Resources and Services Administration; HUD is Department of Housing and Urban Development; MHSA is Mental Health Services Act. Closing the Gap in California's Health Data Exchange: Necessary Investments and Funding Opportunities 27 Appendix E. Strategies for Leveraging Medicaid Dollars While 1115 waivers and FFP may pay only for sys- tems that serve the Medicaid program, DHCS is not precluded from partnering with public or private entities to help finance program data, technology, and infrastructure needs that serve a wider audi- ence. Other state agencies, counties, and private sector partners can align technology priorities serv- ing the health, social, and public health sectors, and coordinate with DHCS to maximize federal partici- pation. Additional requirements for CMS funding are noted below with examples from states that have proposed and received approval. > Cost-sharing or matching funds. CMS requires states to provide cost-sharing or matching funds to offset federal funds.'"" The state can use gen- eral funds designated to a Medicaid agency or other state agencies supported by interagency agreements, city/county funds, or philanthropic donations. Other state matching fund examples include but are not limited to a central State Health IT Fund (e.g., Vermont's State Health IT Fund [32 V.S.A. § 10301(g)] with effective date from 2011 until July 1, 2023, with revenue generated from 0.199% of 1% of all health insur- ance claims deposited into the general fund)."' Additional funding sources for consideration include other tax funds with the appropriate policy designation, such as the Mental Health Services Act, marijuana tax, or tobacco tax. >» Cost allocation. Medicaid FFP is allowable for Medicaid's "fair share" of state technology investments in Medicaid. The cost allocation methodology must be approved by the state Medicaid agency and CMS, with calculations and data sources justifying the proposed cost alloca- tion amount. Operational funding for Medicaid Enterprise Service modules is typically based on number or percentage of Medicaid enroll- ees served by the technical investments."? CMS also provides flexibility and justifiable methoa- ologies for other partner information exchange investments. State examples include Kentucky's APD cost allocation methodology for advanced directives and Maryland's cost allocation meth- odology for PDMP technical services.' Delivery system provider payment incentives. In addition to using state plan authority, states integrating technology and working toward data interoperability can leverage 1115 waiver demon- stration authority. State Medicaid agencies must adhere to the special terms and conditions for a state demonstration to hold the state and man- aged care entities accountable for technology adoption." As an example, CMS approved $650 million in Medicaid funding for North Carolina's Healthy Opportunities Pilots, a Medicaid Reform Demonstration with $100 million available for capacity building."* North Carolina leveraged the 1115 waiver to create a standardized screening initiative, referral platform, and pilot program to link social and medical services using Medicaid funding to address social determinants of health." California Health Care Foundation www.chcf.org 28 Appendix F. Components of CalAIM That Could Support AB 133 Priorities for Data Exchange Using Section 1115 waiver authority and Medi-Cal State Plan Amendments, California''s Department of Health Care Services (DHCS) is currently administering CalAIM (California Advancing and Innovating Medi-Cal), a multiyear initiative intended to modernize Medi-Cal and streamline service delivery using whole-person care approaches and addressing the social determinants of health." Modernizing data sharing and integration across organizations and sectors will be a crucial component to the success of CalAIM initiatives. The follow- ing table outlines the components of CalAIM for which existing publicly available materials reference funding that could support one or more of the identified needs of stakeholders. Of note, guidance is still pending on some programs, which could limit permissible use of funds. INITIATIVE ELIGIBLE ENTITIES PURPOSE RELATED TO TECHNOLOGY TIMING Incentive Payment MCPs Delivery system infrastructure Q1 2022- 78 Program "DHCS anticipates participating MCPs >» Health IT Q2 2024 will maximize the investment and flow of > Data exchange incentive funding to [essential community - providers] ECM and Community Support... _™ Billing providers to support capacity and infra- » Closed loop referral structure development.""" . ; . ECM provider capacity building » Workforce recruiting » Onboarding » Training and TA » Workflow development and redesign » Program operational requirements and oversight Providing Access County, city, and local government Developing infrastructure and systems, Q3 2022- and Transforming agencies, providers, CBOs, public hospitals, including transition of Whole Person Care O2 2025 Health (PATH) Medi-Cal Tribal and Designees of Indian (WPC) pilot infrastructure for managed care Program - Health Programs, ECM and Community contracted services under CalAIM. Capacity and Supports providers, and other entities Staff time for data collection that facilitates Infrastructure approved by DHCS that contract or intend evaluation and monitoring. Transition, to contract with Medi-Cal MCPs to provide Expansion, and ECM and Community Support services. Development Initiative" PATH - MCPs, county, city, and local government Forum to maximize coordination and Q3 2022- Collaborative agencies, providers, CBOs, public hospitals, minimize duplication within regions related 2 2025 Planning and Medi-Cal Tribal and Designees of Indian to gaps within the community, topical Implementation®™ Health Programs, ECM and Community issues, monitoring use of PATH funds, and Supports providers, and other entities disseminating best practices. approved by DHCS that contract or intend to contract with Medi-Cal MCPs to provide ECM and Community Support services Closing the Gap in California's Health Data Exchange: Necessary Investments and Funding Opportunities 29 INITIATIVE ELIGIBLE ENTITIES PURPOSE RELATED TO TECHNOLOGY TIMING PATH - Technical County, city, and local government Customized support from vendors on the Q3 2022- Assistance®™ agencies; public hospitals and providers, technical assistance marketplace, which may Q4 2024 community-based providers; other ECM and include guidance on data sharing, strate- Community Supports providers; Medi-Cal _ gic planning, reporting, and other core Tribal and Designees of Indian Health functions. programs; and other entities approved by DHCS that contract or intend to contract with Medi-Cal MCPs to provide ECM and Community Support services.® Access to published resources developed by TA vendors for the initiative. PATH - The State prisons, jails, youth correctional Information technology investments that Q3 2022- Justice-Involved facilities and probation offices, sheriff's facilitate data exchange between correc- Q4 2026 Capacity Building offices, and county behavioral health tional institutions, Medi-Cal eligibility Program™ agencies build capacity offices, community providers, and MCPs as well as technical support and training for county behavioral health. Behavioral County-operated behavioral health plans Update county technical infrastructure to O3 2021- Health Quality implement CalAIM policies, including EHRs 04 2023 Improvement and reporting systems to facilitate data Program® sharing between county behavioral health agencies and Medi-Cal managed care plans. Housing and MCPs MCP connection with local HMIS or other Q3 2022- Homelessness local data sources. Q1 2024 Incentive Program® California Health Care Foundation www.chcf.org 30 Appendix G. Glossary of Abbreviations HITECH - Health Information Technology for Economic and Clinical Health HMIS Homeless Management Information System HRSA Health Resources and Services Administration HUD Department of Housing and Urban Development IIS Immunization Information System IT Information technology MCP Managed care plan MES Medicaid Enterprise System MHBG = Community Mental Health Services Block Grants MHSA Mental Health Services Act MPI Master patient index PATH Providing Access and Transforming Health POLST Physician Orders for Life-Sustaining Treatment SAMHSA Substance Abuse and Mental Health Services Administration TA Technical assistance USCDI - United States Core Data for Interoperability WPC Whole Person Care AB 133. Assembly Bill 133 ACL Administration for Community Living APD Advanced Planning Document API Application programming interface BH-EHR Behavioral health electronic health record BJA Bureau of Justice Assistance BRIC Building Resilient Infrastructure and Communities CalAIM = California Advancing and Innovating Medi-Cal Cal-HOP California Health Information Exchange Onboarding Program CBO Community-based organization CDC Centers for Disease Control and Prevention CHCF California Health Care Foundation CalHHS California Health and Human Services Agency CMS Centers for Medicare & Medicaid Services CoC Continuum of Care DHCS California Department of Health Care Services DOC Department of Corrections ECM Enhanced Care Management EHR Electronic health record FCC Federal Communications Commission FFP Medicaid Federal Funding Participation FMAP Medicaid Federal Medical Assistance Percentage HHS US Department of Health and Human Services HIO Health information organization Closing the Gap in California's Health Data Exchange: Necessary Investments and Funding Opportunities 31 Endnotes 10. 11. . 2021 Cal Stat 143. . Data Exchange Framework Stakeholder Advisory Group: Meeting #4 (PDF (California Health and Human Services Agency [CalHHS] webinar, Dec. 14, 2021). . California Budget 2021-22, May Revision Budget Summary - Health and Human Services (pF), State of California, May 14, 2021. . California Budget 2022-23, May Revision Budget Summary - Health and Human Services (PDF), State of California, May 13, 2022. . Mark Elson et al., Health Information Exchange in California: Assessment of Regional Market Activity, California Health Care Foundation (CHCF), August 2021; Learning from the History of Statewide Health Data Exchange, CHCF, July 2021; and Mark Elson, Health Information Exchange in California: Overview of Network Types and Characteristics, CHCF, August 2021. . "Grant Terminology," grants.gov, accessed March 28, 2022. . "2022 Federal Register Index," National Archives and Records Administration, accessed March 25, 2022; "Federal Policy Guidance," Centers for Medicare & Medicaid Services (CMS), accessed March 25, 2022; and "Grant Terminology," grants.gov. . The United States Core Data for Interoperability (USCD)) is a standardized set of health data classes and constituent data elements for nationwide, interoperable health information exchange. USCDI v1 is an adopted standard in the Office of the National Coordinator Cures Act Final Rule. Use of the USCDI standard is required as part of the new application programming interface (API) certification criteria, "standardized API for patient and population services" (§ 170.315[g][10]). Health IT developers of Certified Health IT products must be able to share data using the USCDI v1 data set by December 31, 2022. USCDI v2 includes additional data elements and data classes for social determinant of health (SDOH) assessment and plan of treatment coded data elements, SDOH goals, and care team members. . Data Exchange Framework Stakeholder Advisory Group: Meeting #1 (PDF) (CalHHS webinar, Aug. 31, 2021). Expanding Payer and Provider Participation in Data Exchange: Options for California, CHCF, November 2019. Medicare & Medicaid EHR Incentive Program: Meaningful Use Stage 1 Requirements Overview (ppp), CMS, 2010; "Cal-HOP," State of California, accessed March 28, 2022: and Cal-HOP Approved Interfaces (PDF), California Dept. of Health Care Services (DHCS), last updated June 17, 2021. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. Mental health providers are not explicitly named in AB 133. Many county behavioral health plans are collaborating with the California Mental Health Services Authority on procurement of certified EHR technology and consultant support to bring interoperability to scale. However, policy and programmatic support will be relevant as new policies emerge. Large SNFs owned by commercial organizations, which represent about 70% of facilities, have EHRs. However, SNFs are mostly not connected to other parts of the health care delivery system or to other sectors. Authors were unable to reach either of the major lab associations in the state for an interview. While AB 133 specifically names counties, cities, and nonprofits also often play a role in service delivery and should be considered with regard to data exchange capabilities. In Whole Person Care pilots, counties generally served as Lead Entities and drove the design of the initiatives and technology investments. In CalAIM, MCPs are playing a more central role in implementation and infrastructure. Therefore, it will be challenging to sustain the WPC technological investments in CalAIM without MCP buy-in. Timothy Hill (acting director, CMS) to all state Medicaid directors, State Medicaid Director Letter 18-005 (Ppp, April 18, 2018. Strengthening US Public Health Infrastructure, Workforce, and Data Systems, CDC, last reviewed June 17, 2022. On June 16, 2022, the CDC released the Strengthening US Public Health Infrastructure, Workforce, and Data Systems notice of funding opportunity. This five-year cooperative agreement is available to states, counties (over two million population), and cities (over 400,000) for cross-cutting programs intended to meet critical infrastructure and workforce needs and long-term, strategic investments strengthening public health capacity. Key objectives include improving workforce capacity, strengthening public health services and processes, and data modernization for efficient data infrastructure, increased data interoperability, and increased public health data availability and use. Cindy Mann (director, CMS) to all state Medicaid directors, State Medicaid Director Letter 18-004 (PpA, May 18, 2022; and Hill, State Medicaid Director Letter 18-005. This paper focuses on federal funding sources. States may consider how to leverage private sector participation through Medical Loss Ratio (MLR) for quality improvement investments including technology and data exchange. Technology services must pass operational readiness review and certification review processes, as well as provide six months of data for approved outcomes measures to qualify for 75-25 FFP operational funding. Maryland State Medicaid HIT Plan (ppp), ver. 9.0, State of Maryland. California Health Care Foundation www.chcf.org 32 22. 23. 24. 25. 26. 27. 28. 29, 30. "Section 1115 Demonstration HIE Policy," CMS, accessed March 28, 2022. The 1915(c) Home and Community-Based Service waiver is an example of a waiver with technical requirements for enhanced utilization, quality, and cost data for the long-term services and supports population providing a 10% increase in FMAP (10%) through Section 9817 of the American Rescue Plan Act. Funding was available through March 31, 2022. Medicaid and Children's Health Insurance Program (CHIP) Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, and Revisions Related to Third Party Liability Final Rule (Pon, 81 Fed. Reg. 27498-901 (May 6, 2016); and Jonah Frolich, Kevin McAvey, and Jonathan DiBello, CalAIM and Health Data Sharing: A Road Map for Effective Implementation of Enhanced Care Management and In Lieu of Services, CHCF, May 2021. States can develop an EHR incentive program up to the state's allowable FMAP for federal financial support that provides funding to designated Medicaid providers that may not have been eligible for Meaningful Use Program / Promoting Interoperability incentive payments. A program could be designed for long-term care facilities or behavioral health providers to support electronic data capture through certified EHRs or other technical systems to meet the minimum interoperability requirements set forth in AB 133. SUPPORT for Patients and Communities Act, H.R. 6, 115th Congress (2018). "Percent of Specialty Hospitals That Possess Certified Health IT," Health IT Quick-Stat #59, Office of the National Coordinator for Health Information Technology, August 2019. Forty-nine percent of psychiatric hospitals use EHRs compared to 96% of general medicine and surgical practices. "Data Modernization Initiative," CDC, last reviewed March 21, 2022. CDC typically funds 64 public health jurisdictions including 51 state public health agencies, which includes the District of Columbia, territories, and local public health agencies over a certain population threshold. Additional funding streams for programs, populations, and prevention are available through public health authorities for services and technical infrastructure. States receive multiyear cooperation agreements that may fund data and technical infrastructure priorities. An example is Section 1815, "Improving the Health of Americans Through Prevention and Management of Diabetes, Heart Disease, and Stroke." This paper did not identify past and existing funding sources with programs currently underway. CDC funding streams allow cities and counties meeting population thresholds to be eligible for public health funding cooperative agreements and grants. Los Angeles is not the only California county meeting these requirements and receiving funds. Federal Section 317 funding is typically authorized for vaccines for children, adolescents, and adults for immunization program operations and critical infrastructure. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 44. 45. Federal Section 317 funding is typically authorized for vaccines for children, adolescents, and adults for immunization program operations and critical infrastructure. "Data Modernization Initiative," CDC, last reviewed May 10, 2022; and "Data Modernization Initiative: An Urgent Need to Modernize," CDC, last reviewed November 18, 2020. The Data Modernization Initiative is creating a standards-based interoperable public health infrastructure, ensuring all systems can communicate and seamlessly share data; advancing standards so that information can be stored and shared across systems; and facilitating complete and timely reporting so that the CDC has essential data on race, ethnicity, treatments, and comorbidities critical for achieving equity in public health response. Office of Financial Resources Fiscal Year 2021 Annual Report (ppA), CDC. "Community Mental Health Services Block Grant," Substance Abuse and Mental Health Services Administration (SAMHSA), last updated April 16, 2020. "Community Mental Health Services Block Grant," SAMHSA, last updated April 16, 2020. Block Grant Reporting Section CFDA 93.958 (Mental Health) (FY 2022-2023 MHBG Report) (PDF), SAMHSA. Daniel Tsai (deputy administrator and director, CMS) to all state health officials, State Health Official Letter 21-008 (PDF, December 28, 2021. Anita Everett, "Groundbreaking Developments in Suicide Prevention and Mental Health Crisis Service Provision," SAMHSA, May 14, 2021. Kristen K. Beronio, Funding Opportunities for Expanding Crisis Stabilization Systems and Services (PDF), Technical Assistance Collaborative Paper No. 8, National Assn. of State Mental Health Program Directors, September 2021. "FY 2021 Community Mental Health Block Grant Program COVID-19 Supplemental Awards," SAMHSA, last updated March 11, 2021. Sara Rosenbaum et al., Community Health Center Financing: The Role of Medicaid and Section 330 Grant Funding Explained (ppF), KFF, March 2019. "Health Center Controlled Networks," HRSA, accessed March 28, 2022 "Emergency Broadband Benefit," Federal Communications Commission (FCC), accessed March 28, 2022 "Rural Health Care Program," FCC, accessed March 28, 2022 "Continuum of Care (CoC) Program Eligibility Requirements," HUD Exchange, accessed March 28, 2022. Closing the Gap in California's Health Data Exchange: Necessary Investments and Funding Opportunities 33 46. 47. 48. 49. 50. 51. 52. 53. 54, 55. 56, 57, 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. "Continuum of Care (CoC) Program," HUD Exchange, accessed March 25, 2022. "Program Areas: Overview," Administration for Community Living, accessed March 28, 2022. "Funding Opportunities for Your Community in 2022: An Overview of What Is Ahead" (PpF (Bureau of Justice Assistance webinar, Jan. 19, 2022). Christine Nolan, Kelly McPherson, Bryant Karras, Chris Baumgartner, Shawn Roberts, and Jennie Harvell, interview by Kate Ricker-Kiefert, May 5, 2022. Final Bill Report: E2HB 1477 (ppp, Washington Health Care Authority, May 5, 2022. Health and Human Services Enterprise Coalition: Information Technology (IT) Investment Coordination Annual Report (PDF), Washington State Health Care Authority, November 1, 2021. "MES Certification Repository: Health Information Exchange," CMS, accessed May 2, 2022. "Optimizing Maryland's Prescription Drug Monitoring Program (PDMP)," BJA, accessed June 7, 2022. "Overdose Data to Action," CDC, accessed June 7, 2022. 574th Meeting of the Health Services Cost Review Commission (ppF), Maryland Dept. of Health, June 10, 2020. "Health Equity Resource Communities," Maryland Dept. of Health, accessed May 5, 2022. Nebraska leveraged HITECH 90-10 FFP to establish core HIE functionality; sources listed support maintenance and operations. CyncHealth, accessed May 5, 2022. Nebraska Health Information Initiative 2019 Annual Report (PDF), CyncHealth. Social Security Act § 1903, 42 U.S.C. 1396b. Medicaid Financing: An Overview of the Federal Medicaid Matching Rate (FMAP) (Por), KFF, September 2012. MaryBeth Musumeci and Jennifer Tolbert, "Federal Legislation to Address the Opioid Crisis: Medicaid Provisions in the SUPPORT Act," KFF, October 5, 2018. Mann, State Medicaid Director Letter 11-004, Patrick Filbin, "Behavioral Health Providers Falling Behind in EHR Adoption, Critical to Participate in Value-Based Care," Behavioral Health Business, November 13, 2021. Rachel Bennett, "Federal Grant Funding: Types and Best Ways to Progress Your Opportunities," Amplifund, October 6, 2020. "Grant Terminology," grants.gov. "Grant Terminology", grants.gov "Grant Terminology", grants.gov 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. Public Health Financing (PDR, CDC, June 2013. "Grant Terminology," grants.gov Ena Backus, Annual Report on the Receipts, Expenditures, and Balances in the Health IT-Fund (PpF), Vermont State General Assembly, September 1, 2021. Under HITECH, cost allocation was determined based on number or percentage of eligible Medicaid providers. "Health Information Exchange," CMS, accessed March 28, 2022. "Section 1115 Demonstration HIE Policy," CMS, accessed March 28, 2022. Elizabeth Hinton et al., "A First Look at North Carolina's Section 1115 Medicaid Waiver's Healthy Opportunities Pilots," KFF, May 15, 2019. Hannah Crook et al., How Are Payment Reforms Addressing Social Determinants of Health? Policy Implications and Next Steps (PDA), Milbank Memorial Fund, February 2021. "CalAIM," DHCS, accessed March 28, 2022. Funding Opportunities Cheat Sheet (Pp, DHCS, accessed March 25, 2022; and "CalAIM Enhanced Care Management, Community Supports, and Incentive Payment Program Initiatives," DHCS, last modified March 23, 2022. Funding Opportunities, DHCS. "Providing Access and Transforming Health (PATH) Supports All-Comer Webinar" (ppF) (DHCS webinar, Jan. 28, 2022). "Providing Access," DHCS. DHCS. DHCS. Funding Opportunities, DHCS. Behavioral Health Quality Improvement Program: CalAIM - Program Implementation Plan and Instructions for County Behavioral Health Plans (pPpR, DHCS, December 2021. Housing and Homeless Incentive Program: MCP Resource Guide (ppF), DHCS, February 2022. California Health Care Foundation www.chcf.org 34