The Medicaid Transformation Project (MTP) is Washington State's Section 1115 Medicaid demonstration waiver between the Health Care Authority (HCA) and Centers for Medicare & Medicaid Services (CMS). MTP allows our state to create and continue to develop projects, activities, and services that improve Washington’s health care system.

On June 30, 2023, CMS approved MTP to continue for five more years. Our state's MTP renewal, called MTP 2.0, will help widen our reach to provide more programs, services, and supports to our most vulnerable populations. Learn more about MTP and the MTP waiver renewal.

Through MTP, Washington State has nine designated Accountable Communities of Health (ACHs) which are independent, regional organizations. HealthierHere serves as the ACH for King County. ACHs work with their communities on specific health care and social needs-related projects and activities, and are committed to ensuring community needs, values, and priorities guide system transformation.

ACHs play an integral role in Washington’s MTP efforts. Although MTP 1.0 was Medicaid-focused, ACHs are working in many ways to improve the health of their communities as a whole. Learn more about ACHs.

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MTP 2.0 is more prescribed in its structure and its scope is narrower. MTP 2.0’s theme is “Taking action for healthier communities.” In part, it will accelerate care delivery and payment innovation focused on health-related social needs (HRSNs) and equity through:

• Community-based care coordination hubs – aka “Community Hub”
• Community-based workforce
• Funding for Health-Related Social Needs Services (HRSNs)
• Statewide Tribal Hub (led by HCA)
• Re-entry for short-term pre and post release services from corrections settings
• Health Equity programs (TBD)

ACHs’s roles are now focused on building and serving as regional Community Hubs that deliver case management services and health-related social needs (HRSN) benefits to the community. Community Hub funding will support capacity building for delivery of services provided by contracted Case Management Partners and HRSN service providers.  

‍See a graphic overview of the components of MTP 2.0.

Under MTP 1.0, ACHs had flexibility and autonomy to choose projects and approaches, and how to invest funds. Its scope was broad, and HealthierHere largely provided flexible funds for community, clinical, and Tribal partners to invest in capacity building and developing infrastructure to advance whole person integrated care through deliverable based contracts. Through partnership, collaboration, and innovation, HealthierHere and our partners developed promising practices and shared learning through convenings and webinars.  

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Community-based care coordination (CBCC) is defined as “Deliberately organizing patient care activities and sharing information among all the participants involved with a patient’s care to achieve safer and more effective care” (Agency for Healthcare Research and Quality).” Throughout MTP 1.0, our clinical and community partners consistently identified care coordination transformation work as a high area of need. HCA also identified community-based care coordination as a core strategy for improving the health of Medicaid enrollees.

CBCC also emerged as an area of high potential for ACHs to have actionable impact with positionality to be a neutral convener, build trusted relationships with regional partners, steward regional funding, and provide training, technical assistance (TA), and quality improvement (QI) support.

The work is a continuation of HealthierHere’s broadening care coordination efforts, building on our work through the Care Connect Washington Program, Connect2 Community Information Exchange, and Shared Care Planning.

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Health Related Social Needs (HRSNs) refer to the social and economic needs people experience that affect their ability to maintain their health and well-being. They include things like housing instability, food insecurity, employment and income, lack of transportation, and more.

HRSNs differ from the Social Determinants of Health (SDoH), which are the social and economic conditions in which people grow, work, play, live, worship and age, that contribute to health and quality of life outcomes. These conditions are shaped by distribution of money, power, and resource and are related to factors like institutional bias, discrimination, structural racism, and more.

HRSNs can be understood as more immediate individual or family needs stemming from SDOH.  By addressing HRSNs and SDoH, we can advance health equity and reduce health disparities, which are core to HealthierHere’s mission. It can also reduce health care utilization and costs. The Community Hub will provide case management services addressing HRSNs to anyone that needs help and assistance. Medicaid enrollees may be eligible for specific HRSN benefits depending on their diagnosis and treatment plan.

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Under MTP 2.0, a Community Hub is a community-centered entity that organizes and supports a collective of Hub Case Management partners providing case management services and connecting people to health-related social needs services and benefits. Its key functions include supporting:

• Community voice and engagement
• Sustainability and business operations
• Funding for Health-Related Social Needs Services (HRSNs)
• Care coordination operations and reporting
• Network management and capacity building
• Community-based workforce support

A hub is an administrative entity that centralizes administrative and operational functions/infrastructure including:

• Contracting with Case Management Partners
• Payment operations
• Managing and assigning referrals
• Service delivery compliance
• Technology infrastructure
• Information security
• Data collection and reporting
• Training/TA/QI support

HealthierHere’s Hub includes community-based and clinical organizations, and agencies that receive referrals from the Hub to provide care coordination services to community members. The Hub honors and leverages the capacity of local community-based and healthcare organizations to provide culturally responsive services to community through a workforce that reflects the diversity of the community.

The HealthierHere Community Hub is a centralized (but not single) place of coordination for referral to community-based resources. The Hub will provide warm handoffs to connect people to clinical care when needed, in partnership with Managed Care Organizations (MCOs) for their Medicaid enrollees.  

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Rooted in an equity-centered model, the Community Hub will serve the whole community in King County through case management services, moving beyond just the Medicaid population. We recognize that many communities aren’t Medicaid eligible but still have a need for care coordination/case management support, and people cycle on and off Medicaid. TheHub provides a “no wrong door” approach that is consistent with HealthierHere’s values. 

The total eligible Medicaid population in King County includes over 471,000 individuals, including over 171,200 child managed care eligible enrollees. This also encompasses over 77,700 total Medicaid Fee for Service (FFS) members, including over 12,000 child FFS members. 

In serving our whole community including the full Medicaid population,  HealthierHere provides support and services that cater to diverse populations based on age, race/ethnicity, and preferred languages. HealthierHere’s culturally and linguistically appropriate client assignment process (SMART assignment) will aim to make sure that community members are assigned to a case management partner organization that is the best match to ensure cultural and linguistic appropriateness. 

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The Hub’s services are divided into two main categories:

Case Management

• Resource navigation
• Referrals to meet health-related social needs (HRSNs)

These services are the core of community-based care coordination. Case management services are available for everyone, regardless of their Medicaid eligibility. HealthierHere will use the Per Member Per Month rate we receive for all Medicaid clients (Managed Care and Fee for Service) to pay for these services.

Health-Related Social Needs Benefits

• Payment from Medicaid for a service that meets a clinically indicated health related social need for a defined population.

The populations, services, and protocols for HRSN benefits are still being finalized by HCA.  Examples of the types of potential HRSN benefits in MTP 2.0 include the following:

• Nutrition supports (including medically tailored meals, nutrition counseling, health meal prep, pantry stocking, short-term grocery delivery).
• Housing supports, such as recuperative care and short-term post hospitalization housing, housing transition navigation services and deposits
• Community transition services (including non-medical transportation and personal care/homemaker services)
• Stabilization center
• Caregiver respite services
• Medically necessary environmental accessibility and remediation adaptations (home repairs)

These benefits can be provided alongside case management. The Community Hub will provide these benefits for Medicaid FFS members with a demonstrated clinical need. Medicaid MCO members can access these services through their MCO plan. Due to delays at the state and federal level outside HealthierHere’s control, we anticipate the populations, services, and protocols for HRSN benefits to be finalized in Q3 or Q4 2024.

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The HealthierHere Community Hub’s role is to connect, coordinate and create collaboration in the community on behalf of people who need support (outside of clinical care). The services and supports provided through the Hub will help community members more easily connect to the supports and resources that support their whole-person health and well-being.

In addition, the Hub will bring in significant financial resources to our communities through the MTP 2.0 funding mechanism. We have the opportunity to support the community-based workforce on a larger scale than we have been able to before.  We hope to move this important work on a pathway to financial sustainability longer term.  

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HealthierHere is committed to transforming our health and social systems to more effectively and equitably serve our communities. The Community Hub is a unique opportunity to “be the system change” that we want to see. In designing the HealthierHere Hub, we will center community voices, lived experiences, and priorities to create a system for people, by people.

The Hub is one piece of our larger system transformation efforts and advances the goals of our communities. Successful launch and implementation of the Hub is imperative to achieving our broader vision where all people in King County are healthy and achieve their optimal physical, mental and social well-being.

Through the Hub, we aim to create a model that is within the parameters the federal government and state have given us that moves the system beyond the grant-to-grant cycle toward an equitable, sustainable structure.

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HealthierHere is currently waiting on further details from HCA and CMS regarding the following items:

• When provision of case management services can begin under MTP 2.0 (likely in Q3 2024).
• When HRSN benefits protocols will be approved, which HRSN benefits will be launched first (it will be a phased approach) and which populations will be eligible for the different HRSN benefits.
• Mechanisms by which care coordinators and/or the Hub can verify clinical indication for HRSN benefits.
• How the re-entry program will be structured and administered (2025).

We will update this FAQ as we learn more about each of these items and include updates in our outreach and engagement opportunities. If you have additional questions, please contact the HealthierHere’s Community Hub Director, Tavish Donahue (she/her), at tdonahue@healthierhere.org.

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Please see the next question for more information about the new types of partner categories through the Community Hub under MTP 2.0.

Interested organizations can partner as a:  

Hub Case Management Partner: organizations that contract with HealthierHere to receive client referrals and to provide case management services

Hub HRSN Benefit Partner: organizations that join HealthierHere's HRSN Benefit network to receive reimbursement for providing approved HRSN benefits to Medicaid Hub clients from eligible populations. Contracts and funds flow may be through HealthierHere, Health Care Authority (HCA), or Managed Care Organizations (MCOs).

Hub Referral Partner: agencies who refer clients to the Hub for services (inbound referrals) and/or accept referrals from the Hub’s Case Management Partners for HRSN services (outbound referrals).

Partnering organizations are not limited to one partner type. For example, a Hub Case Management partner that offers specific HRSN services that are part of MTP 2.0 can also contract with HealthierHere as a Hub HRSN Benefit Partner. We encourage all HealthierHere partners to become Hub Referral Partners, and refer clients to the Hub, and accept referrals for HRSN services when appropriate.

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Community Hub services are estimated to begin in July of 2024 and an initial cohort of Case Management Partners has already been identified. Organizations interested in becoming Hub Case Management Partners who did not submit an application to be part of Cohort 1 will have opportunities to participate in the future.

Organizations not interested or not eligible to become Case Management Partners may still become Community Hub partners by referring potential clients for intake, accepting referrals for services, and/or becoming HRSN Benefit Partners.

Case Management Partners ready to join Cohort 1 have some or all of the following characteristics:

• Serves a priority population
• Has expertise in a priority HRSN service area
• Organizational leadership is willing to commit time and resources to Hub programming and C2C integration
• Organization has the technical readiness to adopt C2 Coordinator and potentially integrate its existing technology system in the future
• Currently provides services in which information is collected and protected in accordance with HIPAA. The organization has policies and procedures related to privacy and information security, including consent for data collection and sharing, and tracking and responding to information security incidents
• Organization is a leader in King County, who holds trust with partners and community members
• Frontline staff are interested and ready to participate
• Organization’s mission and strategic plan align with goals of the Community Hub and Connect2 Community Information Exchange
• Has available care coordination FTE to dedicate to the Community Hub, or is committed to hiring staff by May 2024 to be ready for training
• Has experience providing care coordination services
• Has worked with HealthierHere in the past

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HealthierHere’s Connect2 Community Information Exchange (Connect2 CIE) includes a network of organizations and technology that supports interoperable data exchange. This has been co-designed with community, Tribal, and health care partners to help service provider organizations build relationships and access and exchange information so your organization can effectively and quickly coordinate care for your clients across systems.

By joining the Connect2 CIE, Community Hub Case Management partners will be able to access an up-to-date resource directory, make closed loop referrals, and share information across health care and social service providers.

HealthierHere will be looking for community-based and clinical organizations to join our first cohort of Case Management partners. The Community Hub will be supported by HealthierHere’s Connect2 CIE. Case Management partners will join this by adopting the technology interface  Connect2 Coordinator as their Client Management System (CMS) for Hub work. Case Management partners will also have the option of integrating their existing technology system over time. Cohort 1 Case Management Partners will participate in a period of infrastructure and capacity building and CIE integration to prepare for service delivery in July 2024.

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HealthierHere’s Community Hub will be supported by our Connect2 Exchange technology to support data exchange for care coordination. All Community Hub Case Management Partners are required to meet the requirements of HealthierHere’s Client Authorization (consent), Participant Agreement, and Data Sharing Agreement. For organizations that are Covered Entities under HIPAA, HealthierHere provides a Business Associate Agreement.

You can find these agreements linked below in addition to a Pre-Agreement Self-Assessment that is intended to help your organization assess your readiness as it relates to meeting the requirements of the Participant Agreement and the Data Sharing Agreement.

• Client Authorization
• Participant Agreement
• Data Sharing Agreement
• Business Associate Agreement
• Pre-Agreement Self-Assessment

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November-December 2023:
1) Early engagement to identify interested Community Hub partners

2) Survey opened to organizations interested in being a Cohort 1 Case Management Partner

January-February 2024:
Additional engagement opportunities for potential Cohort 1 Case Management Partner applicants including overviews of key capacities that Case Management Partners will need to have in place, privacy/data/IT requirements, and demos of the Connect2 Coordinator client management system (CMS)

March-May 2024:
1) Cohort 1 CCA application & selection process

2) Contract development

3) CMS protocols finalized (TBD- answering current unknowns) 

June-August 2024:

1) CMS protocols finalized (TBD- answering current unknowns)

2) Hub Orientation training for Cohort 1 Case Management Partners to prepare for service delivery

3) Launch the HealthierHere Community Hub and begin referrals (exact start date pending HCA and CMS protocols)*

*An early version of the Healthier Community Hub has existed since 2022 to offer the Care Connect Washington Program, which initially focused on supporting people who have tested positive for COVID-19, and currently provides care coordination to support anyone in King County to recover from the long-term effects of the pandemic.

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Please visit www.healthierhere.org/our-work/community-hub for more information.

If you have additional questions, please contact the HealthierHere's Community Hub Director, Tavish Donahue (she/her), at tdonahue@healthierhere.org.

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