Elena Nicolella, executive director of the New England States Consortium Systems Organization (NESCSO), knows first-hand the importance of eliminating silos in achieving population health goals. As Rhode Island’s Medicaid Director from 2009-2013 and director of policy innovation for Rhode Island’s Executive Office of Health and Human Services from 2014-2016, she oversaw numerous efforts that hinged on cross-sector commitments. Now, as head of NESCSO, she is focused on maximizing policy, program, and cost effectiveness across health and human service systems in New England states. CHCS recently spoke with Ms. Nicolella, a former fellow of CHCS’ Medicaid Leadership Institute, about opportunities to foster transformational cross-sector relationships.

Q: You have been a champion of building collaboration between health and human services. What is your vision for bridging agencies?

A: Over my career at both the federal and state government level, I have learned that when services are delivered to address single program requirements, rather than people’s overall needs, those services are not as effective. But, I also recognize the real challenge of true collaboration across agencies. As a state employee, disruption was a constant – there were frequent dramatic shifts in policy and fiscal priorities when there was a change in economic conditions or in administrations. What gets lost in the upheaval is knowing how those changes impact the experience of the people we serve. It is hard enough running your own program. To be able to reach beyond your particular area, I think two basic components are necessary.  The first is data – cross-agency data can give you a valid and long-term understanding of the needs of the people you serve, whether or not those needs are being met, and the impact of changes.  For example, if a state behavioral health agency is required to reduce state-only funding for community-based behavioral health services, Medicaid-funded inpatient hospital stays may increase.  If you are only analyzing spending on services eligible for Medicaid-funding, you will not be able to anticipate that spike and more importantly, people will not be able to access the most appropriate services. A systems-wide approach to data is needed.

Over my career at both the federal and state government level, I have learned that when services are delivered to address single program requirements, rather than people’s overall needs, those services are not as effective.

The second component is staff education and awareness.  Collaboration across agencies cannot happen unless the people working in those agencies are aware of what services are provided and how they impact each other.  For example, in Rhode Island, before the state expanded Medicaid, we did not have systems in place to address the issue that parents lost Medicaid eligibility when they lost their children to state custody.  If a parent lost custody due to a substance use-disorder, she also lost the ability to access treatment services. Unless there is communication and awareness at the state agency level, no single agency is accountable to that family.  There will always be changing priorities, but if you have those two building blocks – cross-agency data and systems understanding – you can begin to build a culture where deep collaboration and interoperability across programs and agencies is possible.

Q: How can states gain through a more person-centered, population-health focus?

A: When states adopt a person-centered focus, the services they provide are more effective and will save money. For example, matching Medicaid claims data with a state’s homeless management information system can show a clear connection between the lack of housing and high emergency department and inpatient hospital use. That information can be used to support more appropriate and effective uses of funding.  In the same way and for the same reasons that Medicaid agencies promote the recognition of social determinants of health and the use of team-based approaches to health care providers, states should mirror that model in how health and human services are delivered.

Q: Why is cross-sector collaboration work so hard and what can state leaders learn to make it easier?

The importance of state agency staff being able to think outside of their boxes is really vital to the concept of person-centered, population-health approaches to care.

A: State government operates in a very challenging structure. Imagine if we expected a private enterprise to be fiscally effective and meet its stated goals even though there is a dramatic change in senior leadership every four or eight years and vastly different priorities. Additionally, if state government employees do not understand how the work they collectively do impacts people’s lives, it is very difficult to develop and sustain efforts to coordinate across programs. The importance of state agency staff being able to think outside of their boxes is really vital to this concept of person-centered, population-health approaches to care.

When you think about many HHS programs, the default go-to position is often “what does the program allow” versus “what are the needs of the population?” In particular, when you have changes in administration or federal policies, it is very easy to get caught up enforcing program requirements and, in doing so, jeopardize progress in integrating services.

Q: How is NESCSO’s State Health and Human Services Training and Leadership Development Initiative creating new opportunities for collaboration in New England states?

A: NESCSO’s Initiative seeks to support culture change within state government and also between state and federal government. Within state government, we are working with HHS Commissioner Meyers in New Hampshire and AHS Secretary Gobeille in Vermont. Both of these leaders are committed to the concept of person-centered care and building bridges across agencies. The work that is happening in our Medicaid Academies brings staff from the various HHS agencies together to understand each other’s programs and goals.  At the federal-state level, we have been hosting meetings where representatives from the federal HHS and USDA-Food and Nutrition Service programs and their state counterparts begin to discuss each other’s programs from a broad, cross-agency perspective. We look at how different program priorities might support or hinder another program’s efforts. Both of these efforts seek to build strong personal relationships, which is often the most effective way to get things done.

Q: How did your participation in the Medicaid Leadership Institute help you to think differently about and/or advance opportunities for cross-program collaboration?

A: I was relatively new to the Medicaid director position when I was honored to be chosen to participate in the Medicaid Leadership Institute (MLI).  MLI helped me to grow quickly in the position. It gave me the confidence to approach the job with a sense of great potential as well as a strong sense of responsibility.

Through MLI, I pursued a project to prepare Rhode Island for Medicaid expansion and to ensure that people leaving corrections had access to Medicaid coverage as soon after discharge or release as possible. We worked with corrections and advocacy organizations to determine how we could assist with eligibility within the constraints of a prison system – for example, how to use an online application system in the prison when laptops were considered contraband. It was an exercise in understanding two completely different cultures with very different missions, but working to overcome those differences because we shared the goal of expanding health care access so individuals were not as likely to return to prison. Rhode Island was one of the first states to deliberately embrace this concept and help promote eligibility for this population. I’m very proud of that – I don’t know if it would have happened without MLI.

Q: What advice would you give to new Medicaid, human service, and public health leaders across the country?

A: My advice would be to always be learning, always stay curious. These are very challenging programs. The complexity of them can be overwhelming. Remember to keep the person you are serving in the front of your mind and understand the impact of our collective decisions and whether or not those decisions improve that person’s experience with health and social service systems, and ultimately, improve the quality of his or her life.

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