Braiding federal funds to scale evidence-based solutions for families battling opioid use

This blog series “Uniting funding streams for health and social innovation” is a collaboration between the Urban Institute’s Pay for Success Initiative (PFSI) and The Brookings Institution-hosted Braiding and Blending Working Group. Though not every post is focused on pay for success, the working group and this blog series aligns with the PFSI mission of researching and supporting innovative financing solutions to today’s most pressing challenges. This series highlights the research of experts in healthcare financing focused on creative approaches.

The nation’s opioid crisis is ravaging communities across the country and tearing families apart: parental substance use is correlated with an alarming rise in child welfare caseloads, including foster care placements. No single service system is equipped to provide the wide range of supports a struggling family may need to manage the disease of addiction, provide healthy home environments, and achieve financial stability.

State and local jurisdictions need to create coordinated interventions and strategies that (1) find parents who are struggling with addiction—more appropriately termed opioid use disorder – and persuade them to seek help before a child must be removed from the home; (2) provide evidence-based solutions, like medication-assisted treatment (MAT), to parents for as long as needed to manage their disease; and (3) help families get other essential services they may need, such as housing or assistance finding work. 

Unfortunately, even MAT – which has been effectively used to decrease opioid use, deaths from opioid related overdoses, criminal activity, and transmission of infectious diseases – is often misunderstood and not accessible enough, and we don’t know the right mix of outreach and retention strategies to help it work even better.

Fortunately, new and expanded federal funding streams provide opportunities to think creatively and use braiding and blending of funding to bridge gaps in treatment capacity and build knowledge, making meaningful inroads against opioid use disorder and its destructive impacts. Notably, this year, Congress: 

• Created the Families First Prevention Services Act, which will provide a 50 percent federal match for evidence-based mental health and substance use treatment, services and in-home parenting programs that reduce the number of children in the child welfare system. 
• Appropriated a $1.5 billion increase for the Substance Abuse and Mental Health Services Administration (SAMHSA) for State Opioid Response Grants and the 21st Century Cures Act which provide access to evidence-based treatment and prevention and recovery services.   
• Appropriated $119 million in new funding for the Administration for Children and Families for initiatives to support community collaborations among substance use treatment providers, courts, and child welfare agencies; to improve safe care for infants born with neonatal abstinence syndrome and their families; and to improve kinship navigator programs that help relatives care for children whose parents are struggling with addiction.
• Reauthorized the Maternal, Infant and Early Childhood Home Visiting (MIECHV) program, which provides $400 million annually in grants to states for evidence-based home visitation strategies that lead to improved maternal and newborn health, reduced child injuries and maltreatment, reduced crime and domestic violence, and improved economic self-sufficiency. The reauthorization provides explicit authority for outcome-based payments.

In addition, theTrump administration has continued Medicaid waiver authority--initiated by the Obama administration--to enable new state-level approaches to addressing the opioid crisis.  Medicaid remains the largest federal program funding treatment for opioid use disorder. 

So, how could states blend and braid these funding streams to develop high-impact strategies for helping families deal with addiction and avoid the child welfare system? 

One option is an outcomes-based funding model that focuses on community partner collaboration and incentivizes longer-term outcomes. Several value-based models exist in the health space but a different, three-part model initially proposed for mental health treatment, could be adapted to support a more comprehensive approach to opioid use disorder. Through this model, an outcomes-based contract would leverage funding streams for outreach and retention programs, use Medicaid to support MAT delivery, and provide bonus payments for providers that achieve certain housing, employment or criminal justice outcomes. An evaluation would trigger these outcome payments, helping to ensure funding rewards verifiable impact and builds evidence on effective programs to support MAT.

Other strategies could include:

• Forming a cross-sector governance model, led by a senior official overseeing health and human services and other supportive services, to bring together key government agencies, community-based organizations, researchers, and families. These partners would co-design new processes that put patients and families at the center of coordinated services that can draw upon Medicaid, SAMHSA, Families First, MIECHV, and other funding streams. 

• Strengthening capacity for data integration, analysis, and evaluation across child welfare, health, and other support services to improve decisions about how to target and coordinate services, evaluate what’s working, and provide reliable data for outcome-based contracting. Programmatic funding could be tapped for this.  Jurisdictions that lack integrated data systems could partner with researchers to use low-cost, privacy-protected data-linkage platforms, such as NYU's Administrative Data Research Facility.

Without cross-system innovation, families in crisis will continue to fall through the cracks of a patchwork of poorly coordinated government services, jeopardizing the future of the next generation. The ideas presented here are just a sampling of braiding and blending strategies that could be knit together to create a coordinated, outcome-focused approach to help families struggling with addiction obtain the healthcare and other critical supports they need. 

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The views expressed in the series are those of the authors; as an organization, the Urban Institute does not take positions on issues. Experts are independent and empowered to share their evidence-based views and recommendations shaped by research. Photo via Shutterstock.