TeamWork: Leadership for Healthy States

CASE STUDY

SOUTH CAROLINA
2015-2016

Team Members:

Christian L. Soura*
Senator Thomas C. Alexander
Joshua Baker
Lefford Fate
Elizabeth (Beth) Hutto
Representative James E. Smith, Jr.
Bryan P. Stirling
Harry H. Stokes, Jr.

*Team Leader

** Christian Soura resigned from government effective April 7, 2017

For additional information, contact:

Beth Hutto
Deputy Director for Eligibility, Enrollment, and Member Services
South Carolina Department of Health and Human Services
Phone: 803-898-2031 | Email: HuttoB@scdhhs.gov

The TeamWork: Leadership for Healthy States programpreviously known as the Excellence in State Public
Health Law Programstrengthens relationships within and across branches of government, builds
understanding of population health issues, and opens channels of communication and problem-solving that can
be used to address future population health challenges.
The Health in All Policies Vision

Team South Carolina approached the Health in All Policies (HiAP) concept by studying the five
key elements of the HiAP model, as set forth in materials published by the American Public
Health Association and other organizations. The five key-elements are: promoting health and
equity, supporting intersectoral collaboration, creating co-benefits for multiple partners,
engaging stakeholders, and creating structural or process change. Team leaders then assembled a
team and designed a project that they believed would satisfy those five conditions. Potential
participants in the project were briefed on the HiAP model and carefully selected based upon a
common understanding of those five elements and a mutual desire to improve health and
wellbeing outcomes for the justice-involved population.
South Carolinas TeamWork project promotes health, equity, and sustainability by seeking to
reduce health disparities between inmates and the general population, and by working to connect
these individuals to a stable source of care that will remain with them after release. The initiative
also supports intersectoral collaboration by bringing together the agencies responsible for the
states prisons and the Medicaid program. The former is responsible for nearly all aspects of an
inmates economic, physical, and social environment during his or her incarceration, while the
latter can bring its contractual and financial tools to bear on many of the same environmental
factors once the individual returns to the community.
One challenge introduced by the HiAP vision has been that it asks project participants to step
back and take a systems-level view at a specific health issue. Looking at the other social and
economic forces that impact health can provide new insight and understanding, but it also tends
to rapidly expand the scope of the project to address other factors that affect health outcomes.
Throughout the past year, the teams leadership struggled to keep its efforts targeted on specific
actions that were consistent with the original vision and which could be completed during the
initial project year. Additional activities were identified through the HiAP lens, which will be
pursued after the cohort period ends.

Project Summary

South Carolinas project focused on enhancing opportunities for former inmates to remain
connected to the healthcare system, to help them improve their health and wellbeing outcomes,
and to reduce the likelihood of recidivism. Initially, the centerpiece was an interagency effort to
identify those who will be released in the coming months, to assess how likely these individuals
are to be eligible for Medicaid under the states eligibility rules, and to support these inmates as
they apply and potentially proceed through a subsequent managed care selection and enrollment
process.
The key agencies the Department of Health and Human Services and the Department of
Corrections began by executing a data-sharing agreement that allowed for the current list of
inmates to be matched against active and historical Medicaid eligibility records. Despite the fact
that the heads of both agencies wanted to complete this document quickly, months passed before
it was finally executed. Both agencies were experienced working with the Health Insurance
Portability and Accountability Act (HIPAA), but other privacy rules (state or federal, statutory or
regulatory) were unique to either the correctional or healthcare arena and needed to be

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integrated. Negotiation between agency counsel slowed progress, frustrating the team, but the
repeated direct involvement of the department heads to resolve disagreements signaled the high
priority on the initiative by team leaders.
The initial exchange revealed that 53% of inmates had been Medicaid beneficiaries at some point
in their lives; in some cases, inmates were still listed as active members. After recognizing this,
the state recovered more than $1.4 million in improper premium payments to managed care
companies, a small portion of which was used to finance the costs of a new team of eight
eligibility workers. Also as a result of this project, when Medicaid beneficiaries are incarcerated,
their coverage is now suspended instead of being terminated. This allows for a more prompt
reactivation of coverage at the time of release and is consistent with new April 2016 federal
guidance from the Centers for Medicare and Medicaid Services (CMS).
Although the overarching vision for the project is largely the same as it was at the beginning of
the cohort period, there have been some findings along the way that have resulted in a project
that looks slightly different than originally expected. For instance, Team South Carolina
launched the initiative believing that it would be augmenting existing efforts to process these
types of Medicaid applications. In reality, although there was a dedicated eligibility worker
stationed at the Department of Corrections, he was exclusively working cases for inmates who
were being sent to inpatient treatment settings. These so-called 24-hour applications allowed
the state to receive federal funds for certain medical services provided in hospitals and other
comparable facilities, but did not provide Medicaid coverage that would follow inmates after
their final release. The team responded by building the new team of eligibility workers to handle
applications for those about to be released.
The team also expected that more applicants would be determined eligible for Medicaid than
ultimately proved to be the case. The group was surprised by how many mothers had surrendered
or been stripped of their parental responsibilities. Without a minor child in the household, many
of these mothers would only be eligible for limited Medicaid benefits (generally, Family
Planning). A series of visits to several correctional institutions also improved the project teams
appreciation for the varied settings in which an inmate may find himself or herself while serving
out a sentence. Early plans to piggyback on the intake process in order to gather additional
information in preparation for later Medicaid screenings were reconsidered after the project team
witnessed how traumatic the intake process could be for the newly-incarcerated and their friends
or families. The team pivoted by amending these plans so as to interact with inmates and their
support networks using visitation areas.
With the establishment of a new eligibility worker team and a triaging process, inmates about to
be released will now be helped through the Medicaid application process based upon the
likelihood that they will be determined eligible. Going forward, we expect to see an increase in
the number of Medicaid applications we can process each month, since we have nearly
completed updating inmates enrollment records to suspend their coverage instead of terminating
it. As we begin to complete these applications further in advance of the release date, we will also
be able to help these individuals proceed through the managed care enrollment process prior to
their release.
The team is now pursuing several areas of additional opportunity:

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 The South Carolina TeamWork group is in discussions with CMS about ways of filling
prescriptions for new Medicaid members on their date of release and potentially even
through the Department of Corrections own dispensaries. The hope is to providing these
individuals with a 30-day supply of medication instead of the 5-day supply that others
receive, improving the odds that they continue to adhere to treatment courses that help
them manage chronic and/or behavioral health conditions.
The team has had positive discussions with the South Carolina Hospital Association
about referring inmates deemed ineligible for Medicaid to its Access Health program,
which can be another pathway to care. There have been initial conversations with The
Duke Endowment as well, which is an important funder of Access Health.
The team has also brought the Department of Probation, Pardon, and Parole Services
(PPP) into the mix. The first discussions with PPP have related to how to track outcome
measures for former inmates and whether there may be a role for probation agents in this
process. The team has now approached PPP about completing a data-sharing agreement
that would allow for that segment of the justice-involved population to be matched
against the current and historical Medicaid enrollment records. Expanding the project to
include those on probation or parole could help to further reduce recidivism.
During the first year of this project, the goals have principally related to health care
access, but in the long run, health outcomes are the more important metric.

Over the course of the project, no lobbying took place with Robert Wood Johnson Foundation
funds.

Cross-Sector Collaboration

When the Department of Health and Human Services first learned about the TeamWork
opportunity, it identified the Department of Corrections as its chosen partner for several reasons.
Although the two agencies had not meaningfully interacted in the past, the heads of the two
organizations had previously worked together in the office of then-Governor Nikki R. Haley, so
they knew they had a common interest in improving health outcomes for the justice-involved
population. Team members were selected for expertise, and in some cases, team members had
past experience with Aspen Institute programming.
The team expected that a successful project might result in cost savings and/or opportunities to
supplant existing state expenditures with federal funds, but did not enter into this undertaking
with a desire to take money off the table. Instead, the group planned to reinvest any
efficiencies into better care for the justice-involved population. As a class, former inmates have
not traditionally been a central focus of the states treatment efforts. Some of the greatest
opportunities to innovate or produce better outcomes only revealed themselves after the
interagency data-sharing agreement was executed. For instance, this was the point at which it
became apparent that many inmates still had active Medicaid coverage, according to that
programs eligibility systems. This was the finding that yielded $1.4 million in recoveries that
will cover the costs of the new eligibility worker team for years to come. Thousands of inmates
files have been updated as well.

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Working to improve continuity and quality of care for the justice-involved population can be a
delicate undertaking in a relatively conservative political environment. The participation of
legislators and a member of the Governors Office staff helped others to see the projects multi-
faceted benefits, whether they were improved services, cost-savings (or cost shifting), or
anticipated reductions in recidivism.
The project has been quite popular within both agencies. Initial concerns that eligibility workers
would not want to be stationed at the Department of Corrections were quickly dismissed as some
of Medicaids most experienced workers volunteered for the assignment. Several participants
stated that they felt that this initiative presented a greater opportunity to have a meaningful
impact on an individuals life than that posed by other more routine tasks.
This initiative also brought together the two agencies pharmacy directors for the first time. That
collaboration has led to further discussions between the two agencies about testing a post-release
treatment program for former inmates with certain substance use disorders.
Other interagency encounters were unexpected. During a visit to a womens prison, the project
team came across staff from the Department of Employment and Workforce (DEW) in a
reception area. They explained that DEW has begun to meet with inmates prior to their release to
assess their skills, identify training opportunities, discuss employment prospects, and take other
steps to help ensure a successful transition back into the community. The DEW representatives
offered additional insights about how the intake process and visitation periods could be used to
further support these goals.

Engaging External Stakeholders

South Carolina used TeamWork technical assistance funding to engage the services of the Center
for Health Care Strategies (CHCS). CHCS took the lead in developing a webinar to introduce the
project to dozens of additional stakeholders. This outreach included representatives from the
Sheriffs Office in multiple counties, along with the Department of Health and Environmental
Control, Department of Juvenile Justice, Department of Mental Health, and the other state
agencies. That webinar was recorded so that it may be shared with other interested parties in the
future.
The team held four in-person meetings over the course of the year. The meetings provided an
opportunity for the team to understand the context of the problem and potential solutions for
Medicaid enrollment. For example, the November 2015 meeting was held at the Manning
Correctional Institution and included a tour of the facility and a discussion of opportunities to
develop the project at that site. Manning hosts a pre-release program through which many
inmates progress during their final six months of incarceration, providing an excellent
opportunity for them to be guided through the application process so that health coverage can
begin as close to the release date as possible.
In December 2015, the team met at Clemson Universitys Sandhills Research and Education
Center. By this stage, the leader of the new eligibility team (Nakia Griffin) had been selected,
along with her initial recruits. Griffin met with the leadership team at this gathering, as did a
senior representative from the Department of Probation, Pardon, and Parole Services. The larger

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project timeline was fleshed out in December, and the group prepared for the January 2016
TeamWork convening in San Diego.
The team also visited the Kirkland Reception and Evaluation Center, where incoming inmates
are initially processed, and the Graham Correctional Institution, which is the states major prison
for women. The team used this opportunity to observe the orientation process and identify
opportunities for eligibility staff to work with the newly incarcerated. Many of the teams
insights about the potential use of the intake and visitation processes in support of the initiatives
larger goals arose from this two-day event. The team met again in July 2016 to review work
processes, available space for eligibility workers, and pharmacy options.

The Benefits of TeamWork

TeamWork was a morale-booster for staff in the two agencies, and has led to new
partnerships and projects
The HiAP vision provided important insight into diagnosing complex public health
problems and planning the most effective response
Readings helped to reorient the teams thinking and also help the group better appreciate
how those in other settings have leveraged their collective impact strategies and applied
systems leadership in order to advance health-related initiatives that may be politically
delicate
Blocking off project time, both out-of-state and also in the teams home location of
Columbia, SC, was essential to moving the teams effort forward
Receiving technical assistance funding in a timely way was important, since CHCS
created essential training and education materials that the state could not have conducted
Experiences and lessons learned were captured in an article in Corrections Today (see
the Appendix)
TeamWork enabled the team to meet their goals and to discover and work on new,
related goals