Thanks to DV/SA testimony: Intimate partner violence recognized as a social determinant of health in Oregon

Domestic and sexual violence intervention services (DV/SA) included in Oregon Health Authority’s request to the federal government for inclusion in service reimbursement for Coordinated Care Organizations under Medicaid

Sarah Keefe, OCADSV Health Systems Coordinator

Domestic violence is a core social determinant of health.  Center for Medicare & Medicaid Service’s (CMS) “better care, smarter spending, and healthier people” approach to improving health care delivery recognizes that interpersonal violence (IPV) is one of the core health-related social needs. This is due to extensive literature demonstrating the health effects of IPV, including those studies in the realm of Adverse Childhood Experiences (ACEs).

Thanks to an incredible response from OCADSV’s membership, DV/SA programs across Oregon provided commentary and testified on Oregon Health Authority’s request to the Center for Medicare & Medicaid Services in May and June of 2016. This led to inclusion of DV/SA services under the request (called the 1115 Waiver) to fund DV/SA services as it pertains to homelessness prevention, submitted to CMS on August 14, 2016. Every five years Oregon must re-file its Medicaid Waiver, received since the early 1990s.  This Waiver provides guidance for CCOs on how they can spend their money.

The submitted application, including all appendices and public comment logs, can be found here​​​.  This waiver is the road map for our healthcare system reform works in Oregon. It has real impact for the majority of survivors we serve.Oregon’s CCO and Medicaid delivery system reaches over 1.1 million Oregonians or 25% of the population. 

Coordinated Care Organizations have made great strides, but they struggle to fund health services outside the clinical environment, despite a mandate to do so through Traditional Health Workers and a global budget that was designed so that clinicians could prescribe upstream solutions (the famous example was the air conditioner:

One of the goals of this waiver is to allow CCOs to better:

“Deepen our focus on addressing the social determinants of health and improving health equity across all low-income, vulnerable Oregonians to improve population health outcomes;”

Which they propose to do through:

“Address[ing] social determinants of health and health equity

  1. Through an enhanced rate setting methodology and new contracting strategies, promote CCO and provider use of health-related services, including flexible services and community benefit initiatives aimed at addressing the social determinants of health.
  2. In partnership with CCOs and regional entities, fund homelessness prevention, care coordination, and supportive housing for targeted populations.
  3. Ensure access to health care services, and improve health outcomes for American Indians and Alaska Natives.
  4. Expand the use of traditional health care workers within the delivery system.”

One of the core strategies to explore this work through Medicaid in Oregon is to invest in pilot programs addressing social determinants of health, including the newly created (through the Waiver process) Coordinated HealthPartnerships (CHPs). This is focused on improving housing services and health service needs of those who are homeless or at risk of homelessness.

“To promote population health and further address social determinants of health, Oregon proposes to create a five-year pilot program, referred to as the Coordinated Health Partnerships (CHP), for adults at risk of homelessness, including adults eligible for both Medicare and Medicaid programs (often referred to as dual eligibles), and families. Through the CHPs, at-risk populations would be offered a combination of housing, health care integration, care transitions and supportive services to improve health outcomes and reduce Medicaid costs.” (p.27, Waiver)

Thanks to comment and testimony by DV/SA advocates and champions, this includes DV/SA specific programs.

“The CHP program consists of three foundational elements, referred to as domains. Taken as a whole, the domains create a continuum of services available within a community to the defined target population. Each CHP pilot will be expected to provide services in all three domains (see CHP framework on pages 39-40).

  • Homelessness Prevention/Transitions of Care: support to ensure care coordination among non-medical settings; fund services to support an individual’s ability to move from institutional settings to less costly community-based care settings.
  • Housing Transition Services: invest in pre-tenancy services to decrease health care cost and reduce use of high-cost health care services.
  • Tenancy Sustaining Services: invest in services that support the individual in being a successful tenant in his/her housing arrangement.

In an effort to address the social determinations of health, the CHPs will have the flexibility to address interpersonal violence and trauma informed care under the homelessness prevention/ transitions of care domain. This is in recognition that there is a likelihood of trauma among individuals experiencing homelessness, as well as a causal relationship between domestic violence and rates of homelessness for women and families.” (p. 29, Waiver)

The timeline for CHPs begins in 2017 and runs through 2022. Stay in touch with OCADSV and your local CCO to stay engaged on these pilots and see if it is right for your program. If you have questions on how to move forward please contact Sarah Keefe, Health Systems Coordinator at or 503.230.1951.

Thank you to all of our DV/SA programs who submitted commentary.  Your voice made a difference and provides CCOs with the ability to better serve survivors of domestic and sexual violence in partnership with you.

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