Empowering Health Beyond the Clinic: Evaluating and Advancing HRSN Solutions with Mother Goose Health

As state Medicaid programs expand efforts to address Health-Related Social Needs (HRSN), the need for scalable, measurable, and equitable solutions is more urgent than ever. The June 2025 CHCS toolkit, Considerations for Evaluating State Medicaid Initiatives Addressing Health-Related Social Needs, offers vital guidance for evaluating HRSN programs across Medicaid delivery systems.

At Mother Goose Health, we empower Medicaid state agencies, managed care organizations (MCOs), providers, and members with a digital maternity care platform that supports scalable, real-time HRSN evaluation, care coordination, and measurable impact.

Aligning with Federal Medicaid Levers to Support HRSN Strategies

The CHCS toolkit outlines four key Medicaid policy mechanisms to fund and implement HRSN initiatives:

• In Lieu of Services (ILOS)
  
  
• Section 1115 Waiver Demonstrations
  
  
• CHIP Health Services Initiatives (HSIs)
  
  
• Home- and Community-Based Services (HCBS) Waivers
  
  

Mother Goose Health’s technology and care model supports these policy levers by:

• Delivering digital-first, community-linked services as ILOS substitutes
  
  
• Assisting in evaluation planning and outcomes tracking for Section 1115 demonstration pilots
  
  
• Supporting maternal and child health outcomes for CHIP HSI beneficiaries
  
  
• Enabling home- and community-based care navigation via real-time referral tools and social support assessments

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Real-Time HRSN Monitoring and Implementation Evaluation

Effective HRSN implementation requires robust program monitoring and evaluation, including:

• Organizational readiness
  
  
• Network adequacy
  
  
• Member access to services
  
  
• Barriers and equity gaps
  
  
• Stakeholder feedback loops
  
  

Mother Goose Health enables this by:

• Collecting and analyzing referral, utilization, and satisfaction data
  
  
• Providing demographic and geographic segmentation
  
  
• Supporting equity analysis and barrier identification for rural and underserved communities
  
  
• Enabling real-time dashboards for Medicaid agencies and health plans to track outcomes and costs
  
  

Our platform integrates both quantitative and qualitative data in line with CMS and CHCS guidance, ensuring states meet federal evaluation requirements while uncovering actionable insights.

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Measuring HRSN Program Impact: Outcomes and Cost Reduction

The CHCS toolkit highlights impact metrics such as:

• Reduced food insecurity and housing instability
  
  
• Improved preventive care utilization and chronic disease management
  
  
• Decreased emergency department (ED) visits and hospitalizations
  
  
• Enhanced emotional well-being
  
  
• Lowered Medicaid costs
  
  

Mother Goose Health supports these goals with tools that:

• Capture social determinants of health (SDoH) data from clinical, community, and digital touchpoints
  
  
• Track self-reported health outcomes and claims-based utilization patterns
  
  
• Measure cost savings and return on investment from HRSN interventions
  
  
• Segment results by race, ethnicity, geography, gender, and age to ensure health equity

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State-Level Scalability: Supporting Medicaid Innovation Across the U.S.

As noted in the CHCS toolkit, states like California, Massachusetts, North Carolina, and Oregon have developed diverse HRSN evaluation models. Mother Goose Health complements these efforts by providing a scalable digital infrastructure that supports:

• Culturally responsive engagement tools tailored to Medicaid populations
  
  
• Cross-sector collaboration between MCOs, providers, and community-based organizations
  
  
• Automated data collection and reporting aligned with CMS guidelines
  
  
• Custom analytics dashboards for performance measurement and continuous quality improvement
  
  

Our technology ensures Medicaid stakeholders don’t have to choose between innovation and compliance—we help deliver both.

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Driving Equity and Efficiency in Medicaid HRSN Programs

Evaluation is more than a requirement, it’s a tool for driving data-informed improvements in Medicaid service delivery. By aligning our platform with the 2025 CHCS toolkit, Mother Goose Health helps Medicaid agencies and partners:

• Enhance member outcomes
  
  
• Streamline cross-continuum care coordination
  
  
• Reduce avoidable healthcare costs
  
  
• Promote health equity at scale

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Ready to Strengthen Your Medicaid HRSN Strategy?

Let Mother Goose Health be your partner in building effective, equitable, and scalable HRSN solutions.

Contact Us Today to learn how we support Medicaid programs in designing, implementing, and evaluating impactful HRSN initiatives.

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