Care Transformation Center Blog

Don't reinvent the wheel: How to retrofit your Medicare care management platform for Medicaid risk success

by Yulan Egan and Christine Lee

Although many providers find the prospect of taking on Medicaid risk overwhelming, success under a Medicaid risk contract need not be daunting. In fact, systems that have invested in care management for other populations—particularly Medicare beneficiaries—already possess the necessary foundations for Medicaid care management. With three key adjustments, you can enhance and expand your existing care management platform for success under Medicaid risk. And while the below adjustments are must-haves for success under Medicaid risk, these investments can also be scaled across the Medicare and commercial populations to enhance broader care management efforts.

1. Staff up for nonclinical support

The Medicare care management platform often hinges on a nurse-led team dedicated to helping patients navigate multiple providers, medications, and clinical conditions. Although this type of management is also critical for many Medicaid beneficiaries, a more comprehensive and cost-effective model also includes social workers and community health workers who engage with patients on psychosocial barriers to wellness. Many health systems already have social workers placed throughout the system; for example, as ED case managers. However, an increasing number of providers are recognizing the value of adding community health workers (CHWs) to the team as well. While CHWs typically do not have a formal educational background in health care or social services, they do have deeply rooted connections across the community and first-hand experience with the types of challenges their patients face. This skill set is especially helpful in building trust with patients and helping them navigate community resources. Learn more about the ROI of community health workers.

2. Stratify considering pressing social needs

Early risk stratification methodologies (frequently developed with the Medicare population in mind) centered heavily on clinical risk factors—as assessed by both care team evaluation and past service utilization patterns. Modifying the risk stratification platform to include psychosocial factors such as level of social support, health literacy, and food security enables providers to better identify the patients who would most benefit from nonclinical care management support—and therefore deploy more tailored and impactful interventions. There are several ways to obtain this data, the simplest of which involves deploying a short survey completed by patients during their primary care visit. Learn more about how organizations incorporate nonclinical data into their care management strategies.

3. Strengthen ties to community resources

Perhaps the most transformative impact of care management in the Medicaid population happens through the convening of resources, both clinical and social, to support patients in managing their own health. While some health systems build out new services such as food assistance when there is critical community need, the more sustainable solution for most providers is to solidify connections between existing services and resources. A reliable community presence can also improve patient recruitment, increase care plan adherence, and solidify trust between the patient and provider. See where you currently fall along the spectrum of community reach.

Learn the other imperatives to succeed under Medicaid risk.

Read our new research report, "Preserving the Community Safety Net," for more information on the three guiding principles outlined above and case studies from best-in-class organizations that have made these investments themselves.



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