5 Strategies to Effectively Manage Medicaid Populations

As of May 2022, nearly 89,000,000 people were enrolled in Medicaid and the Children’s Health Insurance Program (CHIP), according to government data. To effectively manage care for these populations, payers and providers must do the following:

  1. Streamline delivery of preventive, holistic care
  2. Broaden access to resources for enrollees
  3. Boost patient/member engagement
  4. Improve coordination of care

Knowing where to start executing or improving upon these initiatives can be the hardest part. Fortunately, data points to five critical areas to address for Medicaid populations.

  • Pediatric health
  • Access to food
  • Behavioral health
  • Telehealth access
  • Hospital readmissions

In this blog, we look at important insights around these five areas and provide strategies to help payers and providers deliver on the imperatives above.

Pediatric Health

As of May 2022, children represented 45.7 percent of total Medicaid and CHIP enrollment, according to a recent report from Medicaid. Effectively addressing pediatric care means addressing both the needs of the children and their caregivers.

Strategies for Payers and Providers

  • Help families meet immediate needs. Kids depend on their guardians for healthcare. But financial strain, lack of transportation, food insecurity, or other non-clinical factors can prevent families from being able to fully support their children’s health. For example, a single parent with lower income may have to choose between taking unpaid time off for a child’s well-check appointment or working enough hours to pay rent. Does the parent make the doctor’s appointment or keep a roof over the child’s head? The care team needs to be empowered to identify and address both population-level social determinants of health (SDoH) and individual health-related social needs to ensure families are able to focus on their children’s health.
  • Identify kids at risk of developing chronic disease. Certain pediatric populations may be at greater risk for childhood onset of conditions like asthma or diabetes. Care teams need to proactively screen at-risk kids and educate families on prevention initiatives, how to identify risk factors, and when to seek care or treatment. Data-driven insights that identify trends across populations help care managers prioritize members most in need of proactive intervention.

How HELIOS Gets It Done

  • Data connectivity for complete views for all care members. HELIOS captures, ingests, and organizes data gathered from a variety of different sources including medical and pharmacy claims and Admission Discharge Transfer (ADT) events, as well as assessment and screening findings with input from organizations such as early care and education, schools, housing, transportation, food, public health services, child welfare, mobile crisis response, community health services, juvenile justice, legal aid, and more, so that care teams have a holistic view of children’s health.
  • Standardizedscreenings and assessments or create your own help care managers and providers identify families with immediate needs that impact health. The platform offers built-in, out-of-the-box, industry-standard screening tools and assessments. These can be leveraged as-is or configured to meet business needs and requirements. Then, HELIOS layers on automated workflows to quickly surface recommendations and auto-assign tasks for care managers.
  • SDOH and population health insights and alerts. HELIOS collects and aggregates data so that the care team can easily identify where populations with certain conditions or SDOH might live, such as a specific geographic area with a high prevalence of children with a diagnosis of asthma or food insecurity. It can then trigger outreach tasks for care managers to further assess children in those areas to provide education and care coordination. It can also notify care managers about gaps in care, such as when a child is behind on well-care appointments, signaling that intervention may be needed.

Access to Food

Did you know that 23 percent of Medicaid enrollees reported food insecurity in 2020?  Proper nutrition can significantly impact a person’s physical and psychological health, as well as their ability to perform daily functions and tasks. Inadequate access to food is also an added concern for families on Medicaid who may have to choose between food and medication or other health items.

Strategies for Payers and Providers  

  • Recognize members at risk for food insecurity. When access to nourishing food is limited, it’s much harder to maintain good health. First, care managers need to be able to identify individuals facing food insecurity. For example, does the member live in a zip code that lacks well-stocked supermarkets? Has the member identified that nutrition is an issue or concern either during an assessment or virtual visit?
  • Help members meet nutrition needs. Second, healthcare organizations need to be connected to community resources like food pantries, grocery delivery services, and nutrition assistance programs to help their members satisfy those needs.

How HELIOS Gets It Done

  • Virtual check-ins with care managers. HELIOS provides an extra layer of support and visibility into a member’s home life through virtual visits within the platform. Care managers can have more frequent face-to-face encounters with members without ever leaving their home or office. This leaves more time for assessment, education and care coordination efforts versus it being spent driving around.
  • Building trust through accurate data. Data-driven insights into a member’s entire picture of health better positions care managers to build trusting relationships that encourage members to open up and help care managers recognize when proactive outreach and intervention is needed. As a result, that member will hopefully feel comfortable talking about food insecurity and other issues that can be barriers to health.
  • Community partners. HELIOS integrates with best in class partners to help care managers locate community resources, services, and supports, like food banks and transportation services, providing a way to easily connect members to these services within a few clicks. Its closed-loop ecosystem also means that the care manager is notified when the service has been delivered.

Behavioral Health

39% of Medicaid enrolled have a substance abuse disorder and/or mental illness. This is 8 percent higher than privately covered and uninsured people. Moreover, Medicaid enrollees have the highest overall prevalence of moderate to severe mental illness or substance abuse disorders. (See below for a more complete graphic from Kaiser Family Foundation’s recent study.)

29% of Medicaid enrollees have a substance use disorder or mental illness, a 2020 KFF analysis found.

Strategies for Payers and Providers

  • Pivot to whole-person care. Many healthcare organizations still focus exclusively on physical health. However, a holistic approach that takes behavioral and social factors into consideration results in higher engagement, more effective treatment decisions, and better outcomes. Whole-person care is what patients want and what enables better outcomes.
  • Gain better visibility into behavioral health resources. Care managers need a strong understanding of services and resources available in the community (e.g., counseling centers, 24-hour therapy services, day treatment services, psychiatric services, and addiction programs) that can meet behavioral health needs and help members with mental health and/or substance use disorders.
  • Bridge communication gaps. Providers, behavioral health staff, and care managers need the ability to communicate seamlessly about changes or events that signal mental health care could be needed. Leverage automated assessments to flag mental and/or behavioral health risks, as well as virtual visit tools.

How HELIOS Gets It Done 

  • Behavioral health care assessments, care pathways and workflows. Built-in assessments and care pathways designed for behavioral health guide decisions. End-to-end workflows capture historical and current member information, helping care managers more easily identify members in need of behavioral healthcare services and support.
  • AI-based behavioral care planning. The platform tailors care goals and interventions to individual behavioral health needs, which care managers can use their clinical judgment to adjust and personalize to each member.
  • Seamless connection to behavioral health resources. With partner integration capabilities, HELIOS makes it easy for care managers to find and link members to vital services and resources that support behavioral health.

Telehealth Access

“The highest rates of telehealth visits were among those with Medicaid (29.3%) and Medicare (27.4%), Black individuals (26.8%), and those earning less than $25,000 (26.7%).” – 2022 Office of Health Policy report

When working with Medicaid populations, a lower income level is a common occurrence. Additionally, if a member or family is limited by where they live or without transportation, accessing quality health care and health information can be a challenge. This is especially true for individuals with complex chronic conditions.

Telehealth may have gained traction thanks to COVID-19, but it’s continued to grow in popularity as payers and providers leverage it to expand care access and provide more personalized delivery and communication options.

Strategies for Payers and Providers

  • Offer telehealth as an option. Virtual appointments make healthcare more accessible, especially for members with the above limitations that make in-person visits challenging. Dovetailing with the point above, telehealth is also particularly well-suited to meeting behavioral healthcare needs.
  • Understand and account for potential challenges. Internet connectivity, data security, HIPAA privacy, staff training, and demands on infrastructure and interoperability are some common challenges associated with implementing telehealth for Medicaid populations. The Department of Health and Human Services study is a good resource to use for developing effective programs and troubleshooting implementation challenges.

How HELIOS Gets It Done

  • Integrated, simple video experience. HELIOSvisit lets staff initiate a telemedicine appointment from the member’s profile in one click. Members join their visit by clicking a link through email or text, without downloading additional apps or software.
  • Faster delivery of personalized health education and resources. HELIOSvisit also lets care managers exchange files with members. This can help expedite educating patients, providing follow-up materials, completing screenings, or other care-focused actions.
  • Secure and HIPAA-compliant. Video conferencing, chat, and file exchange capabilities are all secure, meeting the HITRUST gold standard for information security.

Hospital Readmissions 

Medicaid enrollees with certain conditions saw a significantly higher rate of readmission within 30 days of discharge as compared to privately insured members, according to a 2019 study in Health Affairs.

Another study found that 40-80 percent of medical information provided by healthcare practitioners is immediately forgotten by patients when they leave.

Strategies for Payers and Providers

  • Improve communication between care teams and care settings. Hand-off and post-discharge instructions too often get lost across disparate systems and data silos during transitions of care. Enabling a seamless transition of information between all care providers and care settings will ensure the patient receives the right care at the right time.
  • Follow up calls or messages. A single phone call within 30 days of discharge can significantly reduce the chance of re-admission, one study found. It can also help members to better adhere to their prescribed care plans. Check in after discharge to ensure timely follow-up with providers, medication adherence, that members understand post-discharge instructions, and to ask about any problems or changes that could indicate a risk for decline or re-admission.

How HELIOS Gets It Done

  • Centralized data for coordination across diverse care settings. HELIOS connects care teams across settings on a single platform, offering a single centralized ecosystem to power care team collaboration as individuals transition between acute care settings, long-term facilities, provider-to-provider, and the community. Event-driven triggers coupled with real-time admission, discharge and transfer (ADT) feeds, ensure that care teams are promptly notified and tasked with the next best action. That means one member, one source of truth, with every interaction and update instantly visible to everyone involved.
  • Automated alerts. Did a member miss a crucial follow-up? Is a patient about to run out of blood pressure or asthma medication soon? HELIOS can track these events and alert the right team members. This allows care managers to proactively act or react quickly to address issues before they become exacerbated.
  • Omni-channel communication. With built-in text and messaging capabilities, care managers can easily reach members and augment telephonic and in-person encounters via their preferred channel to check in during the 30-day post-discharge period. This enables care managers to complete meaningful, two-way interactions with more members, more efficiently and effectively.

See more of HELIOS in action. Book a demo today for healthier Medicaid populations tomorrow.

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