Diffusion Of Community Health Workers Within Medicaid Managed Care: A Strategy To Address Social Determinants Of Health

Authors: Nkouaga C, Kaufman A, Alfero C, and Medina C
Year: 2017
State: NatDoc: National Document
Website link: https://www.healthaffairs.org/do/10.1377/hblog20170725.061194/full/
Publicly Available: Yes
Billing and Reimbursement:
Certification: CHW role scope of practice, Competencies
Evidence Generation:
Policy: Building partnerships, General language around CHW WD, Identifying policy expertise within state
Sustainable Financing: Engaging state partners in general, Expand evidence base, How to engage and work with Medicaid, Including community-based CHWs, MCO or bundled payment reimbursement models, Documentation of how CHWs can work within care teams, Evidence-based interventions, ROI and bundled payment successes/challenges
Workforce Development: CDC expand CHW work into SDOH, Chronic Disease, Data sharing between social services and clinical teams, General other (including mention of “employment practices”)

The integration of CHWs into the health care system in New Mexico began almost a decade ago when a relationship between the University of New Mexico Health Sciences Center (UNMHSC) and the New Mexico Medicaid system was born. As a capitated managed care system, the Medicaid program contracted with insurance companies, which saved money by keeping Medicaid patients healthy and out of hospitals and emergency rooms. However, many of their newly insured Medicaid members, who were automatically assigned to insurance companies and unfamiliar with health insurance, continued to use the emergency room as a primary care provider (PCP) and ran up costs for preventable emergency department visits and hospitalizations. One Managed Care Organization (MCO) wanted to offer case management to these high-user enrollees but could not find many of them. The MCO approached UNMHSC for help.

The university hired a group of CHWs who quickly found most members because of their intimate knowledge of the community and the trust communities had in them. Surprisingly, the CHWs discovered most members they found didn’t need to meet with the MCO’s case managers. The CHWs in the field could handle members’ needs, which included understanding their benefits, learning the value of having their own PCP, and help with transportation to their assigned clinics. The clinics provided access to food pantries and help with health literacy.

The prevalence of adverse SDH was gauged among patients attending primary clinics at the University of New Mexico and First Choice Community Healthcare, a Federally Qualified Health Center in Albuquerque, NM. Local CHWs helped design a questionnaire asking about the 11 most common social determinants of health. Of the more than 3,000 consecutive patients surveyed, approximately half had at least one adverse social determinant and half of those had more than one. These problems were virtually unknown to the clinic, for they are typically not addressed in a routine clinical encounter.

Word spread to the other MCOs about the value of clinic-integrated CHWs working on social determinants. All reached out to the University of New Mexico for assistance. Bringing CHWs into clinical settings was a challenge, for they have neither diplomas nor certificates and had no formal training with other health professional students. But their presence sold itself to the health care team, which came to rely on the CHWs’ contributions. What’s more, the CHWs taught other health team members about social determinants. As the use of CHWs diffused horizontally across the other four MCOs serving New Mexico’s Medicaid program (known as Centennial Care), interest in the role of CHWs on the health care team moved vertically up to the leadership of the New Mexico Human Services Department’s Medicaid Assistance Division. Medicaid was interested in expanding the model and disseminating its findings across the state to other health care systems.

The NM State Medicaid Division invested directly in the development of the model, and in technical assistance to those organizations implementing the integration of CHWs into their clinical settings. Building upon lessons learned from CHW interventions with high-risk patients, the Integrated Primary Care and Community Support (I-PaCS) initiative was born. The initiative continued to provide very intensive intervention for those with the highest health needs and highest costs. At the same time, it provided comprehensive individual and family support for all patients in poor health (not just those with adverse social determinants) and adopted a population health strategy for the entire population in which CHWs intervened at each level of care, aiming to prevent health status from worsening.

Download Document