Building a Medicaid Ambulatory Complex Care Program Within an Urban Medical Home

Sander L, Albert M, Okeke N, Kravet S, Rediger K, Conway S, McGuire M
Source: Popul. Health Manag.
Publication Year: 2018
Patient Need Addressed: Care Coordination/Management
Population Focus: Complex care, Medicaid beneficiaries
Demographic Group: Urban
Intervention Type: Service redesign
Study Design: Pre-post without Comparison Group
Type of Literature: White

Five % of Medicaid patients account for 50% of total costs. Preventable costs are often incurred by patients with complex medical, behavioral, and social needs who disproportionately utilize acute care services. Evidence for design, implementation, and evaluation of complex care programs in the urban Medicaid population is lacking. The article provides a description of a complex care program (CCP), challenges, and early outcomes based on a pre–post evaluation. The CCP was located within an existing urban medical home. Patients were eligible if they lived within 10 miles of the clinic and had at least 2 inpatient visits and/or 3 emergency room visits within the prior 6 months. Ambulatory Care Groups® were used to predict estimated total costs of patients, who were included if potential cost savings exceeded $5000. Patient experience and quality of care were assessed using validated measures and costs. Return on investment was calculated based on investment and cost savings. Costs include visits (clinic, specialty, and emergency room), hospital admissions, medications, tests and services, as well as salary and benefits of clinical staff. Eighty-six of 211 eligible patients (41%) were enrolled during the first 18 months of the pilot program. There were positive trends in quality metrics and patient satisfaction. The pre–post evaluation demonstrated a reduction in emergency room visits and hospitalizations (67% and 65%, respectively), which resulted in a 2.2:1 return on investment. This article offers lessons learned to colleagues considering population health approaches in the care of high-risk Medicaid patients.

Insights Results

Overview of article/program

  • The article provides a description of a complex care program (CCP), challenges, and early outcomes based on a pre–post evaluation
  • The study team developed a comprehensive CCP for Medicaid patients and launched this as a pilot in Baltimore, MD. The pilot was jointly sponsored by a large, regional medical group practice and a payer group that administered a Medicaid Managed Care Organization (MCO). Both were part of a large integrated academic health system. The health system used an electronic health record (EHR) with centralized data management and decision support, and the state offered a regional health information exchange system to link non–system hospitals and providers
  • The complex care program was developed as a separate service center within an existing urban medical host targeting more complex patients. The new CCP was designed to increase access, care coordination, continuity, and comprehensiveness of care. Key elements of the program are payer-provider partnership, clinical staff (i.e., a community health worker, licensed clinical professional counselor, certified medical assistant, certified registered nurse practitioner, and medicinal doctor), primary care delivery, behavioral health services, social services, and care management
  • Program metrics were developed to monitor program implementation in 3 areas: 1) Patient characteristics, experience, and activation; 2) Quality of care; and 3) Utilization. A dashboard of key metrics was developed and monitored during the pilot to assist ongoing program improvement and process monitoring


    • Preliminary results of the pilot are positive, showing reductions in emergency room visits, cost savings, increased patient activation, and more
    • The Patient Activation Measure (PAM) survey was completed at least once by 72 patients, with an average activation level of 3 and a mean score of 60.8. The medication adherence survey was completed by 67 patients and the results showed that 66% reported low adherence, 25% medium adherence, and the remainder high adherence. Trust in the relationship with the team influences these results, as well as information bias, as patients who regularly attend appointments and complete the survey are more engaged
    • The unique provider–payer partnership provided real-time sharing of clinical and claims data, and was particularly useful for patient selection and utilization management. However, with several major stakeholders involved, the pilot was subject to a complex management structure and frequent staffing changes
    • Quality measures showed trends toward improvement in completion of clinical preventive services, with a statistically significant increase in cervical cancer screening completion. Of note, some measures, such as blood pressure control, were met at higher rates than in the surrounding area
    • Overall, the CCP resulted in a 65% reduction in hospitalizations and a 67% reduction in emergency room visits

    Key takeaways/implications

    • Future iterations of the program may include risk sharing between the payer and provider, allowing for better performance incentive and distribution of cost savings
    • Integrated behavioral health and social services were critical in the study high-risk Medicaid population because 97% had at least 1 mental health disorder and all had at least 1 social need
    • Quality measures showed trends toward improvement in completion of clinical preventive services
    • Limitations to the study include natural tendency for costs to decline over time regardless of interventions, limited generalizability, unknown success of patient transition between routine primary care and the program