Using Data and Social Determinants to Treat Medicaid Populations

Speakers at last month’s AHA Annual Membership Meeting shared federal and state innovations in health care delivery, and the social supports that best address the mental, physical and social needs for Medicaid populations.

Moderated by AHA board member John Haupert, president and CEO of Grady Health System in Atlanta, panelists included Calder Lynch, senior counselor to the administrator for the Centers for Medicare & Medicaid Services; Matt Salo, executive director of the National Association of Medicaid Directors; Robert Duncan, executive vice president of Children's Hospital & Health System (CHHS) in Milwaukee; and Rhonda Medows, M.D., executive vice president of population health at Providence St. Joseph Health in Renton, WA.

Medows highlighted Providence’s population health-focused Medicaid strategy, which uses clinical data, social history and community risk factors to anticipate patient needs.

She emphasized the importance of maintaining relationships with patients long after they are discharged. “Simply because [the patient is] not in a hospital does not mean that we’re done,” Medows said, emphasizing that without hospital staff checking in, patients will eventually return.

To keep that relationship going, Providence has armed discharge staff with a range of data to anticipate the particulars of what Medows called “a more complex population that has some very distinct and very necessary social needs.” This includes giving care coordinators a curated patient profile that incorporates hospital admission data, social determinant data and health practitioners’ data.

“Instead of trying to have a whole host of slides and whole bunch of information come to each individual practice with the permission of a clinician, we basically put it all together in a community health pathways platform that provides our clinicians, as well as our care managers, a patient snapshot,” Medows said.

When Providence leaders learned that their care managers were overloaded, they developed a care management service that supports individual regions and allows care coordinators to focus on Medicaid patients. “In addition to the practice-based care coordinators, we have care managers,” Medows said.

Providence also realized the value in strengthening its community relationships. It partnered with federally-qualified health centers, rural and opioid clinics, food banks, transportation companies and even hotels to meet the needs of vulnerable populations and increase their access to care.

Some of this is familiar territory for Duncan. CHHS has pursued similar innovations, such as investing in an array of community resources. The health system created a medical home for children who were otherwise destined for state-run daycare; owns the largest foster care and adoption agency in the state of Wisconsin; and also employs what it calls “health navigators,” which work to help patients and their families get access to housing, food and employment.

This gives CHHS a complete patient data set, enabling it to “wrap” its services around patients and their families, Duncan said. CHHS also placed nurses in schools, ensuring that clinicians have access to the organization’s electronic medical record “from a hospital setting to a primary care setting to the school nurse setting,” Duncan said. “Now there’s a much broader picture of what it takes to be there for those kids,” he explained.

As a result, patients’ initial comprehensive health exam completion rates catapulted from 56 percent to more than 93 percent in the past three years. Development and mental health assessment completion rates climbed from 28 percent to 85 percent, exceeding state and national benchmarks.

This has helped CHHS to reduce its Medicaid spend by 29 percent in the last three years, saving the state more than $19 million from improved outcomes, Duncan said.