Care Management for Medicaid Enrollees Through Community Health Teams

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Executive Summary

The use of shared resources can help primary care practices—especially small and medium-sized ones—thrive under new payment models that demand value and accountability. Community health teams, or networks, are one type of shared resource. These locally based care coordination teams are deployed to manage patients’ complex illnesses across providers, settings, and systems of care. Comprising multidisciplinary staff from the fields of nursing, behavioral health, pharmacy, and social work, the teams provide crucial support to health care providers working in resource-limited small or medium-sized practices.

Unlike some traditional disease management strategies that focus on specific chronic diseases and rely on remote, telephonic management of patient care with limited success in controlling costs, community health teams emphasize in-person contact with patients and integration with primary care providers and community resources.

This report focuses on eight states—Alabama, Maine, Minnesota, Montana, New York, North Carolina, Oklahoma, and Vermont—that provide funding in support of multidisciplinary community health teams that are shared among multiple practices. Together these programs serve more than 2.1 million patients.

Program features. Each of these state-supported programs features a stakeholder engagement strategy, explicit expectations for community health teams, a defined payment and financing model, and an evaluation strategy. Core characteristics of the eight programs studied include:

  • multidisciplinary care teams that coordinate services, promote self-management, and help manage medications; 
  • sustained, continuous relationships between patients and team staff that are established and cultivated through regular face-to-face contact; 
  • mechanisms to routinely send and receive information about patients between practices and care teams;
  • whole-person care of patients identified as high-risk, high-need, or high-cost;
  • a focus on transitions in care, especially between hospital and home; 
  • team members who routinely connect patients with relevant community-based resources; and
  • enhanced reimbursement for primary care practices that collaborate with teams.

A hallmark of the community health team is the early and ongoing engagement of primary care providers throughout program development and implementation. Montana worked closely with the state primary care association to identify and select federally qualified health centers as locations for its teams. In other states, teams or networks are based in a variety of locations, including hospitals, home health agencies, practices, and nonprofit organizations, depending on local community needs.

Expectations for community health teams, which vary greatly across the eight states, are spelled out in contract language or requests for proposals. These expectations encompass:

  • team functions and composition 
  • target population identification 
  • patient care 
  • linkages with hospitals 
  • electronic data tracking 
  • practice education, including helping primary care practices meet medical home standards and quality improvement standards.

Financing. Payers in the eight states have strived to build models that adequately fund the teams, ensure their accountability, minimize administrative burden, and are financially sustainable. Four of the programs have only a single payer—Medicaid—while four others have the support of multiple payers, such as commercial insurers, Medicare, and Medicaid managed care plans. Although adding payers adds administrative complexity, there are advantages to multipayer participation, including greater continuity of team services when patients’ coverage status changes, and the ability to spread the fixed costs of establishing and operating teams.

Effectiveness. All eight states are, to varying degrees, monitoring the effectiveness of their programs using quality, cost, and patient experience data. To date, data on the effectiveness of community health teams are very limited; with the exception of Community Care of North Carolina, state programs have been in operation for less than four years and generally are in the early stages of implementation.

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Publication Date:
May 21, 2013
Authors:
Mary Takach, Jason Buxbaum

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