Community health worker-led program associated with reduced acute care utilization and lower Medicaid and total costs for dually eligible individuals.
Individuals who are dually eligible for Medicare and Medicaid are more likely to be medically complex and incur high health care costs. This population often experiences fragmented care due to the lack of coordination between their Medicare and Medicaid benefits. Rhode Island developed a community health worker-led care management program for dually eligible individuals who were at high risk of hospitalization or institutionalization. This study evaluated the program impact on acute care and skilled nursing facility (SNF) utilization as well as Medicare and Medicaid costs.
Program Implementation Highlights
Structure: Teams, community-based community health worker (with access to social workers, housing specialist, and nurse case managers for consult) supporting a caseload of 50-60 individuals.
Population identification: Individuals who are dually eligible are identified for outreach by social workers and nurse care managers using Rhode Island’s Health Information Exchange with medical and social criteria.
Training: All specialties (community health workers, social workers, nurse care managers, housing specialists) participate and contribute to ongoing professional development geared toward effective care coordination and cultural humility while serving older adults.
Infrastructure: Health Risk Assessments and Functional Needs Assessments are completed to identified health-related social needs and individualized care plans are developed to address goals; tools include Rhode Island Quality Institute Current Care and Care Management Dashboards and Alerts.
Funding: The program is funding through Rhode Island Medicaid.
Participation in this care management program was associated with significantly fewer hospital
admissions and reduced Medicaid and total costs, but was not associated with changes in emergency department visits or Medicare costs. While participation was associated with lower SNF utilization, this result was not statistically significant. On average, community health workers conducted five in-person visits and 35 phone calls with program participants, and length of program participation varied. The most common activities that community health workers provided included support with home care services, durable medical equipment, housing, and administrative challenges, and assistance with the Medicaid Management Information System.
Community-based care management programs have the potential to reduce acute care utilization for dually eligible individuals with complex medical needs, and thus reduce costs. Community health workers with lived experience of navigating health care and social systems can play a key role in delivering these types of programs with dually eligible individuals.