Innovations in Medicaid: Impacts of a Home-Based Intensive Care Model for Complex Medicaid Beneficiaries

Matthew Niedzwiecki
Jia Pu
Maggie Samra
February 2021


A home-based intensive care model for Medicaid and dually eligible enrollees with complex needs led to positive health outcomes and reduced acute care spending, particularly for individuals with a behavioral health diagnosis.


Landmark Health partnered with two California Medicaid managed care health plans to deliver coordinated home-based services to high-risk members with five or more chronic conditions, many of whom were dually enrolled in Medicare and Medicaid. The model included intensive home-based medical management with in-home medical services, crisis management, and care coordination across health and social services. This study evaluated the model to identify lessons for adapting home-based intensive care models for high-risk patients.


Members engaged in this intervention changed their patterns of health care utilization. The intervention decreased emergency department visits and hospital stays associated with a behavioral health diagnosis, increased primary care visits, and increased primary care follow-up after discharge. It also increased medication use and medication adherence. These outcomes suggest that home-based intensive care models can improve access to care among high-risk individuals, especially for those with a behavioral health diagnosis.


Home-based intensive care models for high-risk patients that include a behavioral health component can reduce acute care spending. 

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