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

Area of Science:

• Health Services Research
• Population Health Management
• Healthcare Economics

Background:

• High-risk Medicaid patients incur significant healthcare costs, often due to complex needs.
• Preventable acute care utilization by these patients represents a substantial financial burden.
• Limited evidence exists on effective complex care programs for urban Medicaid populations.

Purpose of the Study:

• To describe a complex care program (CCP) implemented within an urban medical home.
• To evaluate the early outcomes, challenges, and return on investment of the CCP.
• To provide lessons learned for implementing population health strategies for high-risk Medicaid patients.

Main Methods:

• A pre-post evaluation design was used for a CCP targeting Medicaid patients with high acute care utilization.
• Eligibility criteria included proximity to the clinic and recent inpatient/emergency room visits.
• Ambulatory Care Groups® were used for cost prediction, with inclusion based on potential cost savings.

Main Results:

• Eighty-six of 211 eligible patients (41%) enrolled in the pilot program over 18 months.
• The CCP demonstrated positive trends in quality metrics and patient satisfaction.
• A significant reduction in emergency room visits (67%) and hospitalizations (65%) was observed, yielding a 2.2:1 return on investment.

Conclusions:

• Complex care programs can effectively reduce acute care utilization in high-risk Medicaid populations.
• Integrated care models within medical homes show promise for improving patient outcomes and generating cost savings.
• The findings offer valuable insights for healthcare providers considering population health initiatives for vulnerable patient groups.