Transformation Grant Program: Making Strides to Outreach Medicaid Members

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In October of last year, Care Compass Network announced a total of 7 community-based organizations that were awarded funds from the Community-based Navigation Transformation Grant program. The purpose of this program is to support community organizations in their efforts to outreach and engage Low to Non-Utilizers within the Medicaid population that is located with CCN’s nine-county region.

To date, 100 unique Medicaid Low and Non-Utilizers have been successfully outreach and navigated by the community organizations, which is a great start to the program. Throughout this process, the CBOs have shared, as a group, several barriers, success, and key trends that they’ve encountered during their outreach.

Common barriers that were found:

  • Some individuals that needed a PCP, where told to go to the ED for their care due to PCP not having availability
  • When an individual is discharged from the ED, they may be set up with a PCP who is not within a manageable distance. Therefore, transportation and time become a barrier to the individual
  • Difficult to engage the individual over the phone for initial outreach
  • Building a significant rapport with the individual and have consent with them to use the CBO as a point of contact for future needs

Common successes that were found:

  • Willingness of partners and health systems to allow integration into their workflows
  • Meet the individual where they are at (i.e. food pantry, DSS, workforce agency, mental health clinics, etc)

Key trends:

  • Dental services are a huge demand and gap in needed services
  • No warm handoffs have been done to Medicaid Health Home due to clients not interested in this service

Next Steps…
Will include a second set of data that will be sent to the participating CBOs which will include Low and Non-Utilizers who have had an emergency department visit and/or inpatient admission that could have potentially been avoided. The participating CBOs will continue to outreach the identified group of Medicaid members, working to build relationships and navigate them to the appropriate level of services.


Related Topics:
Two Additional Awardees of the Care Compass Network (CCN) Community-based Navigation Transformation Model Grant – November 14, 2017

Care Compass Network’s (CCN) Community-based Navigation Transformation Model Grant Winners Announced – September 12, 2017

Care Compass Network Announces Funding Opportunity for Community-based Organizations to Support Outreach and Engagement Assistance – August 4, 2017