News & Commentary

Medicaid Program’s Care Coordination

The Bridges to Care (B2C) program provides help to Medicaid patients who use the emergency department frequently. It steers them to primary care providers, assists them in getting prescriptions filled, and even tries to find them transportation and housing, if needed. The program was developed by the Camden Coalition of Healthcare Providers, a multidisciplinary, community-based primary care program.

When applied in Colorado, the program led to 30% fewer hospitalizations, a similar reduction in emergency department visits, and a 123% increase in primary care visits in six months compared to a control group, according to a study published last month in Health Affairs.

“There is a perspective from multiple stakeholders that high users of the ED are difficult patients,” said the study’s lead author, Roberta Capp, MD, an assistant professor of emergency medicine at the University of Colorado School of Medicine, in a press release. “But this is the first program to show that care coordination actually works.”

Researchers with the University of Colorado implemented B2C in four types of health care organizations: an urban academic hospital, 13 federally qualified health centers, a community advocacy organization, and a mental health clinic.

They compared results of 402 B2C participants with 3,396 members of the control group. B2C participants enrolled in the program from January 2013 to October 2014. The study was not a randomized control trial but researchers instead used “robust methodological techniques to create an artificial control group.” The authors also noted that almost a third (27.6%) of the enrollees did not complete the 60-day program.

A team made up of a primary care provider, care coordinator, behavioral health evaluator, health coach, and community health worker provided medical, behavioral, and social care services.

It cost about $500,000 to build the program’s infrastructure, and the running costs were estimated to be $640 per 60-day intervention per patient.

One of the keys to the program’s success, according to researchers, was including behavioral health. Most of the patients in the study had mental health problems.

Another important feature was the use of “hotspotting”—a data-driven process that’s meant to locate extreme patterns of utilization in an area and respond with targeted interventions. Hotspotting was an innovation of the Camden Coalition of Healthcare Providers.


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