UnitedHealthcare Community & State is a Medicaid managed care organization operating in 26 states. It has incorporated community health workers into its health team to help members with complex needs who also experience barriers with access to care—to connect them to behavioral, medical, and social supports. Community health workers build rapport and trust with patients, teach them how to utilize the health care system (e.g., the importance of the primary care provider relationship and appropriate use of the emergency department), and connect patients to nonclinical community-based resources to address the social determinants of health. For example, the community health worker may accompany the patient to a primary care visit and help them find resources in the community to better manage their chronic conditions. The community health worker role contributes to improved health outcomes, member experience, and improved efficiencies. Augmenting the traditional health care workforce with community health workers also allows licensed staff to work at the top of their licensure. To read more about this innovative program, see this brief summary [link].
State Category: Ohio
Ohio Correctional Health Project
The Ohio Correctional Health Program (Ohio Offender Project) helps offenders who are preparing to be released from prison develop a transition of care plan to ensure their health needs are met as they re-enter society. The Ohio Department of Medicaid and Department of Rehabilitation and Corrections partnered with all participating Medicaid managed care organizations, the Ohio Department of Health, and the Department of Mental Health and Addiction to begin this program in 2014. Offenders who have two or more infectious or chronic health conditions are eligible to be matched with a peer mentor (peer mentors are offenders who have long-term sentences) who assists them with a Medicaid application and selection of a health plan. The chosen health plan works with the offender to develop a transition of care plan to ensure access to needed care, medication, and assistance with food, shelter, or safety issues, and access to community-based transition services. One goal of this program is to reduce Ohio’s 26 percent recidivism rate by helping released offenders manage chronic health or mental health conditions. The expenses for this program are financed as part of the health plan’s Medicaid capitation rate (administrative dollars). To read more about this innovative program, see this brief summary [link]
Come to the Table
ohiSince 2009, ProMedica’s, “Come to the Table” program has been working to ensure the well-being of communities in northwest Ohio and southeast Michigan by creating services and programs addressing basic nutritional needs. The link between hunger and poor health is clear—adults living in food insecure homes have chronic diseases and behavioral health conditions. Food-insecure children suffer an even greater impact with delayed development and poorer quality of life. Health threats resulting from hunger are preventable and ProMedica continues to develop and implement strategies to feed communities including: operating a food reclamation program to repackage un-served food and distribute to homeless shelters; developing a food security screening program to identify hospital patients who are food insecure to ensure they have food and access to resources upon being discharged from the hospital; and the future opening of the Ebeid Institute for Population Health in Toledo, Ohio, which will have a fresh food market and offer job training and health services. ProMedica’s strong community partnerships at the local, state, and federal levels are central to developing these collaborative opportunities. To read more about this innovative program, see this brief summary [link].
Cincinnati Children’s Hospital Medical Center Community and Population Health Initiative
In 2010, Cincinnati Children’s Hospital Medical Center (CCHMC) started the Community and Population Health Initiative to tackle the most prevalent, challenging, and burdensome health issues facing children and families in southern Ohio. By creating partnerships within the community and focusing on the pillars of the Institute for Health Care Improvement’s Triple Aim framework, the Community and Population Health Initiative has reduced the negative impact of social determinants like education, housing, and the environment on health outcomes. To date, CCHMC has seen a reduction in asthma admissions, improved social and environmental risk screening during both inpatient and outpatient care, and substantial increases in connections between families and key resources in the community. The initiative began with funding from CCHMC, as well as funding from federal agencies and foundations. To read more about this innovative program, see this brief summary [link].