Marginalized populations in our own backyard: A care management program for disabled, chronically ill, Medicaid clients in a midwest metropolitan community

Vulnerable populations frequently possess medical care needs that exceed the current healthcare system's capacity. Community-based, collaborative care management may offer a viable solution to bridge existing gaps in care and improve health outcomes. Using evidence-based methods, care management teams consisting of registered nurses and social workers, assisted chronically-ill, disabled, Medicaid patients in maintaining a primary care medical home, accessing community resources, and managing their health. Participants were predominantly female, single, White, low-income with a high school education or less and showed a greater representation of mental health disorders and diabetes. For the intervention group, outpatient encounters were constant, inpatient days were reduced by nearly half, emergency room visits remained stable, the number of medical provider visits increased (all clients had at least one visit) and clinical quality measures for targeted conditions (e.g., ACE inhibitor medications, HgbA1c tests, controller prescription index) were improved. The chronically-ill, disabled, Medicaid patients in this intervention showed significant cost reductions in inpatient services and modest increases in pharmacy claims and outpatient and emergency room services. Results suggest that the intervention improved communication patterns between patient and healthcare providers in addition to improving patient adherence to medical regimen. Altogether, initial findings suggest that the collaborative care management program ameliorated the effect of poor mental health and poor health literacy in maintaining health outcomes and improving use of healthcare resources.