At Waymark, our mission is to transform care delivery to patients receiving Medicaid. We focus on assisting primary care providers (PCPs), at no cost to them or to their patients, because our research suggests that PCPs are a critical force for improving population health and health equity.
To avoid repeating prior mistakes, we sought the insights of PCPs themselves to understand how Waymark can best provide its services. Through a series of semi-structured interviews and ethnographies, we listened to PCPs and observed their workflows. We sought to better understand how Waymark’s multidisciplinary care team–which includes social workers, pharmacists, care coordinators and community health workers–can address the current pain points and challenges faced by PCPs working in Medicaid-focused practices.
Throughout our research, one thesis rang true: many patients receiving Medicaid are missing patient advocacy and navigation services between visits. A human connection drives outcomes. It takes time and presence to build trusted longitudinal relationships and ensure that patients are able to understand their care, commit to a plan, and remove barriers to healthcare access and quality. Unfortunately, the impactful work of advocating for patients and helping patients navigate the healthcare system between visits can easily fall through the cracks for the most vulnerable patients.
There isn’t time.
“We need to get away from this appointment-based structure,” a PCP remarked. The traditional 15 minute appointment-based model is broken. The highest need patients have the most trouble adhering to rigid schedules. They have complex conditions and need extra time for reviewing challenges and working through barriers to receiving care, especially if their primary language is not English.
What would be more ideal? “Each week you should look at the entire panel of patients that the team is in charge of and say these are the people who actually do need visits, let's work with them to find a time for them to come in, these are patients that might could benefit from someone stopping by their home, or this person just needs a phone call,” proposed a PCP. “Appointments should be a tool to further care, not a crutch to organize care.”
Reducing the time burden on PCPs is one area that Waymark teams can excel. “Taking that burden of advocating for the patient off of the physician is meaningful,” remarked one PCP. “A big source of physician dissatisfaction is when patients have social needs that prevent them from hitting health goals…They need to have a partner.”
The work is invisible.
Assisting patients between visits is impactful but invisible work. The system does not recognize, incentivize, or account for time spent resubmitting rejected prior authorizations, following up on referrals, or dealing with durable medical equipment (DME) suppliers.
One PCP remarked: “The first referral never works, so we have these people who just know our system really well and get things done across the hospital. The MA will be like, ‘Oh no, no, let me call urology…’ When she gets on the phone she's like, ‘Hey girl what's going on? What’d you do last weekend… okay I got this patient here they need this thing…’ and our system has no concept of it… It’s all invisible work.”
Patient navigation is untracked (there’s no billing code), frequent (the job usually doesn’t get done simply by placing an order or referral), and time consuming (problems have to be manually chased). “Under the fee for service [payment] model, it’s very hard to adopt new ways of working or technology unless they can either reduce cost, meaning decrease the number of employees, or increase the ability to see more patients,” remarked one PCP.
While some programs have avoided the fee-for-service model to provide patient navigation services through grants, those programs have often been temporary—sunsetting once a granting agency shifts focus or ends their support. Even if a program provides clear benefits, clinicians may be less inclined to fully integrate the support knowing that they cannot rely on it long term. “Clinicians know that the program will sunset,” remarked a PCP. “They can't rely on the support because it's short term.” Waymark aims to provide sustained support through capitated, value-based, long-term agreements with states and their Medicaid managed care organizations, to avoid both fee-for-service or grant-based models of care.
It’s no one’s job, so it becomes the PCP’s job.
Coordinating care between visits and closing-the-loop on orders and referrals often becomes the de facto job of PCPs. Though care coordination breaks down frequently, and the work of finding and fixing the issue could be done by many staff members, it often falls on the PCP.
“There are a lot of people passing along the work,” remarked one PCP, “and no one whose job it is to figure out where the breakdown happened and why…In-between visits are where things fall off.”
Another PCP noted: “A cane was ordered as DME [durable medical equipment]. The order is sent back to me because the documentation is insufficient. Then it needs to be redone so it can be resent to Medicare… It's an example of a simple $5 item that shouldn't need a physician to solve the problem and go through eight painful steps.”
“It's terrifying when someone needs a scan or procedure and their lives are at risk if they don’t take action,” noted another PCP. “That's where you need CHWs [community health workers] to come in and make sure the care plan gets done in a timely way so that the clinician can stop worrying.”
Why haven’t prior community health worker programs solved these issues?
Implementing a CHW program is unlikely to be a magical way to solve all of the US healthcare system’s navigation problems. Many community-based programs are launched without clear role expectations, clinical support, and permanence of work for a CHW, limiting a CHW program’s ability to fix problems, or even making the problems worse by generating friction between a care coordination team and a clinical team.
“Where I’ve seen this work is that it’s more of a partnership rather than PCP leading and directing the CHW team,” said one PCP. “The most successful CHWs are the ones that integrate into the team,” noted another. “They lean in and fill gaps.”
CHWs are unfortunately sometimes thrown into a provider-patient relationship without setting clear expectations for the CHW role. Lack of role clarity can exacerbate confusion within the clinical team, create inefficiencies, erode trust, and increase frustration–making it difficult for CHWs to effectively integrate into the team.
“CHWs are most effective when they are allowed to focus on connectedness with the members,” said one PCP. “Get them intermediary support so they are not having to do and know everything at the same time… A human with bandwidth to answer clinical questions, and a coordinator to connect dots so that handoffs are minimized.”
CHWs need support themselves—providers to refer to for medical expertise, an understanding of PCPs workflows, familiarity with the system, and training on how to effectively communicate with PCPs. Waymark’s key task, in this context, is to support patients while reducing the burden on PCPs. Adapting to PCP’s current workflows often involves taking paperwork away from the PCP–allowing our staff care coordinators to complete a DME form, redirect a prior authorization to our pharmacists, provide behavioral health services through our social workers, and handle referral coordination through our CHWs–all with the goal of doing these tasks automatically, without asking anything of the PCP.
“If someone suggests that I do something differently,” said one PCP, “I think, ‘Are you trying to kill me? I think you are trying to kill me…’ I need to see a clear return if you are going to tell me to do something different… Changing physician behavior is one of the hardest things to do. If you can find any other lever, you should use that other lever.”
Principles for effectiveness
Based on insights from PCPs, Waymark adopts the following design principles to maximize our effectiveness:
- Adapt. Every physician has their own approach. We don’t expect to change their behavior, but adapt to their workflow and style.
- Reduce burden. If we’re not creating efficiencies, we're getting in the way. We take the initiative to streamline what communications and requests go to PCPs.
- Translate. Clinicians and CHWs speak different languages. We provide tools to help them communicate effectively.
- Structure. Role confusion causes friction and erodes trust. We empower teams with clear expectations and scope.
- Support. CHWs are not magicians. We provide resources and support so that CHWs can deliver a ‘no wrong door’ experience to the patient.