Jason’s* first hallucination was in the middle of high school chemistry class, when he saw a ghost emerge from an Erlenmeyer flask and rush towards him. Since then, he’s had visual hallucinations, and later started hearing voices, nearly every day. He finished high school, but wasn’t able to complete college. He’s obtained a series of odd jobs, but oftentimes he’d experience a hallucination while working, and then be fired by a frightened manager or after a complaint from a customer convinced that he was abusing drugs. Ironically, it was his inability to get drugs that was the problem; the prescription medication that helped Jason’s schizophrenia was often difficult to get coverage for, and he routinely faced paperwork barriers to getting his medications on time. He’d go days without a refill, as the pharmacy waited for his doctors to fax the right disease codes for his order. He’d often have to wait months between primary care appointments due to the lack of availability, and couldn’t find a psychiatrist who would take his insurance. During that time, he’d end up getting kicked out of his apartment building, land in jail, or be assaulted on the King County Metro, in his native city of Seattle.
Jason’s challenges are, sadly, not unique. Like Jason, many people who rely on Medicaid for their coverage experience challenges accessing care, medications, and social support like housing and food. Addressing these challenges is possible, according to several studies. People with complex care needs, like Jason, often benefit from having a team of people who can meet them where they are – including on the streets or elsewhere in the community. Jason now participates in Waymark's pilot program in Washington State to provide him with such support. A team focused on more effective care coordination can be vital – including a pharmacist to help overcome medication coverage problems, a therapist to treat mental health or substance use conditions, and a patient advocate called a community health worker who can assist in addressing many barriers to getting good care. In recent studies, these team members both improved health outcomes, and overall saved the healthcare system money, often by reducing emergency room visits and hospitalizations for preventable or treatable illnesses. While some communities have access to these types of services, they can be temporary because of volatile grant funding, accessible only to a limited number of eligible people, or have an inadequate provider workforce to cover the number of patients in need.
A recent survey by the Washington State Health Care Authority, which oversees the Apple Health Medicaid program, found that primary care providers who treat patients with Medicaid coverage overwhelmingly want to provide more comprehensive care, but lack three major resources: a larger skilled workforce to provide the care coordination; regular funding to support the work; and streamlined data to more effectively know which patients to reach and for what purpose.
Waymark is a physician-founded community based care delivery organization dedicated to solving those problems: providing paid training to strengthen the community health workforce, deploying the community workforce to practices at no cost to the practice or to patients, and enabling that workforce with new data science technologies.
“Providing primary care for patients with complex behavioral health, physical, and social needs is challenging,” said primary care physician Helen Jack MD, who practices in Washington State. “This kind of work necessitates a team-based approach…Many need not only a prescription from their primary care physician, but access to the medication, someone to help them get to their appointments, mental health counseling, and access to housing resources. As a team, we can be meeting patients where they are, establishing their health goals and priorities, and helping them meet those goals.”
The data science innovations that Waymark can provide can serve to enhance the effectiveness of community-based health care teams. For example, previous research by the Waymark team found that combining data on social determinants of health with information on healthcare claims can improve which patients are outreached, and turn retrospective care management to prospective and prevention-oriented outreach. A randomized trial found that when data science was used to proactively direct community based teams helping primary care providers, the rate of emergency room visits significantly declined; without such interventions informed by the data science, emergency room visits remained unchanged.
“Too often, what is proven to work to comprehensively care for patients with complex needs is not sufficiently funded, or delivered by an overburdened safety net suffering from burnout,” said Waymark CEO and co-founder Rajaie Batniji MD PhD, who provides primary care to patients at a homeless shelter. “Waymark was created to support Medicaid primary care providers with a sustainable model for delivering whole-person care that is enabled by technology to solve for the barriers identified by providers in Washington.”
In King County, communities of color represent almost 50 percent of the Medicaid population, with more than 70 spoken languages. “Our program will engage members with a team of clinicians and community health workers to address care gaps, with an acute focus on improving equity and reducing disparities,” said Waymark co-founder, Sanjay Basu MD PhD, who is also a primary care provider for patients with Medicaid benefits at a federally-qualified community health center.
Recognizing that primary care providers are critical to supporting the health of individuals with Medicaid coverage, this collaborative model is designed to help providers reduce their paperwork and “no-show visit” rates, as well as time spent coordinating social services, delivering behavioral healthcare, and managing referrals.
Starting January 2023, Waymark will serve eligible Washington State Medicaid members throughout the greater Seattle and Tacoma areas. Waymark will enhance care coordination efforts for members at risk of elevated care costs from multiple chronic conditions, and provide those individuals with targeted health and social-care related resources. Waymark’s care team – in consultation with providers and patients – will design and execute on a plan to support patients as they work to achieve their healthcare goals.
Note:
*Patient Jason’s name and details of his story are changed or omitted to protect his identity.
