In Richmond, VA, a patient managing her diabetes dreaded pricking her finger, but no one had told her she could have a continuous glucose monitor covered through Medicaid. In Washington state, one patient couldn’t find a way to cut through the red tape to correct a prescription error, and another didn’t know she could arrange transportation to and from primary care appointments.

In each case the care existed and the patient qualified for it. They just couldn't reach it, or didn't know it was an option. That is a failure of the path in between, whether a documentation mistake, an access barrier, or a breakdown between what the system could offer and what the patient could actually get to. These are among the most common reasons care doesn't happen for people receiving Medicaid benefits, and among the hardest to see.

We already know what prompts avoidable acute care use: primary care access, chronic disease management and care coordination, among others. Roughly 40% of acute care utilization among Medicaid beneficiaries could be avoided through better primary care and coordination. The harder question is why the resources meant to help, rides to appointments, glucometers, prescription assistance, so often never reach the people who need them.

The gap sets in before the patient shows up

Part of the answer sits in the procurement documents in which states define what they expect and hold plans accountable for delivering.

In an analysis of more than 372,000 performance claims across 265 Medicaid procurement documents in 32 states, the domains most closely tied to preventing avoidable acute care received markedly less emphasis in the procurement exchange than newer priorities like technology. Essentially, the operational work that keeps patients out of the hospital is the work that is the hardest to specify, fund, and hold accountable once a contract is signed.

Care coordination is the capability that would have arranged the missing ride and followed the stalled authorization through the system. When it draws less emphasis in the documents that shape a program, it tends to be underbuilt in the program itself. The gap in the procurement document and the gap in the patient's experience are the same gap, seen from two ends. Closing it means treating it as core operational work.

"There's a lot of working backwards, trying to figure out where things are," said Abum Ezeonwu, a care coordinator manager in Greater Seattle. A patient comes to the team asking why a clinic never called back, and a coordinator has to retrace the whole path: what led to the referral, where it went, why it stalled. Not all the systems talk to each other, so much of the job is reconstructing a trail no one else can see, then chasing down the piece that broke.

The barriers are rarely dramatic. They are small, procedural, and stacked. Jackie Lawrence, a community health worker manager, described a patient leaving the hospital with a wound who needed supplies her health plan would cover, but only after a prior authorization. 

"I was just in the hospital," Jackie said, recounting the patient's disbelief. "Why can't you just see that and send it?" Another patient's physical therapy referral mentioned only his knee, so the therapist couldn't treat his back until a new referral came through with the word "back" written on it.

Our model is built around direct, sustained contact with patients receiving Medicaid benefits, and care coordinators and community health workers (CHWs) are central to it. Waymark's CHWs and care coordinators reach people by phone and in person, help them work through the system, and document what they encounter along the way. The same team that sees or hears about a barrier is positioned to remove it.

When the Richmond patient shared how much she hated pricking her fingers, a Waymark CHW notified a Waymark pharmacist, and together they found a solution. The pharmacy team comes up again and again in how care teams describe their work. Jackie called it one of her favorite tools. One of her patients, who has sickle cell disease and lives in near-constant pain, had a refill blocked because two prescriptions had come through too close together. The pharmacy team called and explained he wasn't double-filling. "All I know is his medicine was available the next day," Jackie said.

When a care team member sits down with a patient, detection and resolution happen in the same conversation – something that claims data alone cannot reproduce or reflect. Sometimes the fix is simply teaching a patient how to use the tools already in front of them. Jackie walked an older patient through MyChart so he could book his own appointments. "You could just hear the excitement in his voice," she said.

Technology that keeps care teams in the room

We also build technology so our care teams can stay focused on patients rather than paperwork. Waymark's data science teams create purpose-built, clinician-supervised tools that carry the documentation load, so care team members spend the most time possible with the people they serve. Waymark Signal, our patient-targeting and care-recommendation platform, helps the team choose the next best action for each patient.

In a study published in JMIR AI, the recommendations from our next-best action and most likely to benefit algorithms were associated with a 20.7% relative reduction in acute care events, and they narrowed longstanding disparities in who benefits from care. In a study published in NEJM Catalyst, Waymark’s community-based teams, supported by AI-enabled, clinician-supervised tools, were associated with a 22.9% reduction in acute care. In every scenario the priority is the same: position community-based care teams to close the gaps that would otherwise stay invisible.

Easing the administrative burden, opening access to care

This care coordination gap is measurable, and it can be closed. This means treating the work of getting to, accessing, and being aware of care as part of care itself, because that work determines whether care happens at all. Care coordination is a vital part of the path to care, and one that must be included as part of any community-based care delivery effort.

Waymark’s combination of community-based care teams who are aware of the resources available to their patients, and technology purpose-built to alleviate administrative duties that would otherwise slow care delivery, was created to address that gap. Though this operational work is hard to quantify, and though it is challenging to visualize since it so often happens behind the scenes, it is vital that health plans and providers understand how valuable this work is – and how often it can mean the difference between a patient living a healthy life or ending up admitted to the hospital for something that could have so easily been prevented.

The care coordinators doing this work hold their work to the same standard in every case. "If we can't, then who can?" Abum said. "We always strive to make sure our patients are better off than when we first made contact with them."