A primary care physician typically has only fifteen minutes per patient and limited influence over the underlying issues that brought the patient in. At the same time, for patients receiving Medicaid benefits, their health outcomes often depend on factors like housing, missed prescriptions, or lack of transportation – none of which can be resolved during the visit.

Nevertheless, health systems have asked clinical staff to address these issues when possible, which diverts their limited expertise to non-clinical problems outside their training. As a result, the “screen-and-refer” approach has become the default.

Where these patients end up

Nearly 40% of the acute-care visits by people who receive Medicaid are for ambulatory care-sensitive conditions.The immediate reason is generally a condition that has not been properly managed; the deeper causes are housing instability, food insecurity, transportation gaps, or the fact that no one completed the process of navigating benefits.

Despite not being medical or clinical in nature, these needs often surface in the emergency department, which is not equipped to address them. While the ED can treat acute symptoms and discharge patients in improved condition, it cannot resolve underlying issues like housing, leading to repeat visits.

HRSA projects a shortage of 124,180 physicians by 2027, increasing to 187,130 by 2037, with the greatest deficits in primary care and rural areas. Additionally, over one million registered nurses are expected to retire by 2030. The workforce being tasked with social needs is already the most limited and is shrinking fastest, especially in areas where Medicaid patients seek care.

The standard approach is to identify health-related social needs and refer patients to other services. According to an analysis by Waymark’s co-founders, this method is largely ineffective. Screening costs about $5 per member per month and often fails to identify patients with the most complex needs, as many cannot reliably access primary care. Additionally, most referrals are not used because recipient organizations face their own capacity limits, eligibility requirements, and enrollment challenges that referring clinicians may not know about.

“Patients want to have their concerns addressed, and often they feel a care setting is the most accessible place,” said John Morgan, Waymark’s Medical Lead. “But when you look at the physician shortage nationwide and the access concerns, plus the work requirement piece, it’s more important than ever that we have these multidisciplinary care teams in place to connect those patients with resources instead of going with a screen-and-refer model.”

The alternative operating model

The social ACO model, proposed by Waymark’s co-founders and colleagues, would reduce reliance on  health system’s clinical staff while still ensuring patients can access the whole-person support they need to stay out of the ED and live healthier lives. Unlike the screen-and-refer model, this approach relies on non-clinical, community-based teams. Care is delivered in the community, focusing on individuals with rising risk and complex social needs, rather than only those who regularly attend appointments. Social needs are addressed by teams with local expertise, not via referrals to unverified networks.

In this model, the health system serves as an organizer and supporter, not as the direct provider of community-based care. This structure creates a partnership rather than adding responsibilities to already understaffed organizations.

Traditionally, outreach is based on predicted risk, targeting those most likely to require emergency or hospital care. Peer-reviewed research on Waymark’s care-management program tested a benefit-based approach using three years of data from 164,063 adult Medicaid beneficiaries in Washington and Virginia. Benefit-based targeting prevented 13.3 emergency visits and hospital admissions per 2,000 beneficiaries per month, compared to 2.5 with risk-based targeting. One acute event was prevented for every 15 completed calls under the benefit-based rule, versus one for every 80 calls with risk-based targeting.

Two findings are especially relevant for population health leaders. First, the benefit-based and risk-based approaches identified largely different groups; only about one-third of high-risk beneficiaries were also most likely to benefit in a given month. Second, nearly two-thirds of benefit differences were due to changes within individuals over time, highlighting the importance of timing rather than ranking. Quarterly risk scores cannot capture these dynamic windows. The benefits were distributed equally across racial and ethnic groups.

Waymark Signal^TM is the predictive tool in this care model, identifying individuals most likely to benefit from outreach rather than simply targeting the highest-cost patients. This division of labor allows small teams to operate efficiently, with the model selecting whom to contact and staff determining subsequent actions.

With this approach, among 1,652 Medicaid patients at rising risk in Washington and Virginia, Waymark reduced acute care events by 12 percentage points. This outcome directly reflects the intended impact of social and coordination interventions.

The answer to the question

PCPs feel responsible for responding to issues around housing, nutrition, transportation and more because no other role in the healthcare system addresses them. This is due to system structure, not clinical judgment. Assigning these responsibilities to specialized teams allows clinicians to focus on tasks that require their expertise.

This is often where the conversation stops, but the data indicate that reassignment addresses only part of the problem. When community-based teams take on social and coordination tasks, they still have limited capacity and must prioritize whom to contact each month. Therefore, health systems evaluating partners should ask two key questions, especially the often-overlooked second: who is responsible for social and coordination work, and how does the partner determine which individuals to reach out to each month?