As medical professionals, we know that randomized controlled trials (RCTs) are the gold standard for identifying the strongest evidence for clinical practice. RCTs allow us to isolate the impact of a specific intervention, control for confounding variables, and draw conclusions about cause and effect. At Waymark, we take this principle to heart and rely on rigorous RCTs to define the detailed protocols and processes we deploy as our care model. 

In Medicaid care delivery, RCTs help establish which set of protocols will help improve clinical outcomes and quality of life for our most vulnerable patients in primary care. Primary care providers (PCPs) are often most worried about those patients who aren't showing up to their brick-and-mortar clinics due to barriers to care—from lack of transportation to competing work demands. As a result, practices can benefit from having an outreach arm that helps their most vulnerable patients engage in primary and preventative care, address their health-related social needs (HRSNs), and help patients navigate a confusing healthcare system. RCTs can help us determine how to structure community-based teams and deliver evidence-based interventions to support these patients. 

Several of the seminal articles defining the field of community-based, multidisciplinary care were published as a series of RCTs conducted by researchers at the University of Pennsylvania. In these trials, community health workers (CHWs) typically worked with master's-level social workers (MSWs), with a focus on patients receiving Medicaid who had multiple complex chronic conditions. The trials showed that this model of care could significantly improve utilization outcomes, particularly through reduced hospitalizations and hospital length of stay per patient. In a pooled analysis of three RCTs (N = 1,340 participants observed over 9,398 patient months), participants in the intervention group versus control had both fewer hospitalizations per patient (0.27 vs 0.34, p<0.0001) and shorter mean length of stay (4.72 vs 5.57 days, p = 0.03). A further return-on-investment analysis of the model estimated that for every dollar invested in the program, there was a return of $2.47 in healthcare cost savings for the Medicaid payer within the fiscal year. This analysis demonstrated that investing in community-based care teams can be a cost-effective way to reduce healthcare spending among those patients who were predominantly Medicaid-insured and lived in high-poverty regions of Philadelphia.

We know, however, that implementing CHW models can be challenging. CHWs face many risks on-the-job and may have difficulty sustaining a career if they are not supported as part of a broader team—as evidenced by a recent national survey we helped to analyze for the National Association of Community Health Workers (NACHW). To address this challenge, Waymark’s approach is to build a strong and supportive career pathway for CHWs, pay for CHW training, provide the same job benefits that we give to the rest of the team (including our CEO), and integrate CHWs more closely with primary care teams to ensure their patients have a pathway to referrals and medical assistance. By closely linking community-based care teams with primary care practices, including EHR and PCP workflow integration, we can coordinate care between the patient’s home (or shelter, food bank, and other community locations) and the primary care clinic as well as support CHW development. In an RCT in Tennessee, patients randomized to a multidisciplinary team integrated into primary care practices (n = 71) had lower total medical expenditure (a reduction of $7,732 per member per year, p = 0.036), fewer hospitalizations (0.32 per member per year, p = 0.014), and shorter hospital length of stay (3.46 fewer days per member per year, p <0.001) compared with patients randomized to usual care (n = 127). This trial confirmed that by integrating CHWs into primary care teams, we can reduce acute care utilization, even outside of academic medical centers or urban locations. 

But what about the null result of the Camden Coalition study? Famously, the Camden Coalition's 'wrap around' model of care for high-cost patients in New Jersey (profiled by Dr. Atul Gawande in The New Yorker) did not produce a significant reduction in readmissions in a randomized trial of 800 hospitalized patients. We know, however, that just like two different medications can produce different results for the same disease being treated, two different care management interventions can also have different effects on a population of patients. In a much larger randomized study (N = 57,972), colleagues in Contra Costa, California, produced more optimistic results, with a high 40% engagement rate: intervention group participants visited the ED at ratios of 0.96 for all visits (and 0.97 for avoidable visits relative to the control group), and were hospitalized (including index and readmissions) at ratios of 0.89 (and 0.72 for avoidable admissions relative to the control group, both p<0.05). The trial showed the benefits of deeper integration with primary care practices when deploying multidisciplinary community-based teams, and using data science technologies to proactively outreach and engage with Medicaid patients earlier in their disease course rather than waiting until they surpassed a complexity or cost threshold. These critical differences between the interventions are vital for deployment and implementation of effective programs in practice.

At Waymark, we have learned from these randomized trials and built our care model around their findings. Unlike many digital health companies that are building an airplane while learning to fly it, we’ve focused our efforts on implementing care models that have been shown to work and have a strong foundation in the existing evidence base. We’re not trying to simultaneously invent new care models and implement them. By investing in community-based care coordination, integrating CHWs into primary care teams, and using data science technologies to proactively engage with patients, we aim to reproduce the clinical outcomes observed in rigorously tested, peer reviewed, published randomized trials. We believe that investing in approaches grounded in RCTs is the best way to bring evidence-based interventions to more patients receiving Medicaid.

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