HS820 Unit 10 Rural Medicaid Recommendation Report Example

Every Household Has a Name on a List: A Unit 10 Recommendation for Rural Medicaid to Borrow Household Empanelment From Ethiopia and Pakistan

[Student Name]

Purdue University Global

HS820: Global and National Health and Health Systems

Unit 10 System Recommendation Report

[Instructor Name]

[Date]

The state and counties are composite; the international programs, U.S. evidence and sources cited are real. Costs are placeholders in brackets.

Executive Summary

In three rural counties of the state, Medicaid enrollees use emergency departments for conditions that primary care could manage, at rates well above the state average. The report recommends that the state fund teams of community health workers, each assigned about [250] enrolled households, through a Medicaid state plan amendment. The model borrows household empanelment from two large international programs but keeps clinical care with licensed clinicians. It requires payment authority, certification, supervision, a household registry and fair pay. Estimated first-year cost is [$X million], with an evaluation comparing the three counties with matched counties that do not adopt the model.

The Problem

The three counties have few primary care clinicians per person, long travel distances and high rates of diabetes, hypertension and chronic lung disease. Medicaid enrollees there visit emergency departments for asthma, uncontrolled diabetes and similar conditions at about [1.8] times the state rate. Many enrollees have no regular source of care, and clinics report that patients miss follow-up appointments because of transport, cost of time off work and confusion about coverage. The problem is not only a shortage of clinicians but a gap between households and the care that exists.

International Evidence: What the Programs Share

Ethiopia's Health Extension Program, launched in 2003, places two salaried health extension workers, usually women with about a year of training, in each kebele, the smallest administrative unit, typically serving about 5,000 people. They register households, visit them, deliver preventive services and refer patients to health centers, under supervision from health center staff (Wang et al., 2016). Pakistan's Lady Health Worker Program, begun in 1994, assigns each worker to a registered set of households, usually around 1,000 people, in her own community, for family planning, maternal and child health and referral.

The programs operate in settings with too few clinicians, and both workers provide some basic clinical services. But they share four design features that do not depend on that setting: a defined population assigned to each worker, household registration, routine home visits and supervision by facility staff. The World Health Organization's guideline on community health worker programs recommends these features, along with formal pay, training and integration with the health system (World Health Organization [WHO], 2018).

Household empanelment travels to a rural American state; replacing clinicians with community workers does not, and the report borrows only the first.

Domestic Evidence

American programs that pay community workers to support Medicaid patients supply the domestic evidence base. Randomized trials of a standardized model in which workers help low-income patients address social needs and find their way through care have found fewer hospital days and improved patient-reported outcomes, and an analysis of that model estimated a return of about two dollars for every dollar invested by a Medicaid payer (Kangovi et al., 2020). Medicare introduced payment codes for community health integration services in 2024, and a growing number of state Medicaid programs pay for community health worker services through state plan amendments or managed care contracts.

Recommendation

The state should fund community health worker teams in the three counties through a Medicaid state plan amendment. Each worker would be assigned about [250] enrolled households, register them, visit each at least quarterly, help with appointments, transport and coverage, and refer to the household's primary care clinic. Workers would be employed by local clinics or federally qualified health centers and supervised by a nurse or social worker at a ratio of about one supervisor to [eight] workers.

Requirements

1. Payment authority: a state plan amendment defining community health worker services as preventive services recommended by a licensed practitioner, with a per-member or per-visit payment; responsible agency, the state Medicaid office; timeline, [six to nine] months.

2. Certification: a state certification standard with core training of about [120] hours; responsible agency, the state health department with community colleges.

3. Supervision: a required supervisor ratio and clinical oversight agreement at each employing clinic.

4. Household registry: a shared registry linked to Medicaid enrollment and clinic records, so that each enrolled household is assigned to one worker; responsible agency, the Medicaid office with the state health information exchange.

5. Pay: a salaried position with benefits at a rate of about [$X] per year, consistent with the WHO recommendation for formal pay.

Risks and Mitigations

Recruitment may be difficult in sparsely populated counties; the mitigation is to hire from the community and offer paid training. Clinics may lack capacity to absorb referrals; the mitigation is to pair the program with telehealth and same-day appointment slots. Workers may be pulled into tasks outside their role; the mitigation is a written scope of practice and supervision. Enrollees may decline visits; the mitigation is to start with high-need households and use trusted local hires.

A Week in One Worker's Panel

To show how empanelment changes daily practice, consider one worker based at a clinic in the largest of the three counties. Her registry lists 250 enrolled households. On Monday she reviews a list of households whose members visited the emergency department in the past week, generated from Medicaid claims and the hospital's admission feed. On Tuesday and Wednesday she visits six of those households, checks that an asthma inhaler was refilled, arranges a ride for a diabetes follow-up and helps one family renew coverage that was about to lapse. On Thursday she makes routine quarterly visits. On Friday she meets her supervisor, a registered nurse, to review cases that need a clinician's attention. Nothing in that week replaces a clinical visit; it connects households to visits they would otherwise miss.

Costs

First-year costs include salaries for about [30] workers and [four] supervisors, training, the registry and evaluation, estimated at [$X million]. Savings would come mainly from reduced emergency department visits and hospital days, but the report does not count on savings to justify the program.

Evaluation Plan

The evaluation will compare the three counties with matched rural counties on emergency department visits for ambulatory care sensitive conditions per 1,000 enrollees, the share of enrollees seen by their assigned clinic at least once in twelve months, and hospital days. Measures and the comparison group will be fixed before implementation, with results reported at 12 and 24 months.

Limits

The international programs operate in very different health systems, and the report borrows only one mechanism. Cost estimates are placeholders until local salary and registry costs are confirmed.

References

Kangovi, S., Mitra, N., Grande, D., Long, J. A., & Asch, D. A. (2020). Evidence-based community health worker program addresses unmet social needs and generates positive return on investment. Health Affairs, 39(2), 207-213. https://doi.org/10.1377/hlthaff.2019.00981

Wang, H., Tesfaye, R., Ramana, G. N. V., & Chekagn, C. T. (2016). Ethiopia health extension program: An institutionalized community approach for universal health coverage. World Bank. https://doi.org/10.1596/978-1-4648-0815-9

World Health Organization. (2018). WHO guideline on health policy and system support to optimize community health worker programmes. World Health Organization.