🧵 Rising-risk patients receiving Medicaid experience worsening medical and behavioral health conditions and increased acute care utilization, while typically being disconnected from primary care.

Randomized controlled studies show that community-based early interventions improve outcomes for these patients before they become high utilizers of acute care services.

Yet limited data and infrastructure support, inconsistent grant-based funding, and high administrative burdens have limited the accessibility and reproducibility of successful early community-based interventions for patients receiving Medicaid.

The launch of operational infrastructure and enabling technology across two health plans and multiple providers in Washington and Virginia (Waymark) introduced community-based teams providing early intervention services to rising-risk patients receiving Medicaid.

Waymark The teams of community health workers, care coordinators, social workers, and pharmacists provided 1,652 patients receiving Medicaid with interventions including:

Waymark closing care gaps, assistance with care provider instructions, cognitive behavioral therapy, prescription medication access, arranging and accompanying patients to social service and health care appointments.

Waymark Using data synthesis efforts and generative AI to assist teams with streamlined outreach and communications reduced administrative intake time for intervention teams by 34.2%,

Waymark facilitated improvement of HEDIS quality metrics by an 11.8 absolute percentage point average, and enabled patients to achieve 63.3% of their health care and social goals.

Waymark Using novel rising-risk machine learning models to optimize patient selection and outreach timing, the teams achieved a 22.9% reduction in all-cause acute events, including

Waymark 48.3% reduction in ambulatory care–sensitive hospitalizations among patients receiving the intervention, versus a matched control group of nonintervened patients.

Waymark Addressing clinical and social service gaps between primary care practices and health plans provided critical but narrow windows of opportunity to improve patient outcomes: nej.md/482n9cC @RBatniji

A new study in nature from Sadiq Y. Patel, Aaron Baum, and Sanjay Basu once again demonstrates that when we make an active effort to connect people to primary care, health outcomes improve. Read more: nature.com/articles/s4159…

Thank you to Marissa Plescia and MedCity News for their thoughtful coverage of the release of our peer-reviewed first-year results – and what those results mean for the future of Medicaid as so many states are seeing headwinds. More here: wymrk.co/3Nxhwtw

In our latest Care Delivery Spotlight, Waymark Community Health Worker Ethan Hume examines the role community-based care teams play in balancing patient care, PCP bandwidth and ever-evolving healthcare policies. Read his full interview here 👉 wymrk.co/4fk8ITG

Join @Waymark’s Sara Greenbaum and Hannah Ratcliff & CareOps’ @RikRenard for a chat about the impact of community-based care on rising-risk patients. If you’ve ever asked, “How can we reach Medicaid patients before they need urgent care?” this is for you👉 wymrk.co/3NNWIy2

While attending the Camden Coalition annual conference, Waymark's VP of Care Model & Quality engaged in perspective-shifting conversations around the power of whole-person care with peers and industry leaders. Read her reflections here ➡ wymrk.co/4ej8GLd

Traditional A/B testing is limited in finding why & how patients respond to different communication strategies. In a peer-reviewed study in npj Digital Medicine , we share how Medicaid programs can use LLMs to reliably personalize patient communication. More: wymrk.co/40RvxKJ

ICYMI: Waymark and CareOps' Rik Renard shared insights on building care models that scale with patient and provider needs during this webinar–complete with data and case studies on the impact of reaching rising-risk Medicaid patients. Watch here: wymrk.co/495iKpQ

In our latest blog post, co-authors of our recent peer-reviewed study in NEJM Catalyst summarized key takeaways that answer a key question: What can Medicaid programs learn from Waymark’s approach to improving outcomes and reducing costs? Read more ⏩ wymrk.co/3CTQWJc

In a new piece in STAT, our VP of Data Science and AI examines barriers to AI/ML adoption in Medicaid and lays out potential solutions to address these challenges — including actively seeking input from patients and the people who serve them: wymrk.co/4gClRIr