Care Coordination: A Bridge, Not a Barrier
Care coordination is more than a case manager making a few calls. It’s an infrastructure—anchored in trust—that aligns hospitals, Federally Qualified Health Centers (FQHCs), specialists, home health agencies, behavioral health providers, and community resources around the patient. For individuals with serious disabilities and multiple chronic conditions, care coordination prevents crises by addressing issues upstream: medication adherence, transportation, housing insecurity, food access, and caregiver support.
In our work, we’ve seen a staggering difference between individuals with care coordination and those without. Emergency room visits decline. Hospital readmissions drop. Mental health episodes are de-escalated. Primary care visits increase. Patients engage in their care—not as passive recipients, but as informed participants.
Managed Care: Controlling Cost While Elevating Quality
Managed care, especially for Medicaid and Dual Eligible Special Needs Plan (D-SNP) populations, adds critical structure to the coordination process. Rather than fee-for-service silos, managed care organizations (MCOs) work within capitated budgets to deliver value-based outcomes. This approach reduces duplication, encourages preventive services, and provides wraparound supports that traditional coverage models simply do not.
For state governments, the cost savings are measurable. Care coordination and managed care reduce avoidable utilization—preventing costly emergency visits, long-term institutionalization, and redundant testing. More importantly, it aligns public health spending with long-term health improvements for those who need it most.
Who Benefits? Poor Persons with Disabilities
The populations we serve face layered vulnerabilities: economic disadvantage, racial disparities, rural isolation, and functional limitations. They need more than a referral—they need a coordinated response to their daily realities. For a person with limited mobility and severe diabetes living in a food desert, care coordination connects them to diabetic education, meal delivery programs, and primary care—while working with the MCO to fund a home health aide and remote glucose monitoring.
That’s the human side of Medicaid transformation. And that’s the space where 1115 Waivers become catalytic.
Five Innovations Poor Persons with Disabilities Need Now
- Integrated Behavioral and Physical Health Services
Persons with disabilities often have co-occurring behavioral health needs. They need providers who can treat the whole person—body and mind—without forcing them to navigate separate systems.
- Digital Access and Telehealth Inclusion
Isolation should not equal invisibility. Investments in broadband, telehealth-friendly devices, and virtual care coordination are lifelines for rural and homebound individuals.
- Transportation and Mobile Outreach
Transportation remains one of the most cited barriers to care. Medicaid-funded transportation and mobile outreach units—particularly through 1115 Waiver demonstration projects—can ensure no patient is left behind.
- Culturally Competent Peer Navigation
Disabled individuals from underserved racial and ethnic communities face compounding disparities. Peer navigators with shared lived experience provide both advocacy and cultural relevance.
- Supportive Housing and Community-Based Services
Safe, stable housing is healthcare. Programs that combine housing assistance with care coordination reduce institutionalization and improve outcomes for individuals with serious disabilities.
Conclusion:
Coordinating Compassion, Saving Costs, Elevating Care
The path forward is not just about containing Medicaid costs—it’s about transforming how we care for people who have been overlooked for too long. Care coordination, anchored in managed care principles, offers a practical and compassionate approach to serving persons with disabilities and chronic illnesses. When states leverage 1115 Waivers to innovate, they unlock upstream solutions to downstream problems—saving public dollars while honoring human dignity.
As a care coordination entity, we stand in that gap. We work alongside hospitals and FQHCs, MCOs and state agencies, families and frontline providers—to build a system where care isn’t chaotic, but coordinated. Where every person, regardless of income or disability, has access not just to services, but to solutions.
That’s what Medicaid was meant to be. And that’s the future we’re building, together.