Across the country, state Medicaid agencies and Managed Care Organizations (MCOs) continue to face a familiar challenge—how to effectively reach members who remain disconnected from preventive care, fall through the cracks of complex health systems, and use emergency departments for avoidable issues. Traditional outreach methods—automated calls, mailers, or brief telephonic campaigns—have reached their limits. To drive meaningful change, engagement must be personal, rooted in community trust, and aligned with the lived realities of Medicaid members themselves.

That is where a new model of community-embedded care coordination is transforming how high-risk, hard-to-reach populations are served.

From Outreach to Ownership:

Training Medicaid Members to Serve Their Communities

Our care coordination entity has taken a bold, human-centered approach: training and employing Medicaid members themselves to serve as field specialists, community liaisons, and care connectors. These individuals—many of whom have navigated the Medicaid system firsthand—understand the barriers to access better than anyone else.

Through structured training, coaching, and supervision, these members work an average of 80 hours per month, meeting state work-requirement thresholds while providing high-impact, person-centered outreach. This dual mission accomplishes two goals simultaneously:

1. • It helps members maintain their Medicaid eligibility through meaningful employment that meets the state’s community engagement criteria.
   • It builds workforce capacity to conduct face-to-face assessments, complete health risk screenings, and support diversion from unnecessary emergency room use.

By turning beneficiaries into advocates and navigators, we are not only closing workforce gaps but also restoring dignity, purpose, and stability in the very populations that public health systems are designed to serve.

Face-to-Face Care Coordination:

Bridging the Distance Between Systems and Lives

While digital engagement and data analytics play essential roles in population health, they cannot replace the power of in-person, relational outreach—particularly in neighborhoods where distrust, transiency, and competing life priorities often limit participation in care.

Our field specialists conduct face-to-face (F2F) visits in homes, shelters, community centers, and even barbershops or libraries. Each encounter is guided by a structured Health Risk Screening (HRS), identifying social determinants such as food insecurity, unstable housing, transportation barriers, or behavioral health needs.

This approach has shown measurable value for MCOs seeking to meet contractual outreach benchmarks. By converting previously “unable to reach” members into active participants, we support:

• • Reduction in avoidable ER utilization, redirecting members to primary or urgent care alternatives.
  • Improved completion of HRS and preventive screenings, ensuring compliance with MCO and state quality standards.
  • Increased member retention, as engagement leads to better satisfaction and perceived support.

Each outcome contributes directly to cost avoidance, higher quality ratings, and stronger value-based performance metrics for our payer and provider partners.

Partnering with FQHCs to Meet Value-Based Care Goals

Federally Qualified Health Centers (FQHCs) are the backbone of primary care for Medicaid populations. Yet, despite their reach and mission, many centers struggle to locate and re-engage patients who have fallen out of care. Missed preventive visits, gaps in chronic disease management, and incomplete quality data can translate into lost revenue and reduced performance under value-based contracts.

Our partnership model strengthens the FQHC infrastructure by embedding care coordination and outreach capacity directly into their value-based care strategies. Through shared data exchange and referral protocols, our team supports:

• • HEDIS care gap closure for diabetes, hypertension, cancer screenings, and immunizations.
  • Continuity of care through post-discharge follow-ups, medication reconciliation, and appointment scheduling.
  • Population-level health equity initiatives, aligning with HRSA and NCQA standards for culturally competent, community-based engagement.

In many cases, FQHCs report that our field specialists have reconnected patients who had been “lost to follow-up” for more than a year—patients who, once re-engaged, resume regular primary care and chronic condition management.

Value to MCOs and State Agencies

State Medicaid agencies and Managed Care Organizations share a common mandate: ensure access, improve outcomes, and reduce total cost of care. The challenge lies not in designing the policy but in operationalizing it—turning lofty goals into daily, scalable actions.

Our model provides a turnkey, data-driven field extension of the MCO’s care management infrastructure. We track every visit, outreach, and intervention using secure population health platforms, generating real-time dashboards that feed directly into MCO reporting and compliance metrics.

This creates a closed loop between payer, provider, and community—something that has long been missing in fragmented systems. State agencies, in turn, gain confidence that contractual expectations for outreach and ER diversion are being met not only quantitatively but with measurable community impact.

Moreover, the workforce development component of this model aligns with broader economic and social policy priorities, including job creation, self-sufficiency, and equitable workforce participation. By engaging Medicaid members as part of the solution, the model supports both health equity and economic mobility, outcomes that resonate deeply with state policymakers and community advocates alike.

Reframing “High-Risk” as “High-Potential”

Too often, Medicaid members labeled as “high-risk” are defined by cost or utilization patterns, not by their potential contribution to community health transformation. Our model challenges that narrative. By investing in the very people the system was designed to serve, we convert risk into resilience and dependency into empowerment.

This approach is more than a program—it is a movement toward shared accountability and community ownership in healthcare delivery. Every face-to-face visit represents not just a metric achieved, but a relationship rebuilt; not just a cost avoided, but a life stabilized.

As MCOs, FQHCs, and state agencies continue to innovate within Medicaid’s evolving landscape, partnerships that blend care coordination, workforce development, and value-based performance will define the next generation of public health infrastructure.

Conclusion

The future of Medicaid transformation lies in connection—between systems, providers, and the people they serve. By training members, empowering communities, and integrating data-driven field coordination, we can achieve what policy alone cannot: true, sustainable engagement that keeps people healthy, housed, and hopeful.