KEY FEATURES. In partnership with social service agencies and nonprofits, this Medicaid accountable care organization proactively identifies members most at risk and provides them with care coordination and social support. TARGET POPULATION. Low-income Medicaid beneficiaries with complex and unmet care needs related to serious mental illnesses, substance abuse problems, and other non-medical challenges. WHY IT'S IMPORTANT. New approaches are needed to reach and serve those newly eligible for Medicaid, who often use emergency departments as their main source of care. BENEFITS. Patients have a single point of contact for navigating both the health care and social services systems. Reduces need for acute care and thus medical costs, enabling shared savings and reinvestment. Early results suggest this approach may also reduce costs for jails and other publicly funded services. LESSONS. This work is extremely time- and resource-intensive, and may require payment reform and broader community participation to spread.
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