2.d.i- Implementation of Patient Activation Activities to Engage, Educate, and Integrate the uninsured and low/ non-utilizing Medicaid populations into Community Based Care

  • Increase patient activation related to health care while increasing resources to help gain access to primary and preventative services
  • Focus on patients who are not interacting with the healthcare system for various reasons 


Care coordination / patient navigation / population health

  • Obtain list of PCPs assigned to NU and LU enrollees from MCOs; along with the member's MCO and assigned PCP, reconnect beneficiaries to his/her designated PCP (see outcome measurements in #10)
  • Baseline each beneficiary cohort (per method developed by state) to appropriately identify cohorts using PAM® during the first year of the project and again, at set intervals- baselines, as well as intervals towards improvement, must be set for each cohort at the beginning of each performance period
  • Contract or partner with CBOs to develop a group of community navigators who are trained in connectivity to healthcare coverage community healthcare resources (including for primary and preventive services) and patient education
  • Ensure direct hand-offs to navigators who are prominently placed at “hot spots,” partnered CBOs, emergency departments, or community events, so as to facilitate education regarding health insurance coverage, age-appropriate primary and preventive healthcare services and resources
  • Ensure appropriate and timely access for navigators when attempting to establish primary and preventive services for a community member
  • Perform population health management by actively using EHRs and other IT platforms, including use of targeted patient registries, to track all patients engaged in the project

Change management

  • Include beneficiaries in development team to promote preventive care
  • Develop a process for Medicaid recipients and project participants to report complaints and receive customer service

Clinical protocols / standard of care

  • Measure PAM® components (list provided)

Community support

  • Contract or partner with community-based organizations (CBOs) to engage target populations using PAM® and other patient activation techniques - the PPS must provide oversight and ensure that engagement is sufficient and appropriate
  • Identify UI, NU, and LU “hot spot” areas (e.g., emergency rooms); contract or partner with CBOs to perform outreach within the identified “hot spot” areas

Patient and family engagement

  • Survey the targeted population about healthcare needs in the PPS’ region
  • Increase the volume of non-emergent (primary, behavioral, dental) care provided to UI, NU, and LU persons


  • Establish a PPS-wide training team, comprised of members with training in PAM® and expertise in patient activation and engagement
  • Train providers located within “hot spots” on patient activation techniques, such as shared decision-making, measurements of health literacy, and cultural competency
  • Train community navigators in patient activation and education, including how to appropriately assist project beneficiaries using

PMO Project Representatives:

Kendal Pompey - PompeyK@mail.amc.edu

Mark Quail - QuailM1@mail.amc.edu

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