This month (part one
of a two-part series), we begin by exploring CHW roles and revenue
opportunities across payers.
Next month, we will take
a closer look at how CHWs can provide a positive return on investment and
discuss specific opportunities involving direct reimbursement, Transitional Care Management (TCM),
Medicare Community Health Integration (CHI), Provider Delivered Care Management
(PDCM), and value-based reimbursement models.
CHWs and Michigan’s Leadership in Team-Based Care
Original Medicare, Medicaid,
and commercial payers recognize CHWs as bringing value to patient care, care
coordination, and population health. As
reimbursement opportunities expand, CHWs have become important members of the
healthcare team, bringing revenue and value to physician practices.
Michigan has long been
recognized for its commitment to team-based care and innovative payment models
that support care coordination. Through
initiatives involving Original Medicare, Medicaid, commercial payers, and
physician organizations, Michigan has actively demonstrated the value of
multidisciplinary care teams to improve patient outcomes, reduce avoidable
healthcare utilization, and reduce cost.
Programs such as BCBSM-developed
Provider Delivered Care Management (PDCM), patient-centered medical homes
(PCMH), population health initiatives, and Medicaid Community Health Worker
reimbursement have created opportunities for practices to expand care teams and
address factors influencing health outside the clinic setting.
CHWs are a logical and
natural extension of these efforts.
Their ability to support patients during transitions of care (e.g.,
emergency department (ED) visits, hospital discharges, and movement between
healthcare settings) aligns with the goals of improving care coordination and
strengthening patient engagement.
As healthcare continues moving
to value-based care, Michigan practices are strongly positioned to include CHWs
in broad strategies to improve outcomes, enhance patient experience, and
support financial performance across multi-payer programs.
Transitions of Care and the CHW: More than Community Outreach
One of the most valuable
roles for CHWs is supporting transitions of care.
Patients are particularly
vulnerable when moving between health care settings, such as:
- ED to home
- Hospital to
home
- Hospital to
Skilled Nursing Facility or Rehabilitation
- Skilled
nursing facility or rehabilitation to home
These transitions are
often overwhelming for patients and families/caregivers who may struggle to
understand discharge instructions, comprehend medications, schedule follow-up
appointments, arrange transportation, and access community resources. These challenges often result in lack of
primary care follow-up, return to ED, or possible avoidable readmission.
CHWs support patients and
families during transitions by:
- Following up
after ED visits or hospitalizations
- Reinforcing
discharge instructions
- Assisting
with medication access and adherence (within scope)
- Scheduling
primary care and other follow-up appointments
- Identifying
barriers that could lead to returns to ED or inpatient readmissions
- Observing and
escalating patient needs to the care team
By helping patients
successfully transition between care settings, CHWs support continuity of care,
improve patient self-management, and reduce avoidable utilization.
Reimbursement Opportunities Across Payers
When incorporated into
the care team, CHW services provide sustainable revenue for primary care
practices. Recognizing that this revenue stream extends beyond a single payer
is crucial.
Medicare
Original Medicare now
reimburses Community Health Integration (CHI) services that address care
coordination, social needs, patient navigation, and other activities that fall
within CHW scope and help patients successfully engage in care.
Medicaid
State Medicaid programs,
including Michigan Medicaid, now reimburse for CHW services. This creates opportunities for practices
serving Medicaid beneficiaries to integrate CHWs into care teams while
supporting improved patient outcomes.
Commercial Insurance
Commercial payers
increasingly support team-based care, care management, and value-based payment
arrangements that align with CHW services.
Many physician organizations participate in programs that reward
improved outcomes, care coordination, and avoidable utilization.
CHW Reimbursement: A Layered Approach
One of the most common
misconceptions about CHWs is that their value should be measured using a single
reimbursement mechanism. CHWs contribute
to direct reimbursement, quality performance, care management initiatives,
utilization reduction, patient engagement, and multi-payer value-based payment
programs. The greatest return combines
multiple payer programs and financial incentives. When making the decision to
employ CHWs, the meaningful question to consider is how many organizational
goals can CHWs help achieve?
For example, a CHW
supporting patients after ED visits may contribute to the following:
- Original
Medicare Community Health Integration (CHI) services
- Medicaid CHW
reimbursement
- Transitional
Care Management (TCM) services
- BCBSM-developed
Provider-Delivered Care Management (PDCM) goals
- Medicare
Advantage quality measures
- Reduced
hospital readmissions
- Reduced ED
utilization
- Improved
patient engagement and experience
Value-based care has
become a realistic goal. CHWs are essential to create value across all
payers.
The true value of a CHW
is not tied to one patient, payer, or billing code. More often, it is found in the combined
impact they create across the healthcare system.
Next month, in part
two, we will examine specific codes, direct reimbursement, and begin to
understand return on CHW investment.
