SBIR Phase I: Reaching "unreachable" Medicaid Members and Building Bridges to Care

What are the broader impacts of the proposed activity? This SBIR Phase I project redefines how Medicaid recipients access health care. Over 75 million low-income Americans receive health care coverage through Medicaid, but socioeconomic barriers intrinsic to this population make it difficult to navigate the system. Many face challenges including housing insecurity, food poverty, substance abuse and lack of support that further inhibit the ability to obtain basic health care. Without earlier interventions, the most vulnerable individuals are prone to rely on hospital emergency departments for care - a vicious cycle that is costly to health care organizations and patients alike. Increasingly, community-based organizations (CBOs) such as food pantries, mobile health clinics, resource centers and shelters have emerged as survival touch points. As non-profits with limited resources, however, CBOs lack infrastructure for recordkeeping and reporting. The proposed technology addresses the data management needs of CBOs through a free and configurable web-based application that builds longitudinal profiles on the clients served. In turn, this application creates value for health care organizations by alerting care management teams when respective members visit a CBO and establishes a channel for earlier as well as preventive forms of engagement. The proposed technology extends the reach of health care organizations into the communities where Medicaid members reside. This entails equipping CBOs with a free client management application that improves organizational bandwidth and access to funding through streamlined data reporting. On the back-end, a matching engine ingests member enrollment files from health care organizations and queries the CBO database for unique linkages. When matches are found, care management teams at health care organizations receive notifications on the status and location of difficult to reach as well as vulnerable members. Subsequently, they can communicate bidirectionally with CBO staff that directly serve Medicaid members and have stronger relationships. CBO staff are provided with guidance on best practices to engage their clients and effectively serve as extensions of the care team. With at least 400,000 CBOs across the country, this approach has the potential to activate a vast network of existing infrastructure and dramatically improve care coordination for those on Medicaid. During this proposal period, an end-to-end solution will be implemented that links Medicaid members to their respective health care organizations and transforms CBOs into technology-enabled gateways to health care. Furthermore, the feasibility of the proposed technology will be evaluated for Phase II considerations. This award reflects NSF's statutory mission and has been deemed worthy of support through evaluation using the Foundation's intellectual merit and broader impacts review criteria.