From Medicare to Medicaid: Scaling Value-based Care with Emily Volk

Emily Volk 0:05

One of the biggest benefits to partnering with someone for managed Medicaid was access to data and we had found through our managed Medicare work that because we're a small hospital, as you said earlier, most of us wear multiple hats, we're stretched. Having help collecting and then aggregating and also reporting that data has been a huge benefit to the organization

Thomas Royal 0:37

Welcome to the Move to Value podcast. Today, we’re talking with Emily Volk, Director of Quality, Risk, and Compliance at Northern Regional Hospital—a small rural facility that’s made a big name for itself in Medicare value-based care. Now, they’re taking that experience and applying it to the world of Medicaid managed care.

From navigating limited resources to building powerful partnerships and reaching patients where they are, Emily shares how her team is improving outcomes and expanding access—without losing sight of what matters most: patient care.

Thomas Royal 1:10

Emily Volk, welcome to the Move to Value podcast.

Emily Volk 1:13

Thank you. I appreciate the opportunity.

Thomas Royal 1:15

Emily, can you tell me about your role at Northern?

Emily Volk 1:19

Sure. In the almost nine years that I've been here at Northern, I have been in the quality management department. So I started as an ACO care coordinator. That was my first title and moved through several positions to, now I serve as the director of

quality, risk and compliance. Our department is large. Well, it has a large responsibility. It has a small number of people. So we have responsibility over, of course, quality data collection and reporting, accreditation, and then ACO participation of course with everything that entails like gap closure, cost monitoring, care coordination and our department also includes the hospital's infection prevention program as well as the medical staff office. So we have a really broad reach. I often say that quality management touches every part of our organization in one way or another.

Thomas Royal 2:27

That's great. I know that you wear a lot of hats. You guys do a lot of great work. You cover a lot of space and you do it very well. You recently, very recently began offering Medicaid managed care. Can you, can you paint a picture about the range of services offered and where care management sits within that ecosystem and how it supports the overall health of your patients?

Emily Volk 2:53

Sure. And you're right, we're very early in this. We did, at the time we started managed Medicaid, we had partnered with CHESS for several years, but the CHESS Clinical Integrated Network was not yet set up for Medicaid. And so we began with participation in managed Medicaid with only two contracts, 2 payer contracts and we had one care coordinator for that entire population, so it was obviously unsustainable. You know, one person cannot manage all those people. The other thing that was a little bit difficult is we're such a small hospital that we don't have, you know, social workers, we don't have pharmacy consultants, we have pharmacists.

But because they're heavily involved in, you know, acute hospital care, it it didn't really lend itself to managed Medicaid participation and so the range of services that we were able to offer in the beginning was extremely narrow. Now that we are part of the CHESS Clinical Integrated Network for Managed Medicaid, we have access to so many more resources. We have multiple care coordinators who are out reaching our patients, We have access to social work to help with transportation, food, housing, insecurity, all of the, you know, social barriers to care. We have access to pharmacy consultation, which is fantastic. That's something that is really, really valuable to our patients not only to help them with cost, but also, you know, when there's medication changes or if there's something that they are taking that could be optimized, switching to a different medicine or you know, all of those different types of things. That really has helped us to increase the level of care coordination and access to care in that population.

Thomas Royal 5:03

That's great. I I do know that that we we do see a lot of success coming out of of your team and and it's it's been it's made everyone very happy and I'm sure that it's made your patients delighted to know that their their health is is a top priority.

How did your work in value-based care lead to this next step of of managed care and what has that transition look like operationally?

Emily Volk 5:28

Well, once we when we first started to hear rumblings about managed Medicaid, we had been in partnership with CHESS for several years. We knew the value of the resources that we had utilized in managed Medicare. And so we we reached out and said, are you guys going to start managed Medicaid? Because we really valued that partnership. One of the biggest benefits to partnering with someone for managed Medicaid was access to data and we had found through our managed Medicare work that because we're a small hospital, as you said earlier, most of us wear multiple hats, we're stretched. Having help collecting and then aggregating and also reporting that data has been a huge benefit to the organization and then also having access to, we had experience with CHESS social work. We had experience with CHESS pharmacy team and knew how beneficial that could be to our patients for accessing, you know, food pantries in our area or transportation options or getting their medications filled or delivered, you know, in a way that could keep them on track with their health. So our really positive experience with CHESS in in managed care or value-based care really pushed us toward them with managed Medicaid.

Thomas Royal 7:04

Well, since Medicaid's expanded in North Carolina, what changes have you seen in terms of access or patient volume?

Emily Volk 7:11

We have seen an increase in our Medicaid population in the, it was kind of slow in the beginning and we anticipated when we first had our rollout that we would see this huge, you know, increase in Medicaid patients, but it didn't happen that way it.

But our payer mix really has seen a noticeable shift with Medicaid expansion and we we already had quite a large Medicaid population in our pediatric clinic, but we have seen the the Medicaid enrollees come in through all of our practices and in our hospital as well.

Thomas Royal 7:48

Well, Speaking of that population, how do you make sure care management works for patients who face the typical barriers, language barriers, culture? Some folks don't trust the healthcare system. Have you had any outreach efforts or changes that have helped?

Emily Volk 8:04

Yeah. And I think there's two main, I guess I could call them pillars in our care management efforts. And really this, it bleeds into every part of patient care, I think, and those are communication and compassion. And our care coordination team is very good at communicating with our patients about the barriers that they're encountering, getting them access to care. Compassion, of course, plays a role in that because when we feel compassion toward our patients, we can empathize with what they're going through, we work a little bit harder to help them and we communicate a little bit better. And so because we're a small hospital in a rural community, we know a lot of our patients or we know their families or we have a family member who is in the same situation. As they might be in and so it's a little easier for us to understand what is or is not going to work for them. So I'm really proud of our care manage our care coordination team. We we have a lot of good, strong, positive relationships with our patients and that has really expanded into our CHESS team as well. So it's not just the care coordinators here at Northern, but because there's really good communication between the care coordinators and our providers. You know, it really connects those patients to care and helps to work out some of the kinks in getting them access that they need.

Thomas Royal 9:45

Well, have you seen any challenges, you know, specific to Medicaid or even access challenges overall that may be specific to the rural communities that you serve, such as Mount Airy?

Emily Volk 9:57

Yeah, we do have. I think that those challenges are pretty broad. You know, they're going to affect our entire most of our patient population and those are things typical to rural communities. So there are transportation issues. We don't have public transportation, you know, we don't have buses and things like that. So patients do struggle at times with that. We do have some options in the community that our social workers help to connect patients to and then financial, you know, that's kind of related to transportation is financial issues. Especially over the last few years with the economy the way it is and and inflation and you know, grocery prices are high and fuel is high. And so patients struggle with just making their co-pay sometimes or they may be out of work. So those are the types of things that we see. We do see some educational limitations. That's not just specific to Medicaid. That's kind of across the board in rural communities. And so not just, you know, scholarly education, but health education, you know, understanding the importance of taking your medication every day instead of, you know, trying to ration that because of cost, it can really lead to negative outcomes and so we do a lot of education. That's part of that communication piece, educating patients about the importance of seeing their primary care doctor or, you know, taking their medications regularly or just how to take care of themselves. At home so that they can stay where they are the healthiest and the happiest.

Thomas Royal: 11:47

That's good stuff. Well, tell me, Emily, what's working well so far and and maybe what are the biggest operational or data challenges in implementing this program and how did you guys overcome that?

Emily Volk: 12:00

So I'll start with the biggest challenges because we're a small hospital, you know, we have less than 1000 employees. And so we don't have a lot of the resources right at our fingertips that we need to implement a large care coordination program. So data definitely is huge. You know we we can see when patients access our organization and in and we do have access to information from other surrounding hospitals, but really getting all of the information about our patients access to care from all of the places they go is a big challenge for us and I know it is for other hospitals as well, but what has worked really well for us is to partner with CHESS and be able to access a larger network of resources. So you know, CHESS helps us to gather data, helps us to kind of aggregate that to know what that data means to us and what we can do with it. And then having access to just more people to do the work. You know, us trying to utilize one or two people to call all these patients proactively to help them get their appointments scheduled or to make sure they keep them, that is it is almost an impossible task for us to do on our own without a partner. And so that has been our our biggest help that has worked more than anything else is partnering with somebody who has some resources that we can utilize to help our patients.

Thomas Royal: 13:51

Well, is there anything that you want to call out that's working well or would that be a, would that be a combo response?

Emily Volk: 13:59

Well, I think I would say the the proactive outreach for patients, so meeting them where they are, you know, being able to contact patients in their home and that's one one great benefit of care coordination is sometimes patients don't feel connected to their healthcare. They only see their provider maybe once a year, or they might have an emergency department visit, but all of that time in between, they may not know, you know, am I taking this medicine right? Or should I be feeling this way? Or how can I get better access to my medication? So those kind of things, I think being able to contact patients in between visits, manage not only their, you know, strict clinical care that they're receiving, but help them with all of the other things that affect their ability to remain healthy. That is what's working. I think the best for us is being able to reach patients in that in between time.

Thomas Royal: 15:10

Outstanding. How does managed care under Medicaid affect how patients interact with providers? You know, we just talked about how they seem a little disconnected with their with their healthcare and I I see that I feel that way a lot of times.

I'm not quite on the on the on the Medicare bandwagon just yet, but I'm getting there. So you know, compared to traditional Medicare, how does how does this work under Medicaid?

Emily Volk: 15:42

So I think it's a little bit different for Medicaid patients. We, there's a lot of focus on Medicare in our country. You know, we hear a lot about Medicare beneficiaries and here's what you can access and there's a lot of programs. And so we're starting to see that happen in the Medicaid realm. And a lot of times we just think about Medicaid applying to pediatric patients or, you know, unemployed patients. But the reality is there's there's a huge population now with Medicaid expansion of folks that you work with, that you shop with, that you go to church with, who have Medicaid. And so all of those benefits that we have seen available to Medicare patients, they're going to be a little bit different in the Medicaid population here and there. But I think all of those things are now becoming available in the Medicaid population to really reconnect them with their provider. So that that becomes true in, like I said in that in between time between your visits with providers, someone is reaching out to say, how's everything going with your physical therapy or, you know, did you get the

the durable medical equipment that you needed, did you get your nebulizer machine? Are you getting your oxygen? Did you, were you able to pick up your medications or did they get delivered from the pharmacy? So it's just someone having a little bit of a an in-between check kind of see what's happening with those patients and then even for issues like loneliness, you know, there's a care coordinator who's going to reach out and call them probably every month and and touch base so that they can kind of just be a person, a point of contact so that they patients know I don't have to do this by myself, I don't have to try and figure it out by myself and if I have a question I have somebody to call.

Thomas Royal: 17:56

Yeah, that loneliness is something that I don't think gets talked about near enough. Well, tell me what strategies you found that have worked best for provider buy-in for care management because you know, clinical time stretched so thin and nobody has time to do everything throughout the day. Does this seem like a hurdle for your providers or is it something that seems to be be widely accepted or or gaining momentum?

Emily Volk: 18:22

So this is something I'm really excited to see emerge because we have seen it with Medicare, with our Medicare patients. And so you are right, providers are stretched just like the rest of us. You know there's pressure to keep clinic running and get patients in and out and and increase volumes and all of that kind of stuff. And so having an intermediary like a care coordinator is really helpful to providers because they can keep their clinical day going knowing that the care coordinator is touching base with patients. They're going to alert them to an issue. They'll come to them and say, hey, you know, so and so is having difficulty with this medication. They have a side effect. What are the options? Can we switch it to something else? The provider can give that feedback that takes just a short amount of time and then have confidence that the care coordinator then will take care of it with the patient, they'll finish the rest of the process and so you know, they can pretty quickly resolve issues that if they were left to do that by themselves, would take a ton of time that they just do not have. And then that care coordination hopefully keeps patients out of the emergency department. You know, we can avoid an inpatient admission or some, you know, oftentimes a really terrible consequence just for one small thing that the care coordinator is able to take care of. So it's a you know it goes right back to team, team based approach. The more people you have to help, the easier it is to take care of patients.

Thomas Royal: 20:03

Well, that's great. Emily, we're coming up on time and I was hoping that you could stick around for a few minutes so that we could continue this conversation.

Emily Volk: 20:11

Sure, happy to.

Thomas Royal: 20:13

Great.