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LanguageENES

Five populations, each with its own borders

A member who is hard to reach is usually blocked by something specific: a phone number that changed, a language, a missing ride, a fear nobody asked about.

The barriers differ by plan type, so the work does too. Here is how we approach each population we serve.

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Representative image: a grandmother, two parents and two children laugh together on their front steps
Representative image: a young mother smiles at her baby as she pushes a stroller down a sidewalk
Representative image: an older man with a cane walks arm in arm with a home care aide in a park

number verified, member reached

Representative images, not real members or staff

Representative images, not real members or staff

Representative image: an older couple cooks dinner together in their kitchen
  • Published result 12:1 ROI for risk adjustment (RAF) A Medicare Advantage plan

Medicare Advantage

Older members managing several conditions and several prescribers, often wary of one more unknown caller.

What gets in the way

  • Several chronic conditions and several prescribers, with no one holding the whole picture
  • Hearing, vision or mobility limits that make phone calls and trips harder
  • A healthy suspicion of unfamiliar callers
  • Caregivers who are central to decisions but hard to identify

What we do

A coordinator takes the time to explain, groups screenings into as few trips as possible, follows up on statin and blood-pressure refills, and makes sure conditions are documented at real visits so risk adjustment reflects the member’s health.

Representative image: a father holds his two children’s hands at a neighborhood bus shelter
  • Published result 10% Reduction in total cost of care A Medicaid plan
  • Published result 19% Reduction in inpatient and ER utilization A Medicaid plan

Medicaid

Members whose phone numbers, addresses and work shifts change faster than any eligibility file.

What gets in the way

  • Phone numbers and addresses that change often
  • Hourly work and childcare that leave little room for appointments
  • Food, housing and transportation needs that come before care
  • Gaps that span a whole household: a child’s checkup, a parent’s screening

What we do

We keep contact information verified, address the social needs first, and work the household as a whole, so one trusted outreach closes several gaps and keeps members out of avoidable ER visits.

Representative image: a home health nurse talks warmly with an older man in his armchair
  • Published result +22 Weighted Star improvement A D‑SNP plan

Dual Eligible Special Needs Plans

Members with the highest needs and two sets of benefits to navigate.

What gets in the way

  • Medicare and Medicaid benefits that are confusing to use together
  • Multiple chronic conditions and frequent hospital transitions
  • Social needs layered on top of medical ones
  • Long gaps between a discharge and the next primary care visit

What we do

ADT feeds tell a coordinator when a member has been admitted or seen in the ER, so the follow-up starts with the transition. Coordinators help members use both sets of benefits and stay with them through the appointments that keep them well.

Representative image: a young man takes a phone call on his lunch break, smiling
  • Published result 99% HEDIS® SNS-E intervention rate An Exchange plan
  • Published result 96% Improvement in the HEDIS® CBP measure An Exchange plan

Exchange and ACA plans

Members new to coverage, or new to using it, who need help turning a plan into a first visit.

What gets in the way

  • No established primary care doctor
  • Uncertainty about what preventive care costs, often nothing
  • Coverage that changes from one year to the next
  • Unscreened social needs behind missed visits

What we do

Coordinators help members choose and see a primary care doctor, explain the preventive benefits they already have, screen for social needs and act on what they find, and follow up on blood-pressure control between visits.

Representative image: an older man fishes from a lake dock with his grandson

Veterans

Veterans who get care in more than one place and respond to people who take the time to listen.

What gets in the way

  • Care spread across more than one system
  • Long distances to appointments, especially outside cities
  • Reluctance to ask for help, and to talk about mental health
  • Follow-up that falls between providers

What we do

A coordinator helps a veteran keep track of appointments across the places they receive care, arranges transportation, and calls after each visit until the next step is clear.

Each figure is one plan’s published result, shown with its plan type. None is an average across plans, and none is a guarantee.

Results across populations

Whatever the plan type, the work aims at the same four results.

  • Star Ratings

    Adherence, screenings and member experience, the measures behind CMS Star Ratings.

  • HEDIS® gaps closed

    Preventive screenings, blood-pressure control and social need screening and intervention.

  • Avoidable ER and inpatient use

    Earlier care and follow-up after a hospital stay, so fewer crises reach the ER.

  • Satisfaction and retention

    Members who were helped by a person they know have a reason to stay.

Tell us which members you need to reach

Start with one population and one measure. We will show you how coordinators would approach it.

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Representative image: two older men laugh as they walk their small dogs down a leafy street

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Representative images, not real members or staff