Medicaid Transformation Project… Ballad Health improves care for vulnerable populations

Published 4:07 pm Tuesday, August 11, 2020



JOHNSON CITY – Ballad Health is pleased to announce the results of its participation in the Medicaid Transformation Project (MTP). The results of the full project can be found in the recently published Phase One Report, which summarizes its first two years of work.

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Through the MTP, Ballad Health and 29 other innovative health systems have been working together for two years in a national, collaborative effort to transform healthcare and related social needs for the nearly 75 million Americans who rely on Medicaid.

“When we formed Ballad Health, we knew we had a singular opportunity to create something new and transformational – not just for our region, but for healthcare nationally,” said Anthony Keck, Ballad Health’s executive vice president of system innovation and chief population health officer.

“And in all the ways we’re redefining what healthcare means for the Appalachian Highlands by investing in our communities, expanding access and bolstering services, we’re also examining how we can continue to shape and shift from providing healthcare services to promoting overall health.

“That’s why we were so honored and excited to take part in the Medicaid Transformation Project – to partner, collaborate and share ideas with other innovative and like-minded health organizations that want to make substantial, effective changes that can strengthen the future of healthcare – providing an enormous benefit not just nationally, but, most importantly, to the people, we’re privileged to serve.”

Since its launch in 2018, MTP has generated more than 150 actions across its member health systems, including the launch of new mobile apps, increased virtual visits and dissemination of mobile devices to monitor patients, as well as operational changes to extend care beyond the brick-and-mortar walls of hospitals and doctors’ offices.

Through Phase One of the project, Ballad Health and other providers focused on how they could advance the health of vulnerable communities in high-impact and sustainable ways.

Ballad Health implemented community health workers as a mechanism to reduce unnecessary emergency department visits, shifting Medicaid patients’ care from that high-cost, resource-intensive setting into a more appropriate outpatient facility, such as primary care providers’ offices.

The community health workers also helped patients identify social determinants of their health, such as food and housing insecurity, and worked to find solutions and paths to success.

Ballad Health enrolled 257 patients in the program, who in a short time had a cumulative 588 emergency department visits prior to the start of the project.

Of those 257 patients, 118 successfully graduated the program, with 93 linked to a long-term support resource, 48 reporting no emergency room visits or re-admissions during the project and 85 attending all scheduled follow-up appointments, including many who brought their community health worker with them.

“As multiple social, biological, behavioral and environmental elements contribute to our overall health, it truly takes a multidisciplinary, well-rounded approach to address the issues that plague our healthcare system and limit people’s ability to reach their optimal level of health and well-being,” said Greg Neal, president of Ballad Health’s Northeast Market, who helped lead and implement the project.

“We’ve been fortunate to bring in new community health workers, who work in tandem with our other talented, compassionate team members and physicians, as well as numerous community partners, to address different aspects of health and make a tangible difference in hundreds of lives.”

Neal cited multiple successful patient encounters that resulted from the project, including a patient who expressed interest in establishing a relationship with a primary care provider but canceled her initial appointment.

The assigned community health worker made weekly check-ins and facilitated a successful appointment, even attending alongside the patient and helping her seek further care and understand medications for her heart, neurological system, thyroid and back pain.

Beyond medical care, the community health worker helped the patient identify a food insecurity and provided her with long-term food support resources through local food banks and food delivery services.

The community health worker also worked with the patient to evaluate the pros and cons of her current residence in a local hotel, vs. finding long-term stable housing.

“Community health workers are the missing link to provide hands-on, boots-on-the-ground support for our region’s most vulnerable populations,” said Allie Verlander, Ballad Health’s community health worker manager.

“Community health workers are integral to bridging the gap between Ballad Health and an array of community providers, such as our regional departments of social services, insurance providers, transportation departments, mental health providers, homeless shelters and non-profit human service agencies such as the United Way and Bristol Faith in Action.

“Community health workers have an innate gift because they can draw from their own stories and experiences to help them relate to the patients they compassionately aim to support.”

Phase One Results

Phase One of AVIA’s MTP consisted of member organizations representing 378 hospitals in 28 states. Findings reveal members are embracing new digital solutions and innovative care models across four key areas:

  • 81% of members are improving care in the community to help people rely less on the emergency department
  • 64% of members are helping people with acute behavioral health needs
  • 75% of members are closing gaps in care for moms and babies
  • 38% of members are increasing access and support for people with substance use disorders

The MTP is led by AVIA, with support from Andy Slavitt, former acting administrator of the Centers for Medicare & Medicaid Services (CMS) and general partner at Town Hall Ventures.

“Healthcare needs to work for everyone. Coronavirus disease 2019 (COVID-19), financial hardship and racial disparities have only heightened the need to improve care for the vulnerable and communities of color,” Slavitt said.

“The health systems in MTP strive to be leaders in this fight. Two years ago, they dedicated themselves to serving underserved communities. Using innovation to serve these forgotten populations has never been more important.”

The report reveals 72% of all actions involve using technology in disruptive but beneficial ways. The project vetted more than 400 digital health solutions with a rigorous evaluation model, including evidence-based research, to help its members make informed technology decisions that can improve care delivery for those who need it most.

MTP produced a best-in-class list of companies that could solve member challenges and advance evidence-based care models; 43% of these companies are led by women and people of color.

Additional findings, trends and success stories are available in the Medicaid Transformation Project Phase One Report, free for download.

The MTP is continuing into Phase Two, which will welcome payers, community health centers and other regional partners to find new ways to collaborate that drive greater, more sustainable and local impact.

Health systems, payers and other organizations interested in joining the Medicaid Transformation Project can visit or email for information.

More information about Ballad Health’s community transformation and public health initiatives can be found at