A New Model of Care

Medicaid recipients struggling with Serious Mental Illness (SMI) face countless systemic barriers that prevent them from accessing the care and support they need to get and remain well in their communities.  Gaps in the healthcare system and inadequate funding have often broken their trust in traditional community providers. As a result, these individuals frequently utilize hospital emergency departments for care, which have traditionally failed to address their true needs, causing repeat visits and inpatient stays that drives up the cost for managed Medicaid organizations (MCOs) without any improved outcomes for the individual. 

These gaps in care and exorbitant costs have, for decades, required an innovative solution that has remained elusive. At firsthand, we have taken on the challenge of finding a meaningful, scalable and lasting solution to this long-standing behavioral healthcare problem. We are addressing the unique challenges and needs of this population through a peer-led approach. Certified Peer Recovery Specialists (CPRS) are at the front lines, building relationships with individuals directly in their communities. They are able to tap into the power of empathy and lived experience to rebuild trust and dramatically improve care outcomes for individuals living with SMI.

Our peer Guides use their lived experience of SMI to support individuals in obtaining socio-economic assistance and in developing and maintaining successful primary care and behavioral health relationships.  In addition, firsthand care teams employ social workers (Community Resources Guides), medical assistants (Health Guide Associates), and clinicians (Health Guides) to ensure comprehensive assessments and provision of care. Behind the scenes, our support teams in operations, clinical, engineering, and  IT work to enable the frontline teams to build high-quality human-to-human connections through our custom internal software. Support like this creates millions of dollars in savings for taxpayers by decreasing inappropriate healthcare utilization by Medicaid members.

The Problem: Transportation

firsthand teams operate in large and medium size cities such as Nashville and Memphis, Tennessee and Youngstown and Cleveland, Ohio. While the firsthand peer-led model immediately proved successful at engaging high-cost users of hospital care in their homes, transportation emerged as a prominent challenge to accessing community-based clinics and resources. Insufficient public transportation systems meant that low-income individuals with complex medical needs could not attend specialist care appointments, exacerbating their reliance on emergency care. 

While Uber Health and other ride sharing services appeared as an alternative, they were not devoid of drawbacks - high cost and a lack of wheelchair accessible vehicles. Beyond transportation, many of the individuals firsthand serves lack traditional support systems who they can depend on for rides, and often experience cognitive difficulties which make it particularly challenging to plan the steps necessary in remembering and attending an appointment outside the home.

The Solution: Peer-Assisted Telehealth

Confronting these challenges brought us to a realization that technology could play a role in bridging the transportation gap.  However, our experience had also informed us that many of our individuals either lacked access to technology or were not proficient in using telehealth tools, requiring assistance in both aspects. We saw that our CPRS team members could stand at the forefront of this necessity, serving as both technology and relationship conduits. Technology and fostering tech literacy are crucial to the individuals we serve, not only in managing their mental health, but in achieving a greater sense of independence as they advance in their recovery. 

In search of a solution, we ran a pilot integrating technology with the empathetic touch of peer support guides to facilitate healthcare access. We began in the city of Nashville with Adam, a clinician, and Michelle, a peer supporter. Michelle engages individuals who have traditionally been high-cost users of hospital systems. As she works to support them with their social needs, she connects them to Adam for an in-depth health assessment within 90 days of enrollment. She and Adam coordinate visits and determine those in need of telehealth visits due to transportation issues. They then allocate one day a week solely for these visits.

On this day, Michelle goes to the home of her first individual, sets up the telehealth visit and connects the individual to Adam. Once the individual is comfortable, she moves to the next home and gets that individual set up while Adam is conducting the first assessment. We found that this method not only maximized the time of our care team, but also drastically reduced no-shows rates.

Previously, our internal data was showing a 50% no-show rate in the population we serve. However, when guided by peers, we found that appointment attendance skyrockets, with no-show rates diminishing to below 35%. It is not rare for Michelle to show up at an individual’s home at the time of an appointment to find them asleep, and she is able to wake them and prepare them for a productive assessment. Although technology has opened new gateways to healthcare, it wouldn't be complete without the human touch. This is particularly true for those grappling with social or technological barriers, or those requiring additional support.

Beyond ensuring appointment consistency, peer support guides like Michelle can also bridge critical gaps in healthcare. As the peer relationship forms, individuals develop a deep level of trust and comfort and often share concerns with their peer that they don't share with their clinician, such as the side effects of medication or changes in health (new cough, rash etc.).  With this knowledge, the peer can inform the clinician, who can then set up a wellness visit and do a deeper dive. As telehealth becomes an integral part of our daily lives, the firsthand model has been able to successfully implement a blend of technology and face-to-face peer support. The strategy highlights the power of human-technology partnerships in creating more inclusive and effective healthcare services. By focusing on technology adoption in the homes of our individuals, we have improved our reach and efficiency.

This approach not only boosted our service delivery, but has also elevated the status of our peers to stakeholders in the clinical relationship, imparting them with a greater sense of purpose and meaning. Our approach has led to a significant reduction in ED use, with an annualized rate of 565 ED avoidances per 1,000 engaged individuals. This is a substantial stride towards better, more efficient community mental healthcare. 

Feedback and Iteration: The Importance of Humility and Flexibility

As a value-based healthcare company, we understand the need to be agile, both in perspective and action. We regularly scrutinize and update our practices based on feedback from our peers and the entire care team. The direct experiences they share with us not only guide our present, but also shape our future strategies. We discard what isn’t working and amplify what does into best practices, such as the peer-assisted telehealth strategy that Adam and Michelle piloted.

Our goal is to provide the best patient care, while also delivering cost savings to Medicaid programs and taxpayers. Our peers, care team and the individuals we support are critical partners in this. With their feedback, we refresh our strategies, ensuring they remain effective, compassionate and empowering. With every shared idea, every piece of advice, every experience, we have an opportunity to enhance our care, and improve healthcare outcomes.

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Article written by: Mark Graham, VP of Operations at firsthand.