A program recently implemented through a partnership between MedZed and Molina Healthcare providing home-based medical care and social supports to high-risk Molina Medi-Cal members has significantly lowered hospital utilization rates in the San Diego area, according to MedZed Co-founder and Chief Medical Officer Neil Solomon, MD.
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The program provides longitudinal team-based care, with a primary care provider, nurse, and community health worker on each team. The program aims to help vulnerable populations become more medically stable by ensuring they get to all the specialists they need and teaching them self-management skills.
According to Solomon, the program targets individuals with complex medical and social needs, oftentimes unhoused individuals or individuals with housing challenges, with a major focus on health equity.
“We really focus on a population where health equity is a huge piece because many of these people have not previously had very good experiences with the healthcare system, they haven’t really felt the love of the system,” Solomon said. “We really find a way to connect with them—we have people from their own communities who are helping them and getting to know them and supporting them in ways that allow them to become more successful in their health and in their lives.”
The program teaches them how to navigate the typical healthcare system more effectively on their own, and identifies and addresses key social needs they may have, such as housing challenges, nutrition support, and safety issues.
Solomon added that they often use telemedicine in order to have more frequent and rapid interactions with these patients.
“When we can manage to [take] people to those [outcomes], then we can usually graduate them so they can go back to their usual source of care, their usual primary care provider and other providers and do so more successfully,” he said.
Explaining Molina’s choice to contract with MedZed on this work, Solomon said Molina identified significant need in San Diego and was aware of MedZed’s successful work in this area in other California markets.
“Having a service that can find [individuals from high-risk populations] and come to them, that they can get to know, trust, and work closely with [so that] each of the individuals can build up their skills and their confidence to be able to manage and navigate [the healthcare system] would be helpful.”
With the program now in its second year, Solomon said MedZed and Molina will continue to expand the number of people enrolled in the program across the county, as well as the services provided, particularly with behavioral health and palliative support.
“We’re all pleased with the results after the first year—we’ve helped a lot of people, we’ve reduced their need to go to the emergency department and the hospital, their costs are less … It’s been a successful first year, and so now [we’re] thinking about expanding the program.”
He emphasized the importance of supporting these vulnerable populations, especially with so many beneficiaries having unstable housing.
“There are at least 161,000 Californians who are homeless. That’s a gigantic number, and that’s just those who are known to be homeless, which is clearly an undercount of how many people actually are experiencing homelessness. And then you have all the people who are one step away from being homeless, if they’re kicked out of somebody’s house if they miss one more rent payment. There’s all kinds of reasons why people are teetering on the edge, and there’s so many of them, so we need to find ways to support this population.”