Addressing Chronic Disease Management in Medicaid Populations 

April is National Minority Health Month, a meaningful opportunity to recognize the importance of equitable care in managing chronic conditions across all communities. For Medicaid case managers, particularly those working with Black and Hispanic populations, chronic diseases like diabetes, hypertension, and asthma present complex challenges—deepened by systemic barriers and social determinants of health (SDoH). 

The Reality: Health Disparities in Medicaid Chronic Disease Care 

Recent research makes the need for targeted solutions clear: 

• Diabetes: Hispanic adults are 1.3x more likely than non-Hispanic white adults to be diagnosed—and 1.2x more likely to die from complications. 
• Hypertension: Black Americans are 40% more likely to have high blood pressure, but less likely to achieve control. 
• Preventive Care Gaps: Black and Hispanic Medicaid enrollees are 28% less likely to receive recommended services.
• Pandemic Impact: COVID-19 caused a 31% greater decline in preventive visits among minority Medicaid beneficiaries. 

These disparities highlight the importance of meeting Medicaid members where they are—with empathy, education, and the right tools. 

What Works: Community-Centered Strategies That Make a Difference 

1. Tailored Education that Resonates

• Ensuring culturally relevant materials go beyond translations, and that they reflect lived experiences, diet, and family dynamics. 
• Community Health Workers (CHWs)—especially those from the communities they serve—play a vital role in increasing preventive and chronic care engagement. 
• Faith-based programs see stronger participation rates, especially in Black communities. 

2. Tackling Social Determinants Head-On

• Programs providing non-emergency medical transportation have reduced missed appointments by up to 27% among minority Medicaid members with chronic conditions. 
• Food prescription services and food bank partnerships are improving diabetes control. 
• Housing support can lower asthma-related emergencies among pediatric Medicaid members. 

3. Tech That Connects, Not Confuses

• Remote Patient Monitoring (RPM): A 2024 Health Affairs study demonstrated that RPM programs for Medicaid members with hypertension closed racial disparities in blood pressure control by 42% when combined with culturally competent care coordination.  
• Programs pairing technology with digital literacy training show higher engagement rates among older minority members with chronic conditions. 
• Telehealth-enabled services have decreased readmission rates among Hispanic members with chronic conditions. 

4. Stronger Community-Clinical Partnerships

• Collaborative networks bring together healthcare providers, social services, and local organizations. 
• Community pharmacists increase adherence among Black Medicaid members with multiple chronic conditions. 
• Peer support groups empower better self-management behavior among Hispanic members with diabetes. 

MedScope’s Comprehensive System for Closing Gaps in Medicaid Care 

At MedScope, we believe effective care starts in the community. Our approach combines cultural awareness, personalized outreach, and easy-to-use technology to help Medicaid members take control of their health. We have developed a complete system to help Medicaid case managers reach difficult-to-engage populations and close critical care gaps through a blend of emergency response technology, remote monitoring, and culturally tailored communication. 

Emergency Response System (ERS) with Built-In Engagement 

• Two-way communication connects case managers directly with members for wellness checks, screenings, and follow-ups. 
• AI assistance delivers personalized reminders, health tips, and culturally relevant education. 
• Live wellness team support adds a human touch when needed. 

Omni-Channel Outreach for Maximum Reach 

• Phone, direct mail, email, and in-device messaging—we meet members where they are. 
• Engagement strategies are customized by preference, language, and cultural nuances. 

Integrated Remote Patient Monitoring 

• Condition-specific tools track diabetes, hypertension, COPD, CHF, and more. 
• Early alerts notify care teams before problems escalate. 
• Interfaces are designed for simplicity and accessibility, regardless of age or tech comfort. 

Built for Case Managers. Designed for Equity. 

Every part of MedScope’s platform is created to help case managers: 

• Reach previously disengaged members. 
• Close care gaps with timely interventions. 
• Support chronic condition management with personalized education and reminders. 
• Identify and address issues before they lead to crises. 

We’re committed to helping Medicaid programs deliver care that’s not only equitable, but effective—for every member, in every community. 

The Path Forward 

National Minority Health reminds us that health equity requires action. For Medicaid case managers, that means implementing strategies that address the unique challenges minority communities face in managing chronic disease. 

By combining culturally tailored outreach, strong partnerships, and smart technology, we can make meaningful strides toward better outcomes. 

MedScope remains committed to supporting Medicaid case managers with the tools, insights, and partnerships needed to deliver equitable, effective chronic disease management for diverse communities. Our comprehensive system that combines ERS technology, omni-channel outreach, remote monitoring, and analytics provides the infrastructure needed to reach even the most difficult-to-engage Medicaid members and ensure they receive the care they need to manage chronic conditions effectively.  

Learn more about MedScope’s Medicaid solutions at medscope.org.

National Patient Safety Week in March reminds us that ensuring patient well-being requires a healthy balance between technology and compassionate care. As Medicaid case managers navigate an increasingly complex healthcare landscape, integrating digital solutions while maintaining meaningful personal connections is essential to enhancing both patient safety and overall experience.

The Role of Technology in Patient Safety

Technology continues to transform healthcare, reducing errors, improving efficiency, and enabling proactive patient monitoring. Several evidence-based advancements are making a significant impact:

• Personal Emergency Response Systems (PERS): A comprehensive study published in Managed Healthcare Executive found that PERS technology, when integrated with analytics, resulted in a 68% decrease in 90-day readmissions, a 53% decrease in 180-day readmissions, a 49% reduction in EMS encounters, and a 31% decrease in hospitalization costs. These findings underscore how PERS enables Medicaid case managers to drive earlier interventions and reduce care costs while supporting aging-in-place initiatives critical to Medicaid home and community-based services programs.
• Remote Patient Monitoring (RPM): Studies show RPM has reduced hospital readmissions by up to 76% for Medicaid beneficiaries with chronic conditions, offering real-time insights into patient health and allowing for earlier interventions by case managers.
• AI-Driven Alerts & Predictive Analytics: Research from Johns Hopkins University demonstrates that AI-based systems have achieved a nearly 20% reduction in sepsis mortality by detecting early warning signs and enabling timely clinical responses—particularly beneficial for vulnerable Medicaid populations.
• Electronic Health Records (EHRs): EHRs play a crucial role in patient safety by reducing medication errors and improving care coordination, allowing case managers to access accurate and timely patient data across the Medicaid care continuum.

While these innovations significantly enhance patient safety, they should complement—not replace—the critical role of human connection in Medicaid care management.

The Importance of Human Connection

Despite advancements in digital health, personal interaction remains the foundation of quality, person-centered care. For Medicaid case managers, fostering meaningful relationships with beneficiaries leads to improved outcomes by:

• Reducing Anxiety & Improving Compliance: Evidence shows that strong case manager-beneficiary relationships improve medication adherence and care plan compliance. When Medicaid members trust their care team, they are more likely to follow prescribed care plans, reducing complications and hospitalizations.
• Enhancing Trust: A survey by the Beryl Institute found that 64% of patients prioritize compassionate care in their healthcare experience, highlighting the importance of personal engagement—especially for Medicaid beneficiaries who may face additional social determinants of health challenges.
• Improving Health Outcomes: Programs of All-Inclusive Care for the Elderly (PACE), which emphasize personal interactions within a Medicaid framework, have demonstrated a significant reduction in emergency room visits among participants, showcasing the impact of integrated, person-centered care models.

By balancing digital solutions with personal engagement, healthcare providers can ensure patients feel heard, valued, and supported.

Achieving the Right Balance

To maximize patient safety without sacrificing the human element, Medicaid case managers can:

1. Leverage Technology Thoughtfully: Use RPM and AI tools to enhance, not replace, human oversight and intervention, particularly for high-risk Medicaid populations.
2. Prioritize Empathetic Communication: Ensure that digital interactions do not overshadow the importance of personal connection, especially for beneficiaries with limited health literacy or technology access.
3. Use Data for Personalized Care Plans: Utilize insights from monitoring devices to develop tailored interventions that address individual Medicaid beneficiary needs and social determinants of health (SDoH).
4. Empower Beneficiaries & Caregivers: Educate Medicaid members and their support networks on how digital tools work alongside traditional care to enhance safety, independence, and self-management.
5. Invest in Hybrid Solutions: Consider solutions like MedScope, which blends technology with proactive engagement to support Medicaid case managers in closing care gaps and improving outcomes for complex populations.

How MedScope Supports Patient Safety for Medicaid Case Managers

At MedScope, we recognize that patient safety requires both innovative technology and compassionate care. Our solutions, including personal emergency response systems (PERS) and remote patient monitoring (RPM), empower Medicaid case managers with real-time data and actionable insights while ensuring beneficiaries receive the human support they need.

With MGEngage360, we bridge the gap between digital tools and personal engagement, equipping Medicaid case managers with the resources needed to intervene earlier, reduce hospitalizations, and enhance patient safety—all while optimizing limited program resources.

Patient safety in the digital age isn’t about choosing between technology and human care—it’s about integrating both effectively. As we observe National Patient Safety Month, let’s commit to rethinking our approach, ensuring that digital advancements enhance—not replace—the human touch at the heart of Medicaid care management.

Schedule a consultation today to learn how MedScope’s solutions can help you improve patient safety and engagement for your Medicaid population.

Cardiovascular diseases (CVD) are a top concern for Medicaid Managed Care plans. A group of disorders of the heart and blood vessels, CVD is the leading cause of death in the U.S., costing $251 billion a year in direct medical costs. Medicaid case managers and care coordinators play a critical role in improving cardiovascular outcomes, yet managing these high-risk populations and their complex needs has historically been a challenge. Through collaborative care models and innovative engagement strategies, however, plans can close care gaps, reduce hospital readmissions, and enhance member well-being. 

Addressing Cardiovascular Disease Among Medicaid Populations  

With rising rates of diabetes, obesity, cases of CVD are expected to surge in the coming years. By 2035, the number of those with CVD is projected to increase to 131.2 million—representing 45% or a staggering nearly half of the total U.S. population. of the total U.S. population.

(“Projected Prevalence of Stated Disease” page 7).

By 2035, the cost of CVD is expected to reach $1.1 trillion.

Disparities are also seen among these populations. CVD and its associated risk factors disproportionately affect many racial and ethnic groups, and account for nearly 40% of the disparity in life expectancy between black and white  individuals. Heart failure, in particular, is associated with higher rates of healthcare utilization and hospital readmissions among Medicaid populations. 

Research shows collaborative care models can improve care and result in 13% PMPM (per member per month) total health care cost savings, according to one study. With comprehensive strategies that include proactive, personalized care and the right technology, case managers can better support these high-risk patients, ensuring they receive the right care and support at the right time.  

Here are 3 key areas for Medicaid case managers to focus on:  

Take An Interdisciplinary Approach  

According to a 2020 scientific statement, the American Heart Association stated that interdisciplinary care is necessary to achieve optimal population cardiovascular health. An interdisciplinary team approach combines multiple specialties and subspecialties including general cardiology, interventional cardiology, primary care, nursing, social work, as well as members and their caregivers. Engagement solutions can empower case managers to deliver an interdisciplinary approach for managing cardiovascular populations. With phone outreach and 2-way voice communication through Personal Emergency Response Systems (PERS), these solutions improve access and close care gaps by helping members: 

• Identify primary and specialty care providers 
• Schedule screenings and follow ups 
• Adhere to prescribed medications
  

Invest In Digital Health Solutions  

Nearly 90% of health plan executives say remote monitoring devices are effective in managing chronic illness, allowing for more personalized and proactive care plans, a 2024 survey found. 

Remote Patient Monitoring (RPM) can help improve access to care, manage risk by monitoring blood pressure, for example, provide timely interventions, and drive patient engagement and treatment adherence.  

Several systematic reviews and meta-analyses show that RPM can improve CVD care management, including identifying clinical events faster, reducing hospital readmissions and mortality rates, and improving quality of life. In fact, a 2024 study among patients with respiratory or cardiovascular diseases found after 6 months of using RPM, the average number of ED visits and hospitalizations decreased by 58%.  

When paired with Remote Patient Monitoring (RPM), Personal Emergency Response Systems (PERS) empower care teams to track vitals, gain real-time data insights, and actively engage members in their care. Additionally, recognizing that movement is often the best medicine, newer PERS devices now feature a daily step-count function. This not only provides activity feedback to the user but also keeps caregivers and long-term care support coordinators informed. Even a small nudge—like wearing a PERS wristband—can encourage movement and help combat a sedentary lifestyle, making every step a step in the right direction. 

Address Social Determinants of Health (SDoH)  

Medicaid populations are more likely to have SDoH needs, unmet, non-medical needs that can drive between 80 and 90% of health outcomes. SDoH are linked to health disparities, inequities, and poor outcomes such as increased ED and hospital admissions.  

The percentage of people with CVD who face food insecurity has more than doubled over the last 20 years.

Among members with cardiovascular conditions, factors such as food insecurity, health literacy, language barriers, and “super” social determinants of health such as digital access and digital skills can affect their ability to engage in their care and adhere to treatment.  

To identify and address SDoH factors, close care gaps, and drive better cardiovascular outcomes, Medicaid managed care plans should consider engagement solutions that combine high-tech and high-touch approaches.  

These solutions combine RPM and PERS devices with a dedicated team of wellness advocates who proactively engage with members to facilitate preventative care. Advocates conduct outreach to identify needs and connect members to resources such as local food banks. They also ensure devices and equipment are properly tested, and provide support when a low battery is detected or members need help using the technology, for example. Targeted engagement campaigns can ensure members schedule their vaccinations and complete health screenings. With this unique approach, members receive personalized, proactive care that leads to better outcomes and lower costs.  

Improve Cardiovascular Outcomes With MedScope 

Engagement is the key to closing cardiovascular care gaps and improving outcomes among Medicaid populations. MedScope is a leading provider of PERS and RPM solutions, allowing care managers to deliver proactive, patient-centric care. Our AI-powered solution combined with our highly empathetic wellness team connect and build trusted relationships with members to close care gaps and drive engagement. Ready to enhance cardiovascular care for Medicaid populations? Schedule a demo or contact us today. 

National Senior Independence Month is the perfect opportunity for care managers to empower older adults with tools and resources that enhance their quality of life. Independence is key to seniors’ well-being, allowing them to maintain their dignity, confidence, and overall health. As a care manager, you play a crucial role in ensuring that seniors have the necessary support to live safely in their homes and engage actively in their communities. Here are four key areas where you can help your members maintain their independence and how MedScope, a Medical Guardian company, can support these efforts. 

Enhancing Safety at Home 

Creating a safe living environment is essential for maintaining independence. Here are a few recommendations care managers can provide: 

• Fall Prevention: Encourage seniors to install grab bars in bathrooms, use non-slip rugs, and ensure their homes have adequate lighting. 
• Medical Alert Systems: Equip seniors with a MedScope personal emergency response system (PERS) to provide immediate access to help in case of an emergency. 
• Remote Patient Monitoring (RPM): Utilize technology to track vitals, detect health concerns early, and reduce hospitalizations. 
• Home Modifications: Suggest ramps for wheelchair users, stairlifts, and easy-to-reach storage solutions to promote mobility and accessibility. 

Access to Healthy Meals 

Proper nutrition plays a vital role in seniors’ health and energy levels. Care managers can guide seniors toward nutritious meal options through: 

• Meal Delivery Services: Recommend programs such as Mom’s Meals, which deliver nutritious meals to seniors’ homes. 
• Grocery Delivery & Assistance: Suggest local grocery delivery services or volunteer programs that assist seniors with shopping. 
• Nutritional Counseling: Connect members with dietitians who can create customized meal plans based on their health conditions and dietary needs. 

Reliable Transportation Options 

Many seniors face transportation challenges that limit their independence. Care managers can help by: 

• Ride-Share Services: Introduce seniors to accessible ride-sharing programs like Lyft and Uber with senior-friendly options. 
• Public Transit Assistance: Encourage the use of senior transit programs that offer discounted fares and assistance for those with mobility concerns. 
• Community Volunteer Drivers: Research local organizations that provide free or low-cost rides for medical appointments, grocery shopping, or social outings. 

Encouraging Social Engagement & Mental Well-being 

Isolation and loneliness can impact a senior’s mental health and overall quality of life. Care managers can: 

• Promote Community Activities: Encourage participation in local senior centers, exercise classes, or group activities. 
• Virtual Connection Opportunities: Introduce seniors to video calling options like FaceTime, Zoom or Skype to stay in touch with family and friends. 
• Support Groups & Counseling: Recommend local or online support groups that provide emotional support and guidance for seniors dealing with aging-related challenges. 

How MedScope Supports Senior Independence 

MedScope, a Medical Guardian company, offers innovative solutions that enhance senior independence while providing peace of mind to caregivers and family members. Our Personal Emergency Response Systems (PERS) and Remote Patient Monitoring (RPM) services ensure that seniors receive timely assistance when needed. With 24/7 emergency response capabilities, MedScope enables seniors to live confidently in their homes and maintain their independence for as long as possible. 

Final Thoughts 

National Senior Independence Month is a reminder of the importance of empowering older adults to live fulfilling, independent lives. Care managers play an essential role in connecting seniors with the right resources and support systems. By prioritizing home safety, nutrition, transportation, and social engagement, care managers can make a lasting impact on their members’ well-being. 

At MedScope, we are committed to providing solutions that help seniors live safely and independently. To learn more about how our services can support your members, contact us today!

Medicaid managed care provides health care and long-term services and supports (LTSS) to more than 92 million people in the U.S. Medicaid and dual eligible members are vulnerable, hard-to-reach populations who often have a myriad of factors that affect access and outcomes, and drive healthcare costs.

Disparities in health and healthcare among underserved populations have led to higher rates of chronic disease, lower life expectancies, and poor health outcomes.  

Six in 10 Americans have at least one chronic disease and 4 in 10 have two or more. Chronic diseases are leading causes of illness, disability, and death and drive the $4.9 trillion in healthcare expenditures.  

32% of Medicaid enrollees rate their physical health “fair” or “poor.” 

How to Improve Engagement Among Medicaid & Dual Eligible Populations  

Finding effective engagement strategies to improve quality, close care gaps, and drive better outcomes among Medicaid and dual eligible populations has been a challenge for plans.  

These populations have unique needs and engagement isn’t one-size-fits-all, yet there are certain approaches that can start to move the needle on closing care gaps.  

Improve Care Coordination and Support

Gaps in access to care are an ongoing challenge in Medicaid populations. Provider shortages in low-income communities, lower physician payment rates, and participation in Medicaid are among the many barriers.  

Those who live in rural areas are also disproportionately affected. Compared to urban areas, rural communities have fewer primary and specialty care physicians. In fact, only 10% of physicians practice in rural areas, and over 65% of primary care Health Professional Shortage Areas (HPSAs) are located in rural or partially rural areas, according to the American Hospital Association.

Engagement solutions that combine digital health technologies, as well as human interaction, can help to improve access and close care gaps. These solutions include phone outreach and 2-way voice communication through Personal Emergency Response Systems (PERS) and provide members with support in identifying primary and specialty care providers, scheduling preventive care and screenings, medication adherence, and follow-ups.  

Identify and Address Social Determinants of Health (SDoH)

Between 80 and 90% of health outcomes are attributed to social determinants of health (SDoH)—non-medical factors such as economic stability, food insecurity, and health literacy. SDoH are linked to health disparities, inequities, and poor health outcomes such as increased hospital readmission rates.

While SDoH has been an increased focus in recent years, plans have more work to do. Among Medicaid and dual eligible members, 60% are less than fully satisfied with their care manager’s ability to provide access to essentials such as housing, food, utilities, or transportation, one survey found. 

Engagement platform solutions that conduct SDoH screenings to identify an individual’s factors and connect them to community resources such as medically-tailored meals can help close gaps in care and improve outcomes. These solutions may provide member education and support for those with low health literacy and limited English proficiency (LEP). 

Some solutions also have teams of wellness advocates who conduct proactive outreach to facilitative preventative care, ensure devices are working properly, and provide high-touch engagement and support, for example. 

Adopt Digital Health Solutions 

More than one-third of healthcare executives (36%) say that investments in technology platforms are a priority this year, a recent Deloitte survey found.

The adoption of remote patient monitoring (RPM) technology, in particular, is on the rise.  Between 2019 and 2021, remote patient monitoring (RPM) use among Medicaid members increased by more than 1,300%, a study in Health Affairs found.

Research shows RPM can improve patient engagement, adherence, and access to care, and reduce costly ED visits and hospital readmissions.

RPM, when integrated with personal emergency response systems (PERS), can monitor vitals, gather real-time data insights, and engage members in their care. Some platforms combine human and AI interactions to identify fall risks, provide preventative guidance, close care gaps, and allow members to manage their conditions. 

Implement a Multichannel Communication Strategy

Health plan executives are increasingly using multi-channel communication strategies to engage members and improve quality and outcomes. In fact, more than half of health plan executives (55%) have increased their member engagement budgets and about 75% say they have placed more attention on these departments, one survey found. 

A multichannel communication strategy can be an effective way to reach and engage members, meet them where they are in their journeys, build trusted relationships, and provide tailored communications and education that address member needs and preferences— boosting satisfaction and HEDIS scores.

Provide Proactive Care and Support For Older Adults  

Most older adults want to age in place, with 75% who say they want to live in their homes and about the same (73%) in communities, a recent AARP survey found.  

Many, however, are living alone and are at risk of hazards and falls around their homes. In fact, one in 4 older adults falls each year, but less than half tell their doctors. This drives up ED visits and hospitalizations. Each year, Medicaid pays $9 billion for medical costs related to non-fatal falls.  

Digital health solutions that include PERS devices monitor older adults 24/7, provide 2-way voice communication with operators, and include fall detection for members who cannot send an alert during an emergency. With round-the-clock monitoring and timely interventions, members have peace of mind knowing they have support when they need it most

Boost Member Engagement With Medscope

Engagement is the key to closing care gaps, better outcomes, and member satisfaction that boosts HEDIS scores and drives retention and loyalty. MedScope is a leading provider of RPM and PERS, allowing care managers to deliver patient-centric care. Our AI-powered solution in combination with our highly-empathic wellness team connect and build trusted relationships with members to close care gaps and drive engagement. To learn more about our solutions and schedule a demo, contact us today.  

Care management agencies and Managed Care Organizations (MCOs) face the challenge of efficiently managing Personal Emergency Response System (PERS) referrals and ongoing member support. CareManager360, a proprietary platform developed by MedScope, simplifies this process, offering a seamless, all-in-one solution for managing member populations and optimizing care workflows. 

A Smarter Way to Manage PERS Referrals 

CareManager360 revolutionizes the referral workflow, eliminating inefficiencies and providing a streamlined experience from start to finish. With its intuitive interface, care managers can: 

• Add New Referrals effortlessly, ensuring prompt enrollment of members. 
• Check Referral Status in real-time, tracking progress and required actions. 
• Monitor Installation Updates to stay informed about deployment phases. 

Comprehensive Member Management Tools 

Beyond referrals, CareManager360 offers robust capabilities for monitoring and managing active members: 

• View Active Members at a glance, providing instant visibility into member status. 
• Agency-Level Dashboard with key metrics, including button presses and dispatch trends. 
• HIPAA-Compliant Data Management, ensuring secure handling of member health information. 

Actionable Insights and Data-Driven Decisions 

One of CareManager360’s key strengths is its ability to provide deep insights into member engagement and PERS utilization. The platform generates valuable data to help care managers make proactive decisions, including: 

• Trends in Member Activity: Identify patterns in button presses, device activations, and emergency dispatches. 
• 7-Day No Signal Alerts: Receive early warnings when a device has gone inactive, allowing timely intervention. 
• Low Battery Notifications: Ensure that members’ devices remain functional by monitoring battery levels. 
• Monthly Utilization Reports: Track member participation and overall program engagement to assess effectiveness.

Enhanced Care Coordination & Efficiency 

By integrating CareManager360 into their workflows, care teams can enhance communication, improve efficiency, and reduce administrative burdens. The platform’s streamlined approach enables care managers to: 

• Improve Member Outcomes: Faster processing of referrals ensures that members receive their PERS devices promptly. 
• Optimize Staff Productivity: Automated tracking and reporting reduce manual data entry, allowing care teams to focus on delivering quality care. 
• Enhance Compliance & Security: With HIPAA-compliant protocols, CareManager360 ensures that all member data remains protected. 

Why Choose CareManager360? 

CareManager360 empowers care teams by offering an efficient, data-driven approach to PERS management. By integrating advanced reporting and tracking features, the platform enables care managers to make informed decisions and provide better member support. 

As a proprietary solution from MedScope, CareManager360 is uniquely designed to support the needs of care managers, ensuring that PERS referrals, installations, and monitoring are handled with precision and ease. 

Experience the Future of Care Management with MedScope 

MedScope has been a leader in personal emergency response systems and healthcare technology, developing solutions that enhance safety, efficiency, and care coordination. 

Discover how CareManager360 can transform your approach to care management—schedule your demo today!