Assessing Equitable Implementation of a Social Care Initiative Integrating Medical and Social Services for Medicaid Members.

Abstract

Objective: To assess the equitable implementation of a case management program integrating medical and social services for Medicaid members.

Study setting and design: This qualitative study assessed the equitable implementation of a case management program in Contra Costa County, CA. Study participants were identified using purposive sampling. Semi-structured interviews were conducted in person or by phone.

Data sources and analytic sample: Primary data were collected between Fall 2019 and Spring 2021 and included 92 semi-structured interviews with patients (n = 31), case managers (n = 47), and county administrators (n = 14). Data were coded using an inductive-deductive framework analysis approach informed by the Health Equity Implementation Framework (HEIF).

Principal findings: Characteristics of the innovation influencing equitable implementation included experienced public health nursing leadership and inclusion of social risk factors in a predictive algorithm determining patient program eligibility. Recipient factors included inequitable emotional demands of medical and social service integration work on case management teams from diverse racial/ethnic and training backgrounds, and patient experiences of mistreatment from medical and social service institutions. Clinical encounter factors highlighted the necessity for trust building between patients and case managers and the importance of multidisciplinary expertise to address patients' interconnected medical and social needs. Contextual factors described organizational readiness in the form of multidisciplinary teams with reduced hierarchical power imbalances, system-wide investments in a universal data infrastructure and data insights team, and strong intra- and inter-organizational partnerships. Societal factors included systemic discrimination and racism, insufficient affordable housing and public transit, pervasive administrative barriers in accessing health and social services, and federal funding for holistic approaches to integrated care.

Conclusions: Case management programs aiming to equitably integrate social and medical services should invest in multidisciplinary case management teams, organizational readiness for equitable implementation via committed, experienced leadership, and interventions to address systemic factors hindering the engagement of historically marginalized groups.