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Center issues report on benefits of expanding Missouri’s Primary Care Health Homes Program for the chronically ill

Photo: Zach Vessels – Unsplash

The Center for Health Economics & Policy has released a report suggesting that Medicaid recipients can receive better quality, comprehensive home care by expanding the state’s “Primary Care Health Homes” (PCHH) program. The program currently enables patients with at least two chronic health conditions (heart problems, diabetes, etc.) to receive extra help managing their health care. In addition to seeing a primary care doctor or nurse practitioner, patients also benefit from a team approach of care that includes a nurse care manager, a care coordinator, a behavioral health consultant or other professionals such as a dietician, pharmacist, or a community health worker.

The team approach might include calls to ensure patients have appropriate medications, or to discuss medication side effects, reminders of upcoming appointments, or discussion about health or social concerns. Social workers or community health workers connect patients with the resources they need like food stamps, transportation vouchers, and affordable housing applications. The goal is to support patients who already have multiple health complications, by staying on top of their health and minimizing preventable and costly emergency department visits or hospitalizations. In its latest report, the Center for Health Economics & Policy recommends taking the current health home model one step further.

We spoke with Tamara Sánchez Ortíz, WUSM student author of the report, about why her team’s findings are important for Medicaid patients across the state.

What was the impetus for creating this report?

Since it is one of the single largest budget items in Missouri’s state budget and covers about one million Missourians, Medicaid carries a lot of heft in the healthcare system. In fall 2020, when we came up with the idea for this report, we saw the expansion as an opportunity to re-think how Missouri Medicaid (also known as Missouri HealthNet Division) could better structure some of its programs to provide better quality care while remaining cost-effective. The idea of leveraging Primary Care Health Homes (PCHH) to meet these “triple aim” goals (I.e., increased access, higher quality care, cost controls) stemmed from a “Transforming Health Care in Missouri” event hosted by the Center for Health Economics & Policy in August 2020.

Additionally, as a current medical student and future primary care doctor, I have a personal interest in finding different ways to provide coordinated, thorough health care. This includes addressing mental health and other issues that affect patient health outcomes such as lack of access to fresh fruits and vegetables, or safe, mold-free housing; or, exposure to trauma (I.e.: interpersonal violence or a caregiver with a history of incarceration or drug-use.)

How will expanding PCHH fit within the new Missouri Medicaid expansion and benefit Missourians?

The PCHH program is for Medicaid patients only, so by expanding Medicaid, more Missourians may be eligible for the PCHH program and will benefit from the added support this care model provides. Medicaid expansion is expected to help more than 250,000 Missourians gain access to Medicaid and its programs. According to, many Missourians struggle with multiple chronic health conditions (11% have three or more chronic health conditions, like arthritis, diabetes, and asthma), so it is likely that many of these newly eligible residents will qualify for the PCHH program.

“It’s a relatively simple concept: increasing funding to enable extra patient support by the PCHH program can make all the difference in a person’s life. In our research, we heard many moving stories about patients whose lives are transformed because they received proper assessment of their health problems and appropriate treatments or, they moved into stable housing. Some gained access to medical equipment and healthy foods or received mental health counseling. Most agreed that they have become healthier, more productive members of their community.”

Tamara Sánchez Ortíz

How will expanding the program be more cost-effective for Missouri? 

Hospitalizations and emergency department visits are two of the most expensive health care costs. By providing more proactive support to PCHH patients in lower-cost settings, we can help decrease the need for patients to get medical attention at a hospital ER, and help prevent complications that require hospitalization.

What were a few of your suggestions in the report for expanding the current PCHH program?

In addition to supporting Medicaid expansion and thereby PCHH, a Medicaid-sponsored program, this report proposes the following top three suggestions for improving PCHH in Missouri:

  • Broaden the list of qualifying conditions: Currently, a person must have MO Medicaid and two or more chronic conditions to participate in the PCHH program. Our report suggests expanding that list of qualifying conditions to include other debilitating health problems like chronic liver disease, sickle cell disease, or inflammatory bowel disease.
  • Systematically incorporate upstream factors of disease into the care evaluation plan: Documenting a patient’s social determinants of health (like asking whether a patient has safe, stable housing) should become a standardized part of patient care. There are many useful screening tools that can be used across the state to measure and monitor these factors. Since traumatic childhood experiences (physical/mental abuse or neglect and household dysfunction) can also affect adult health, our report also argues that adverse childhood experiences should also be assessed and documented as part of patient care.  
  • Formally add Community Health Workers to the PCHH team to help address issues that are not immediately medical but that could affect patient health, if not addressed: Currently, some PCHH nurses report feeling overwhelmed because they not only provide direct medical care (e.g. taking blood pressure, giving vaccines, drawing blood), but also help patients with social issues such as applying for medication discounts. Our report suggests adding Community Health Workers into the PCHH model. They are members of the community with added health training, and often know the neighborhood and its resident’s social norms and cultural practices. Given their access to local contacts, these workers can connect patients with resources, help make patient health education more relatable, and motivate patients to engage in health goals in a culturally-appropriate way, perhaps even in a patient’s preferred language. Community Health Workers are shown to improve patient health outcomes, so our report suggests that they could be very helpful members of the PCHH team.

What were the main conclusions you drew from your research?

The PCHH program in Missouri has been successful at improving patient health. According to a 2019 report published by the Missouri HealthNet Division, the state has seen a 35% reduction in ER visits, a 35% reduction in hospitalizations, and fewer cases of high blood pressure, cholesterol, and blood sugars. Since the program began in 2012, and due to a reduction in ED visits and hospitalizations PCHH is estimated to have saved Missouri Medicaid at least $5.7 million. PCHH partucipants like the program because they feel personally cared for—they know they can call their care team with medical, transportation or social questions. Likewise, they know their PCHH team is looking out for them and will conduct random check-ins; call them after hospitalizations, and give reminders of up-coming medical appointments.

Health care providers like this program because it allows them to provide the best patient care through a team approach as well as increased time and resources for comprehensive patient care.

Read the full report, Expanding the Primary Care Health Home Model by Tamara Sánchez Ortíz, MD/MPH candidate, and Abigail R. Barker, PhD, Center for Health Economics & Policy, Washington University in St. Louis