In this episode of Move to Value, Emily Volk, Director of Quality, Risk, and Compliance at Northern Regional Hospital, returns to share how her team is navigating the operational realities of Medicaid managed care. From the early challenges of inconsistent documentation and payer confusion to building smarter EMR templates and leveraging care coordination through CHESS, Emily offers a grounded look at how one small hospital is tackling big problems. She discusses the importance of automation, proactive outreach, and the power of partnerships to streamline workflows, reduce hospitalizations, and improve continuity of care especially in a rural setting.

I hope that we can arm patients with the information they need to take care of themselves at home. So we know of course everyone is going to need to come to the doctor or you know you might end up in the emergency department and

have a hospitalization. But for the most part, I think that the information and the care is available for people to largely remain at home where they're comfortable.

Welcome to the Move to Value podcast. In this episode, we pick up our conversation with Emily Volk from Northern Regional—this time focusing on how her team is navigating the red tape of Medicaid managed care. Emily breaks down the early headaches of documentation, how they’re solving for care continuity, and why their top priority is automating the noise so teams can focus on what matters. We discuss the early frustrations of manual reporting, why partnerships like CHESS have been game-changers, and how technology and teamwork are improving patient outreach.

Thomas Royal 1:09

OK. Emily, thanks for sticking around to continue this conversation. I want to, I want to touch on an area of expertise for you and that is documentation. Have you had to change any clinical documentation practices or care pathways to better support the managed Medicaid managed care reporting requirements?

Emily Volk 1:33

So initially, yes, this was a really heavy lift because there was not a really clear guidance from the health plans as to how we could report. And so it was very clunky. You know, we had to, we'd receive patient lists of our attributed patients and there were data points that we needed to gather. And so we could gather those internally, but then we couldn't transmit that back to the the health plan very succinctly. So it was a lot of manual work in the beginning and so that that was really taxing and very frustrating to be to be honest. However, now with the help of CHESS, that burden has really been lifted. And so you know, we built some note types in our medical records system. We built some templates and then some communication pathways for the CHESS care coordinators to communicate with our providers or with the clinical teams. That's simple and I am, I'm really looking forward to the partnership with CHESS in helping us with reporting this data because that I think was the biggest struggle that we encountered. So that that has been a really, really huge benefit to us.

Thomas Royal 3:08

That's great. I I know that that can really be a complicated mess at times.

Emily Volk 3:13

Yeah, it's terrible.

Thomas Royal 3:15

Well, in what ways has managed care improved or complicated the continuity of care for your Medicaid patients?

Emily Volk 3:23

I think it really has improved communication because patients have a point person who can get in touch with their provider pretty directly and so that is going to help us to meet the needs of our patients and then knowing who our patients are. So one thing that is a benefit is the health plans let us know you know these are your enrolled patients. This is who you are responsible to coordinate care for and so it helps us to identify and do outreach with those patients. So before you know we we didn't really have a good way of knowing who all of our Medicaid patients were and then with expansion, you know we were concerned about assuring that we we were able to serve the Medicaid patients in our service area and our our population, but having just some a little bit more clear information, a little bit more clear data has helped us to identify those that we serve.

Thomas Royal 4:31

Speaking of those you serve, what what systems do you have in place to track whether those patients are getting the preventative and follow-up care that the managed care is designed to promote?

Emily Volk 4:42

So we use the same systems that we have previously for all types of patients. So we're really fortunate in our electronic medical record, we have some templates in there or some systems that can capture when patients last, for instance, had their mammogram or when they had their annual physical or their vaccines or something like that. And so it helps us to be able to keep up on that. And then we have in our department, our care coordination department, we have just some phenomenal folks who track that information for us and then get it back to the provider. We really make strong efforts to get that information to providers ahead of the patient visit so that we know when that patient comes in, we know OK, we need to, they need to have their A1C checked to see how their diabetes is doing. Or they're due for their tetanus shot or you know, whatever other preventative care we can give to them. And so we some of that is manual, but a lot of it is teed up for us in our electronic medical record and I cannot underestimate the help that having CHESS as a partner has brought to the to the table. The data that they give us and you know care gap data is so valuable and then we of course validate all of that but having someone hand us a report that tells us here's what's missing is just so helpful. It's something that we would have had a hard time doing ourselves, even with our electronic medical record.

Thomas Royal 6:26

Well, as my mom always says, many hands make light work. So well, I know it's early, but are are you seeing any differences in health outcomes or patient satisfaction since the shift to managed care? And if so, what stands out to you?

Emily Volk 6:41

I think it's too early for managed Medicaid, but I definitely have seen differences in how health outcomes for the other patients that we participate in managed care for or value-based care, you know we see. We can point directly to less hospitalizations for patients. We do a every month we have a high utilizer review and so those high utilizer patients who are having frequent emergency department visits or frequent hospitalizations are on our radar and then we as a team work together to figure out how can we connect them with care because these hospitalizations are occurring in between these doctor visits. So how can we connect them with care to avoid having them have that high utilization. So I do anticipate for our Medicaid population, we're going to see the same. We'll see less hospitalizations, we'll see less emergency department visits. We'll see more access to medication, really more participation in their their own healthcare and being connected with their provider, communicating with care coordinators, just receiving the resources that they really need in order to stay home and stay healthy.

Thomas Royal 8:04

Well, that's definitely a good thing. How does managed care allow or perhaps limit your ability to address complex needs? I mean, we talk a lot about mental health. We talk a lot about substance use and housing instability right now in our in our country and I'm I know that that's a big determinant. How are you, how are you approaching this?

Emily Volk 8:28

So we struggle just like everyone else. You know, there is a terrible shortage of mental health professionals. We experience that pretty acutely in in a rural setting.

And so having access to social work through our partnership with CHESS and then our monthly care coordination meetings where we talk about specific patients and how we can help them, really allows us to address those complex needs and I think just having more people at the table and and having the history and experience of those people that are at the table helps us to see things or discover resources for our patients that we may have known nothing about because we haven't experienced that. So I think also the demographic variety in our teams is really helpful because there are resources that may be available in an urban setting that we just don't have, but it kind of opens our mind to, OK, how could we replicate that or how could we access that maybe in our area, maybe there's something virtual we can do. So just having, you know, more brains focused on these complex issues and complex needs that our patients have is really helpful. We I I will say that we have a great relationship with many of our community partners, you know like our our EMS folks, our substance abuse folks. We have some some clinics that serve low income patients here in our area that we partner with and so having a lot of community involvement has helped because that gives us some really right here local resources that we can tap into.

That's wonderful. Well, tell me what your top priorities moving forward in terms of expanding or improving, improving Medicaid managed care and value programs at Northern. What's on the horizon?

Well, we have always been pretty progressive as far as pursuing a technology solution, so I want to automate as much as we possibly can. And you know, there's there's a little voice in the back of my head that says you're gonna automate yourself out of a job. And maybe, maybe I will. I think that's coming probably for many of us, but the ability to reach more patients and see through data the impact that we are having, it's really one of my top priorities in in moving forward with moving forward with improving managed Medicaid and so we really try and leverage data and technology as much as we possibly can so that we can spend more energy on communicating with our patients and on giving compassionate care. You know, the less time we have to spend looking through reports and tabulating data, we can call patients and we can help connect them with, you know, a ride to come to see their primary care doctor or we can educate them about, you know, their stroke risk factors. There's so much that we can do personally if we don't have such a tech burden. So that's really been a a push for a long time for me is to figure out how can we automate all of this stuff that we need to gather and report so that we can really focus on patients.

Again, that would be, that would be a wonderful thing to see. That's that's that's that can eliminate any of the a lot of the confusion would be very helpful cause obviously we're all here to care for the patient and make sure that they have optimal help. Well, tell me now, now that you're you've gotten, you know the the 101 courses out of the way and the the virtual meetings and all of these other other things that probably don't have much time to do during the day, what what have you seen just from top of mind that if you could change or improve one part of the Medicaid managed care model, what would it be and why?

Less bureaucracy. I think it's this way with any any managed program where there are a lot of people that you've got to report to. There's a lot of different entities and there's a lot of hoop jumping. And so I would love if there could be less of that. If everything was done the same by each payer and you report the same way, you know there's been the the rollout I think anyone who participated in the early days of Medicaid managed care felt like it was extremely confusing because there was a different ask from every health plan and then, you know, just figuring out how to get information and get it back to them. So I would say less, less of that, less of the confusion, less of the bureaucracy. It's been really a struggle. Even now we struggle with this to know who our patients are, you know, who's assigned to us and to get a good clean patient list. So I am looking forward to once all of these kinks get ironed out, just a much smoother process of understanding who our patients are so that we can get started taking care of them.

Yeah, it's sometimes not knowing is that is a challenge. Well, Emily, First off as as a nurse first and then as a director of quality and risk and compliance second, which I'm not sure that's necessarily the case, but I feel like it is after after knowing you for for a little while, what's your biggest hope for how managed Medicaid, Medicaid managed care can improve patient outcomes?

I hope that we can arm patients with the information they need to take care of themselves at home. So we know of course everyone is going to need to come to the doctor or you know you might end up in the emergency department and

have a hospitalization. But for the most part, I think that the information and the care is available for people to largely remain at home where they're comfortable.

And so I think we see a lot of utilization of of care that we could probably avoid if we just communicate with patients, give them that compassionate care that they need and then touch base in between those doctor visits. And I think that's the whole goal of managed care. We we get preoccupied with a lot of, you know, what are, what do we have to do and who's got to do what and how do we report it? We get really distracted by all of those logistics. But I really hope that we can give patients what they need in order to take care of themselves.

Awesome. Is there anything that I haven't asked that you feel would be meaningful to this conversation?

Not that I can think of. We've covered a lot of ground today.

We certainly have and I appreciate your time. So Emily Volk, thank you for joining us today on the Move to Value podcast.

Been my pleasure. Thank you for the opportunity.