Results Summary
What was the research about?
Medicaid is public health insurance for people who don’t have insurance and can’t afford to pay for it on their own. Women who are new to Medicaid may need help getting care from a primary care doctor, such as regular checkups or vaccines.
In this study, the research team wanted to learn if an offer by phone for support from a community health worker helped women new to a Medicaid health plan get care. Community health workers teach people about health and link them to health services. The team compared two groups of women. In one group, health plan staff called women and offered assistance from a community health worker. In the other group, women didn’t receive a call offering community health worker assistance. All women in the study got standard health plan information.
What were the results?
Overall, the study found no difference in getting care from a primary care doctor between women that health plan staff called and those who they didn’t call. However, health plan staff couldn’t reach 78 percent of the women they called.
Who was in the study?
The study included 2,267 women ages 18 to 39 who had just joined the University Family Care Medicaid health plan in southern Arizona. Of these, 39 percent were white, 15 percent were other races, 32 percent were Hispanic, and 14 percent didn’t indicate a race or ethnicity. The average age was 27.
What did the research team do?
The research team assigned women to one of two groups by chance. Health plan staff called women in the first group to offer them help from a community health worker. Staff tried calling women three times. They called at different times and days of the week and left a message if no one answered the phone. The second group didn’t get a phone call from health plan staff. After six months, the team looked at healthcare records for women in both groups to see if the groups differed in whether they got care from a primary care doctor.
What were the limits of the study?
The research team designed the study to look at whether the offer of community health worker support was helpful to women in getting primary care. The study didn’t compare women who worked with community health workers with those who didn’t.
Future studies could look at other ways to offer help to women new to Medicaid.
How can people use the results?
Health plans could consider the results from this study when deciding how to offer help to new members.
Professional Abstract
Objective
To examine whether a health plan’s offer of support from a trained community health worker (CHW) helped women newly enrolled in Medicaid to access primary care and preventive services
Study Design
| Design Elements | Description |
|---|---|
| Design | Randomized controlled trial |
| Population | 2,267 women ages 18–39 newly enrolled in the University Family Care (UFC) Medicaid health plan for people living in southern Arizona |
| Interventions/ Comparators |
|
| Outcomes |
Primary: use of a primary care provider, defined as at least 1 visit to a primary care provider in the first 6 months after enrollment Secondary: receipt of recommended preventive services (defined as at least 1 visit for immunizations or any of 5 reproductive screenings recommended by the US Preventive Services Task Force), avoidable emergency department visits and hospitalizations (defined as the number of emergency department or hospital visits for conditions that a primary care physician could have appropriately managed) |
| Timeframe | 6-month follow-up for primary outcome |
This randomized controlled trial examined whether offering CHW education and navigation support to women who recently enrolled in a large Arizona Medicaid health plan helped these women access primary care.
The study included 2,267 women ages 18 to 39 living in southern Arizona and newly enrolled in the University Family Care (UFC) Medicaid health plan. All women in the study had access to standard health plan information. The health plan randomly selected 1,521 women to receive a telephone call offering them CHW services. UFC call center staff attempted to contact these women three times and left recorded messages when calls were not answered. For women who were reachable by phone, staff offered CHW services including a 30-minute in-person planning session to discuss preventive services and educational resources and two follow-up calls. The remaining 746 women did not receive an offer to use CHW services.
Among study participants, 39% were white, 15% identified as other race, 32% were Hispanic, and 14% did not indicate a race or ethnicity. The average age was 27.
Using six months of Medicaid data, the research team examined differences in healthcare utilization between the women selected to receive the telephone offer of CHW services and those not selected.
An advisory board of UFC administrators, providers, and patients and representatives from the REACH Pima County Cervical Cancer Prevention Partnership and the Arizona Community Health Workers Association provided input to the research team during the study.
Results
Of the 1,521 women randomized to receive a telephone call offering CHW services, 78% were not reached by phone. Of the 331 women successfully contacted by phone, 48% accepted the offer and received support from a CHW.
Primary care use, receipt of recommended preventive services or immunizations, and avoidable emergency department visits and hospitalizations did not differ between the women in the group selected to receive an offer of CHW services and those not selected.
Limitations
UFC staff were unable to contact most of the women randomized to receive a call offering CHW services. As a result, the actual number of women who accepted the offer of CHW support was small; this may explain the study results. The study did not examine healthcare utilization outcomes for women who received CHW support compared with other study participants.
Conclusions and Relevance
Relying on phone contact information from the UFC health plan to offer additional services to Medicaid enrollees was ineffective. Combining telephone contact with other outreach methods may be more effective.
Future Research Needs
Future studies could examine other ways for health plans to offer support to new enrollees, such as through direct interaction with patients in local clinics or hospitals, or multimodal attempts to reach patients, such as texting, emailing, and direct mail in addition to telephone contact.
Final Research Report
View this project's final research report.
Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented and the researchers made changes or provided responses. Those comments and responses included the following:
- Reviewers noted that the report’s conclusions overstated the success of the intervention since most of the differences favoring the intervention were not statistically significant. The researchers explained that since the nonsignificant findings were in one direction, it was reasonable to assume that the intervention had some effect. However, with further urging from reviewers, the researchers removed the assertions that the intervention affected outcomes despite the lack of statistically significant differences.
- Reviewers pointed out that a major finding of the study related to the reachability of study participants, rather than the intervention outcomes. The researchers acknowledged this point and added language to their report describing their lessons learned about contacting and engaging participants. The researchers argued further that despite the very low participation and completion rates for the intervention and control groups, the results could be generalizable to other populations.
- Reviewers expressed concern about the potential for post-randomization selection bias. The study randomized participants before inviting them to the program itself, which meant that people who entered the program could differ from those who did not, as well as from those participants randomized to the uninvited group. Therefore, it is possible that the benefits seen in the intervention group were because the participants who were easier to contact to issue the invitation to were also those who would respond better to the intervention. The researchers acknowledged this potential confounder but were not comfortable concluding that the observed benefit among program recipients was due entirely to the ease of contacting such recipients about participating in the program. However, the researchers revised their conclusions to acknowledge the potential effect of selection bias for as-treated analyses.