PICO National Network, Bring Health Reform Home

How might we improve the quality of healthcare for high-need patients while lowering Medicare and Medicaid costs?

Project Dates: August 2010-March 2013

Services: Advisory and Strategic Planning, Ethnographic Research, Political Research, Stakeholder Engagement, Coalition Building, Training and Facilitation, Program Design, Event Planning and Mobilization, Partnership Development, Training Materials and Toolkits, Staff Coaching, Project Management


High-need Medicare and Medicaid patients living in underserved communities don't have access to good healthcare options, often ending up in emergency departments and suffering repeat hospitalizations due to lack of primary care. This results in poor health outcomes for patients and sky-high costs for Medicare and Medicaid.   



Establish local teams of doctors and social services to provide intensive care to high-need patients in their home environment. Improve patient health outcomes and generate savings to Medicare and Medicaid by interrupting patterns of emergency room use and hospitalization. Ensure sustainability by reinvesting captured savings generated for Medicare and Medicaid into local primary care practices. 



  • Oversaw a collaboration between Rutgers University Center for State Health Policy, The Center for Healthcare Strategies, and The PICO National Network to secure $20 million dollars in funding from the Center for Medicare and Medicaid Innovation to rapidly advance the development of an innovative care management strategy for high-cost, high-need populations from low-income communities in four sites across the country.  
  • Led early development of a Learning Network among four diverse communities in San Diego, California; Aurora, Colorado; Allentown, Pennsylvania; and Kansas City, Missouri, building capacity for this approach and supporting local partners to establish strong coalitions among local primary care, behavioral health, social services and public health organizations.
  • The project engaged 2,425 high-cost, high-need Medicaid, Medicare, and uninsured patients across the four communities in assertive care management, leading to estimated savings of $67.7 million over three years.
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