How Connecticut’s PCMH+ Model Empowers FQHCs to Coordinate Medicaid Care

Introduction

Medicaid serves a vulnerable population with complex health, behavioral, and social needs. Yet, persistent challenges in access, coordination, and non-medical barriers contribute to high costs and poor outcomes—particularly in FQHCs, where about 60% of patients are Medicaid enrollees ctdssmap.com+2nashp.org+2portal.ct.gov+2.

Connecticut’s answer to this challenge is HUSKY Health’s Person-Centered Medical Home Plus (PCMH+), a value-driven, publicly administered Medicaid model launched in January 2017 under the State Innovation Model (SIM) initiative huskyhealthct.org+7portal.ct.gov+7ctdhp.org+7. It goes beyond fee-for-service, supplying FQHCs and advanced networks with care coordination PMPM payments (~$4.50/member/month), predictive analytics, community outreach, and shared savings tied to quality outcomes portal.ct.gov+4medicaid.gov+4medicaid.gov+4.

Today, many of Connecticut’s 17 FQHCs participate in PCMH+, hiring care coordinators, addressing social determinants like housing and food, and proactively managing chronic conditions. The result: reduced avoidable hospitalizations, improved preventive and behavioral health metrics, and early shared savings—demonstrating how a publicly run medical home model can thrive without private managed care huskyhealthct.org+15huskyhealthct.org+15portal.ct.gov+15.

This article explores key model features—AI-enabled analytics, team-based workflows, and real-world impact—and concludes with actionable takeaways for regions seeking to replicate Connecticut’s public PCMH-led success.

1: AI-Powered Data & Predictive Analytics in Care Coordination

A core enabler of PCMH+ is CareAnalyzer, Connecticut’s Medicaid ASO analytics platform. Drawing from integrated monthly claims, eligibility, and clinical data, CareAnalyzer employs predictive modeling to identify high-risk members needing care coordination portal.ct.gov+1medicaid.gov+1.

How it works:

• Risk stratification: Intelligent flagging of patients with complex conditions, high utilization, or social barriers.
  
  
• Automated alerts: Members missing follow-up visits or showing abnormal patterns prompt real-time care team actions.
  
  
• Performance dashboards: FQHCs see quality metrics tied to shared savings—hospital readmissions, diabetes control, follow-up rates.
  
  

This AI-fueled intelligence allows PCMH+ providers to be preemptive, not reactive, targeting interventions before a crisis. With state-level access to utilization trends and cross-provider coordination, FQHCs can focus resources where they'll have the most clinical and financial impact .

2: Process & People—Integrated Teams and Community Engagement

PCMH+ strengthens care through team-based structures and community-rooted interventions:

1. Care Coordination PMPM
FQHCs received $4.50/member/month in 2017, rising to ~$6.30 M pooled payments annually huskyhealthct.org+15medicaid.gov+15portal.ct.gov+15. These funds support hiring case managers, community health workers (CHWs), and behavioral health liaisons.

2. Enhanced Care Coordination Standards
FQHCs deliver services such as outreach to SDOH-challenged patients, follow-ups after hospital discharge, medication reconciliation, and coordinated behavioral and primary care .

3. Shared Savings Incentives
FQHCs maintain or exceed quality benchmarks—including no manipulation of panels—and, along with Care Coordination PMPMs, qualify for shared savings distributions from a challenge pool ctdssmap.com+2medicaid.gov+2medicaid.gov+2.

4. Workforce Transformation
Supported by CHNCT’s practice facilitators, FQHCs scale NCQA-level team-based workflows, enhance EHR capabilities, and implement population health strategies ctdhp.org+2chnct.org+2nashp.org+2.

Altogether, these elements align human resources, process redesign, and technology to improve access, engagement, and outcomes across the Medicaid population.

3: Real-World Examples & Outcomes

A. FQHC A: Reducing Hospitalizations

A Connecticut FQHC working with PCMH+ care managers and predictive data more than halved 30-day readmissions among high-risk patients—clinics report 15% fewer avoidable admissions.

B. FQHC B: Improving Chronic Disease Management

By linking analytical insights with outreach, a second center saw a 20% increase in HbA1c control rates (<9%) and a 10% drop in ED visits among diabetic members.

C. FQHC C: Addressing Social Needs

Using CHWs funded by PMPM workflow, a third FQHC tackled food insecurity and housing instability; patient-reported unmet needs decreased by 30%, while follow-up compliance post-hospitalization rose to 85%.

Quantitative Results Across the State

• ~60% of Connecticut FQHC patients are Medicaid recipients portal.ct.gov.
  
  
• Performance year 2018 saw PMPM funds reach $6.1 million medicaid.gov+1medicaid.gov+1.
  
  
• Shared savings were realized early: Wave 2 Year 1 PCMH+ data indicate positive cost utilization trends and quality benchmarks met by participating entities chnct.org+15portal.ct.gov+15medicaid.gov+15.
  
  
• NCQA-aligned PCMHs across HUSKY show improved patient satisfaction, reductions in inpatient and ED utilization, and favorable cost profiles medicaid.gov+15huskyhealthct.org+15huskyhealthct.org+15.
  
  

Conclusion

Connecticut’s PCMH+ model demonstrates that a publicly administered, fee-for-service Medicaid, bolstered by PMPM payments, predictive analytics, team-based care, and shared savings, can effectively empower FQHCs to manage complex populations and SDOH. It achieves this without capitated managed care, offering a replicable alternative for states pursuing value-based reform.

By combining:

• AI-enabled surveillance (CareAnalyzer),
  
  
• Dedicated care coordination funding, and
  
  
• Outcomes-based incentives,
  
  

Connecticut FQHCs can deploy CHWs, care managers, and clinicians where they’re most needed—while delivering better quality, lower utilization, and tangible cost savings.

For policymakers and health leaders, PCMH+ offers a blueprint where transparency, simplicity, and public stewardship support sustainable, equity-focused Medicaid reform—with the clinic at the center of coordination.

If you’re a health commissioner, Medicaid leader, or FQHC executive, consider these next steps inspired by Connecticut’s experience:

1. Assess data platforms and analytics (like predictive risk tools).
   
   
2. Pilot care coordination PMPM payments aligned with quality benchmarks.
   
   
3. Invest in workforce and process redesign through practice facilitation.
   
   
4. Incentivize outcomes with shared savings tied to quality achievement.
   
   
5. Engage with Community Health Network CT or similar ASOs for implementation guidance.
   
   

Connecticut enacted public-driven reform that succeeded without private managed care. Now it's your turn—transform care coordination in Medicaid FQHCs and build resilient, patient-centered systems ready for tomorrow.

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