24/7 Tech-Enabled Care Extension for Serious Mental Illness Populations With Medical Comorbidities

Illustration of providers, payers, and Mindoula

The Psych/Med Population Health Management Program deploys teams of tech-enabled care extenders to deliver 24/7 care coordination and psychosocial support to members with serious mental illness and medical comorbidities. By focusing on the most complex and difficult to engage members with behavioral health challenges and medical comorbidities, the Population Health Management Program able to reduce the total cost of care by 30% - 50% for many of a payer’s most expensive members.

How does the program work?

We analyze claims data and other payer information to risk stratify members with behavioral health diagnoses and medical comorbidities and generate a member outreach list. The Mindoula care extender team then uses telephonic and on-the-ground outreach to engage eligible members and enroll them in the program. Hand-picked teams of four tech-enabled Mindoula care extenders, supervised by psychiatrists, are assigned to each enrolled member and provide 24/7 virtual and in-person support. Using proprietary psychometrics, predictive analytics, the Mindoula Messenger secure texting app, and multi-platform engagement tools, Mindoula care extenders help high cost members address both medical and social determinants of their health.

Key program elements:

The SMI Psych/Med Population Health Management Program helps members:

  • Get mental health and substance use treatment
  • Find food, housing, transportation, and other community supports
  • Arrange transportation to take members to medical appointments
  • Access community resources, including legal services
  • Complete applications for benefits and assistance
  • Schedule appointments
  • Navigate the healthcare system
  • Access and coordinate with payer’s contracted provider network
  • Access and coordinate with payer’s case management programs
  • Fill prescriptions and stay on track with medications
  • Coordinate home care and other home-based services
  • Address challenges and crises, 24/7
  • Understand payer programs & benefits
  • Use technology to improve their health and well-being