Make time to connect: Advice from the Monarch HealthCare team on medical management for the Medicaid population

Nancy Boerner, MD, MBA, Chief Medical Officer, Monarch HealthCare and Optum Care Pacific West Region


Serving the Medicaid-eligible population presents unique challenges. 

With the help of a social worker-led team of patient care coordinators, Monarch HealthCare, part of Optum, has developed successful approaches to engage Medicaid members by providing personalized care that connects them to the resources they need to achieve better health. 

Know the barriers

It is important to avoid generalizations about patient background and experience, no matter the group. Medicaid-eligible members qualify for services based on similar economic status, but each has unique circumstances. 

By taking time to get to know patients as individuals, social workers and patient care coordinators uncovered barriers to wellness. 

The care team removes these barriers by providing help with language translation and interpretation, information about financial resources, health education, and goal setting. 

In some regions, cultural and linguistic differences can make communication with health care providers difficult. Monarch HealthCare provides interpreter services to bridge the gap.

Patient care coordinator Elona Culwell recounts her experience caring for a Spanish-speaking member suffering with diabetic retinopathy. 

“Having an interpreter in the room made it possible for me to really hear and understand her questions and concerns. When she was concerned about her blurred vision, I helped change her existing ophthalmology appointment for an earlier date so the doctor could assess and treat her sooner.” 

The clear communication in her first language helped the patient express her worries, while knowing she would be attended very soon by her doctor calmed her anxiety.

Additionally, studies show that Medicaid patients, more often than commercial patients, suffer from complex, chronic medical conditions that can be complicated by home instability and food insecurity.  

Helping patients meet these basic needs is an important and often-overlooked component of helping them maintain their health. Social worker Craig Pulido assists members by providing information about resources to meet these basic needs as part of his care. 

"Connecting patients with social services, especially food and housing, is major. I assist with information about applications for food assistance, energy bill assistance, whatever members might need. I get the ball rolling on these services so that clients have the resources they need to be healthy.”


Grow trust

Building rapport is an essential part of patient engagement, and this can be a challenge when there are language or other barriers present. Monarch HealthCare social worker Alison Leff advises listening first, asking questions, and allowing the member an opportunity to express their needs. 

Motivational interviewing, the psychotherapeutic practice that encourages goal setting and identification of positive traits to help achieve those goals, is a helpful engagement strategy.

Provider-patient relationships are strengthened when patients have the chance to define wellness for themselves. 

“We might hope for a patient to achieve a fifty-pound weight loss. It could be that they only wish to lose ten. If we encourage and support that goal rather that impose an unrealistic number, we are more likely to get good results,” says Elona Culwell.

Invest in members

Sheri Shafie, a Monarch pharmacist, says there is big pay-off in “Taking the extra step.” She recalls adjusting her care planning to help a homeless patient with insulin-dependent diabetes. Sheri talked with the patient about his challenges and worked to meet his specific needs. 


Shafie arranged for smaller insulin vials, a cooler and ice packs so that he could be mobile and still have his insulin available.  Shafie also assisted the patient with access to food banks and free community meals to help him manage his blood sugar.

Care plans that are patient-specific have a greater chance of success. “Giving members the time to share their health concerns, to see it from their eyes, helps break down barriers and meet goals. One step at a time,” says Shafie.

Make the time

A personalized, tailored approach is the strategy behind better patient care for Medicaid patients of Monarch HealthCare. Each member is approached as an individual with unique challenges and skills. The time put in yields a great reward.

Monarch HealthCare team members are forging patient-provider relationships built on trust and respect, an important key to improving member heath.

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This publication is informational and for educational purposes for practitioners only. The views and opinions expressed herein are those of the authors and do not necessarily represent the views of Optum Care. The views and opinions expressed may change without notice. 

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