A Novel Intervention for Medicaid Beneficiaries with Complex Needs
A peer-reviewed study of Pair Team’s model, which combines Enhanced Care Management, telemedicine, and social care delivered with community-based organizations, for adult Medi-Cal members with complex medical and social needs.
Headline results
The year after enrollment compared with the year before enrollment.
- fewer emergency department visits
- 52%
- fewer emergency department visits
- fewer inpatient hospital visits
- 26%
- fewer inpatient hospital visits
- more outpatient visits
- 21%
- more outpatient visits
- of ED and hospital discharges were followed by contact with the Pair Team care team within 30 days
- 94%
- of ED and hospital discharges were followed by contact with the Pair Team care team within 30 days
Fewer patients with depressive symptoms
Among patients with depression screening (PHQ-9) data at enrollment and follow-up, the share with depressive symptoms dropped from 74% to 36%.
Average PHQ-9 scores decreased by 4.0 points between intake and follow-up.
More routine testing after enrollment
HbA1c (diabetes) testing rose from 22% of patients before enrollment to 53% after.
Blood pressure readings rose from 74% to 82%.
Patients averaged 3.3 interactions per month with their Pair Team care team over their first year.
About the study
- Design
- A retrospective cohort study of adult Medi-Cal members eligible for Enhanced Care Management, comparing the year before and the year after enrolling with Pair Team.
- The Pair Model
- Local care managers, nurses, behavioral health clinicians, and telemedicine nurse practitioners, coordinated through Pair Team’s care platform and working with community-based organizations on needs like housing, food, and transportation.
Study limitations and disclosures
- This was an observational study without a control group, so it shows changes after enrollment but can’t prove the program caused them.
- The study covered adults in their first year of enrollment.
- Several authors work for and hold equity in Pair Team.
Citation
Mueller L, Batlivala N, Palisoc J, et al. A Novel Intervention for Medicaid Beneficiaries with Complex Needs. J Gen Intern Med. 2026;41:1222–1228. doi:10.1007/s11606-025-09839-2
Published under a Creative Commons Attribution 4.0 International License