Discover how states are advancing care for the most vulnerable populations by leveraging person-centered assessments, long-term services and supports (LTSS), and coordinated crisis response models to deliver the right care, at the right time, in the right place. This session highlights practical strategies to improve outcomes, reduce unnecessary institutionalization, and strengthen care delivery across Medicaid programs.
What you'll learn:
- How assessments enable better Medicaid outcomes:
Understand how tools like PASSR and comprehensive assessments help identify risk earlier, guide level-of-care decisions, and ensure individuals receive appropriate, person-centered services. - How home and community-based services (HCBS) improve care and reduce costs:
Explore how LTSS and waiver programs support independence, enhance care coordination, and deliver cost-effective services in the least restrictive setting. - How coordinated crisis response improves children’s behavioral health:
Learn how innovative models—like West Virginia’s centralized crisis response—accelerate assessments, streamline access to services, and improve outcomes for children and families in crisis.
Participants
- Verlon Johnson, Chief Government Relations & Corporate Affairs Officer, Acentra Health
- Ellen Olsen, LCSW, MBA, Vice President of Operations, Acentra Health
- Nancy Sullivan, MAJ, Lead Executive Director, Acentra Health
Read the transcript
Note: This is a polished transcript of the full session and is not intended to be a verbatim record.
Opening and policy context
[Approx. 00:00] The session opens by framing the importance of caring for the most vulnerable populations in Medicaid, emphasizing the need to deliver the right care, at the right time, in the right place. The discussion highlights how rapidly evolving CMS policies, managed care rules, and rural health funding are creating new opportunities for states to improve care delivery.
[Approx. 01:00] Speakers define “most vulnerable” populations as individuals with complex health needs, disabilities, or limited resources, stressing that person-centered care and timely access to services are critical to improving outcomes and reducing risk.
PASSR and person-centered care
[Approx. 03:00] The discussion introduces PASSR (Pre-Admission Screening and Resident Review) as a key Medicaid safeguard to ensure individuals with serious mental illness or intellectual/developmental disabilities are placed in the most appropriate care setting.
[Approx. 07:00] PASSR is positioned as a gatekeeper for appropriate placement, helping prevent unnecessary institutionalization and ensuring individuals receive both medical and behavioral health services aligned with their needs and preferences.
Challenges and best practices in PASSR implementation
[Approx. 10:00] Panelists outline operational challenges, including cross-agency coordination, provider shortages, and complex regulatory requirements, which can make PASSR programs difficult to manage without strong systems and processes.
[Approx. 13:00] Best practices include data-driven tracking, compliance with federal requirements, and coordinated workflows that improve care transitions, reduce hospital readmissions, and ensure individuals receive appropriate services.
Long-term services and supports (LTSS) and HCBS
[Approx. 16:00] The focus shifts to long-term services and supports (LTSS) and the role of home and community-based services (HCBS) in enabling individuals to receive care in the least restrictive setting.
[Approx. 18:00] Assessments are highlighted as critical tools for determining eligibility, uncovering unmet needs, and guiding care planning—helping individuals maintain independence while improving outcomes and reducing costs.
Assessments, waivers, and care coordination
[Approx. 20:00] The panel discusses how Medicaid waiver programs and assessments support diverse populations, including individuals with disabilities, chronic conditions, and behavioral health needs. These programs require flexible, state-specific approaches to meet regulatory and community needs.
[Approx. 22:00] Effective care coordination ensures services are delivered where people live, strengthening community-based care models, provider collaboration, and individualized support plans.
Children’s behavioral health and crisis response
[Approx. 24:00] The discussion highlights the growing children’s behavioral health crisis, noting rising rates of mental health challenges and the critical role Medicaid plays in supporting youth and families.
[Approx. 26:00] West Virginia’s model is presented as a case study, demonstrating how a centralized crisis response system and standardized assessments can streamline access to services and reduce confusion for families during critical moments.
Implementation model and outcomes
[Approx. 29:00] The West Virginia approach includes a single-entry point for crisis support, standardized assessments, and coordinated service navigation, ensuring families receive timely guidance and support.
[Approx. 31:00] Results show significant improvements, including faster family outreach (within three days), reduced eligibility determination timelines, and improved access to care, demonstrating the impact of coordinated, person-centered systems.
System impact and community outcomes
[Approx. 33:00] The model emphasizes treating the whole family, not just the individual, recognizing that behavioral health crises affect entire communities and require comprehensive support systems.
[Approx. 35:00] Faster access to services and improved coordination lead to better health outcomes, reduced system complexity, and stronger community-based care delivery.
Future direction and policy alignment
[Approx. 37:00] Panelists highlight the future of Medicaid programs, emphasizing data-driven decision-making, system modernization, and expanded use of HCBS and waiver programs to better serve vulnerable populations.
[Approx. 39:00] The session connects these strategies to broader opportunities, including the Rural Health Transformation Program, which enables states to invest in infrastructure, care coordination, and workforce capacity.
Closing takeaway
[Approx. 43:00] The closing message reinforces that improving care for vulnerable populations requires person-centered assessments, strong partnerships, and coordinated systems. States that invest in these capabilities can deliver better outcomes, reduce costs, and ensure individuals receive care where and when they need it most.