Engaging Hard-to-Reach Members – Vulnerable Populations

Date: July 17, 2023
Time to read: 6 minutes.

Effective member engagement can enhance a health plan’s ability to meet member needs and improve health outcomes. Active and consistent engagement is even more critical for members in vulnerable circumstances. Health plans may face challenges engaging members who experience housing instability, speak a language other than English, or have a serious mental illness (SMI) diagnosis, among other factors. These “hard-to-reach members” are not consistently engaged in their health care and may be difficult for health plans to locate.

Many of the characteristics of vulnerable, hard-to-reach members are disproportionately present among individuals dually eligible for Medicare and Medicaid.1 Dually eligible individuals are more likely to experience disability, poverty, and poor health than their Medicare-only counterparts. They average more chronic conditions than those not dually eligible and comprise a disproportionate share of Medicare spending.2 Difficulties reaching members can have downstream effects on a plan’s ability to conduct required health risk assessments, provide information on health plan benefits and responsibilities, provide care coordination, and ensure continuous enrollment.3

This blog post highlights four strategies for engaging members who are hard to reach, often due to multiple, complex risk factors. Health plans participating in the 2022 Resources for Integrated Care (RIC) Integrated Care Community of Practice (ICCoP) on care coordination informed the strategies outlined in this post. These strategies include creative outreach approaches, such as utilizing licensed community health workers (CHWs), proactive care planning when an individual experiences a hospital encounter, and motivational interviewing techniques.

1. Use Strategic Communication Approaches

There are specific outreach strategies health plans can deploy to improve engagement with hard-to-reach populations. This may involve concerted efforts to reach individuals through alternative communication methods or applying a creative communication approach.

  • Leverage electronic communication, such as e-mail or a patient portal. This may offer a more enduring and accessible means of connecting with vulnerable individuals. As compared to street addresses or cell phone numbers, e-mail addresses are less likely to change, and, in addition to accessing e-mail on personal devices, public libraries offer individuals access to computers and the internet at no charge.
  • Perform outreach efforts at strategic times. Conducting outreach during non-business hours or at various times of the day, including nights and weekends, can maximize the likelihood of connecting with an individual when they are available to answer. Health plans may also have more success reaching members at the beginning of the month when members are more likely to have minutes available on their cellular plan.
  • Conduct outreach from familiar area codes and provide advanced notice of outreach. One health plan shared its practice of sending text messages to alert individuals that their care team would soon contact them via a phone call. By providing advance notice of the call, these text messages can promote engagement and alleviate concerns about spam phone calls.

2. Leverage Trusted Health Plan Staff in the Community

CHWs can bridge the gap between clinical care workers and vulnerable, dually eligible individuals receiving care. A CHW is a frontline public health worker who is a trusted member of the community they serve, or someone with specific knowledge of and familiarity with the community. This understanding allows a CHW to liaise between a health plan and the community to facilitate access to services.4 Certified CHWs can connect with hard-to-reach members by visiting them in their homes or at shelters and can engage members’ families and other connections to strengthen outreach.

3. Engage Members at the Right Time

Documenting and updating contact information during critical transitions can support member engagement. For example, health plans can engage hard-to-reach, dually eligible members when a member visits an emergency department (ED) or is admitted to an inpatient facility. Upon discharge from the ED or inpatient facility, care coordinators and care transition staff can capture an individual’s current contact information and preferred methods of outreach, schedule the member for appropriate follow-up care, and work within their health plan to track this information.

4. Use Person-Centered Approaches with Members

Every hard-to-reach member has unique motivations, intentions, and goals. Health plans successfully use motivational interviewing techniques, such as reflective listening, to address the most appropriate and prioritized health care concerns for dually eligible members. For example, health plans may assume a member wants to work on managing their diabetes or hypertension; however, housing instability or food security may be the member’s immediate priority. Some health plans also match care coordinators with members based on cultural preferences and language needs to support engagement. These strategies can build trust with members, which can support care planning and drive improved health outcomes.

Supporting Health Plan Success with Vulnerable Members

Engaging hard-to-reach, dually eligible members can feel like an overwhelming challenge. For the vulnerable population, meaningful and tailored engagement is even more critical; shifting housing circumstances, food insecurity, and fragmented communication pathways may make managing health care and basic daily needs a difficult balance of priorities. Health plans should consider multiple approaches to ensure members receive person-centered health care they value amidst other personal challenges. By deploying creative outreach strategies, engaging members during hospital encounters, and actively listening to member needs, health plans can more effectively reach the vulnerable dually eligible populations they serve.


For additional information, please see the following:

1 Resources for Integrated Care. (2022). Locating and Engaging Members: Key Considerations for Plans Serving Members Dually Eligible for Medicare and Medicaid. Retrieved from https://www.resourcesforintegratedcare.com/key_considerations_plans/

2 Sorbero, M.E., Lovejoy, S.L., Kandrack, R.Y., Taylor, E.A., & Bouskill, K.E. (2018). Types and Costs of Services for Dual Beneficiaries by Medicare Advantage Health Plans: An Environmental Scan. RAND. Retrieved from https://www.rand.org/pubs/research_reports/RR2213.html.

3 Resources for Integrated Care. (2022). Locating and Engaging Members: Key Considerations for Plans Serving Members Dually Eligible for Medicare and Medicaid. Retrieved from: https://www.resourcesforintegratedcare.com/key_considerations_plans/

4 National Center for Chronic Disease Prevention and Health Promotion. (n.d.). Community Health Worker Resources. Retrieved from https://www.cdc.gov/chronicdisease/center/community-health-worker-resources.html.