Pear Suite partnered with BluePath Health to translate state health care policies into enhanced technology solutions that enable under-resourced community-based organizations to grow sustainably.
Challenge
Medicaid continues to invest in health-related social needs (HRSNs), recognizing an opportunity to improve health outcomes while reducing the cost of care. States are applying these resources through a range of mechanisms, including Section 1115 waivers, In Lieu of Services (ILOS) authority, 1915(b) waivers, and community health worker billing, each expanding the scope of covered services beyond historical federal rules. These programs are a major opportunity for health technology companies to build products to specifically serve organizations that provide health-related social services to individuals receiving Medicaid benefits. However, implementing these programs requires significant programmatic and policy expertise to support how products meet both the needs of their users and allow organizations to operate sustainably.
Pear Suite, a platform built to help community-based organizations (CBOs) deliver and finance care, recognized an opportunity for their customers, primarily CBOs delivering care management services, to serve more members in their respective communities.
California’s current Section 1115 waiver demonstration, also known as CalAIM, introduced a major reform effort focused on delivering integrated, whole-person care to high-need individuals. The CalAIM initiative created new opportunities for CBOs to get reimbursed from managed care plans for providing clinical and social services, like housing supports, medical respite, and medically tailored meals, to Medi-Cal (California’s term for Medicaid) members with complex needs. As already under-resourced CBOs stretched to expand their services, the pressure to reduce administrative burden and operational risk, meet compliance standards, and reliably get reimbursed by managed care plans became critical.
To create reimbursement opportunities for CBOs under CalAIM’s Enhanced Care Management (ECM) and Community Supports programs, Pear Suite engaged BluePath Health to assist in building, implementing, and driving the adoption of its care management platform to allow Pear Suite to:
- Translate policy into product and implementation requirements while preserving the capacity of product, engineering, and client services teams
- Develop a differentiated product and service offering by clearly tying features to programmatic requirements for reimbursement under the Medi-Cal program
- Be a thought leader on CBO technology adoption by engaging a partner that could convene stakeholders and gather objective feedback
- Utilize an objective, external perspective to understand drivers of adoption
Approach
BluePath Health’s collaboration with Pear Suite unfolded across multiple phases:
- Evaluation of the Pear Suite platform in light of the current CalAIM requirements and regulatory challenges
- Identification of product enhancements required to support the ability of CBOs to collect data, provide care, and document clear workflows for staff
- Support the platform capturing documentation necessary to meet compliance standards and reduce potential billing errors, allowing CBOs to be compensated in a timely manner by Medi-Cal’s managed care plans
Solution
Phase 1: Incorporating policy into a practical solution for CBOs
Pear Suite engaged BluePath Health to review CalAIM policy documentation across five domains necessary to implement ECM services: outreach and enrollment, care plan development, case management, reporting, and billing. BluePath Health then mapped these programmatic requirements directly to Pear Suite’s platform capabilities, identifying gaps and prioritizing features, in partnership with Pear Suite’s technology leaders. BluePath Health’s ability to forecast future program requirements and market opportunities were vital in developing a comprehensive product roadmap that positioned Pear Suite as a trusted technology platform for organizations seeking to provide reimbursable health-related social services.
Phase 2: Designing a path for implementation
Once the CalAIM policy requirements were incorporated into Pear Suite’s platform, BluePath Health identified specific needs for clients to onboard successfully. BluePath Health created a playbook and resource guide for customers delivering ECM services to implement Pear Suite. The playbook includes a step-by-step process to support a seamless transition from sales to go-live for Pear Suite’s customers. BluePath Health strategically designed each phase to guide customers through system configuration, workflow customization, billing setup, and final readiness checks. Dedicated training sessions, hands-on system walkthroughs, and iterative feedback loops were aligned with the customers’ operational needs and were designed to address challenges as they arise. BluePath Health’s implementation guide and corresponding onboarding documentation provided Pear Suite with the framework needed to equip customers with the necessary tools, knowledge, and support to maximize their success with Pear Suite’s platform.
Phase 3: Building the evidence for market readiness
Pear Suite noticed wide variability in readiness to implement a technology platform and knew that this challenge would persist among under-resourced CBOs. Although these organizations were driven by a strong sense of purpose, many lacked the internal organizational, operational, technological, and workforce foundations needed to use Pear Suite effectively. As a result, Pear Suite sought to address this issue before future implementations.
The Pear Suite team created a 40-question readiness assessment designed to assess an organization’s capacity and readiness for implementation of a case management system like Pear Suite. BluePath Health was hired to encourage organizational leaders, including community health workers (CHW) and those offering reimbursable care management services, to take the assessment, and then evaluate those responses to determine whether readiness to implement a technology platform impacts the ability of a CBO to sustain reimbursable care management services.
The assessment—now publicly available on Pear Suite’s website —also introduced more than 100 CBO and CHW practitioners to the concept of readiness through a co-hosted webinar with the California Association of Community Health Workers (CACHW).
BluePath Health analyzed the responses from CBOs providing care management services and conducted follow-up interviews with organizational leaders, ultimately determining that organizations implementing Pear Suite were 2.8 times more ready than organizations without a case management system to successfully manage eligibility, claims, payment tracking, and secure data exchange with partners. The complete results are available in Getting Paid for the Care You Deliver—a practitioner-facing call-to-action for CBOs, funders, and policymakers.
| 2.8x
more ready than non-users to successfully manage eligibility, claims & payment tracking |
2.3x
more ready than non-users to securely share data with health plans & partners |
25–50%
higher readiness scores across all four domains for Pear Suite users |
Outcomes
The phased engagement gave Pear Suite something health technology companies rarely have when entering Medicaid markets: a concrete, independently validated plan to expand its reach to a wider audience of community members by supporting the capacity of CBOs and CHWs that deliver care management services.
After completing the engagement with BluePath Health, Pear Suite now has:
- A robust product suite that aligns with one of the biggest needs in a market segment that, to date, has had significant gaps in billing, documentation, and security
- A playbook for onboarding clients and supporting their success in capturing new billing opportunities specific to a particular program
- A new business case for CBO clients that did not previously exist, and better insights into what organizations need to do before implementing Pear Suite
BluePath Health’s expertise in adapting health policy into tactical product and service enhancements enabled Pear Suite to expand the use and impact of its platform to under-resourced CBOs serving the CalAIM program. As a result, a wider range of vulnerable, high-need individuals have been able to receive coordinated care.
“BluePath can take incredibly complex Medicaid policies and turn it into something practical and actionable. Their team helped us think ahead, strengthen our platform, and ultimately build better infrastructure for the community-based organizations and frontline workers we serve.”
– Colby Takeda, Co-Founder & CEO, Pear Suite
###
BluePath Health is in a unique position as a credible, neutral collaborator adept at translating policy into strategies that can be implemented in a clearly documented operational plan. For health technology start-ups balancing competing priorities and resource constraints, a trusted partner like BluePath Health, with team members who have worked at technology vendors themselves, offers firsthand insight into the challenges start-ups face. As a result, this type of partnership expands technology companies’ bandwidth to build impactful tools in a mission-driven space.