Summit County expands targeted case management for Medicaid infants, staff describe outreach and registration barriers

The Summit County Health Department told the Board of Health on June 3 that its restarted Targeted Case Management (TCM) program is delivering in-home support to Medicaid-eligible infants and their families while staff work to overcome state registration and outreach hurdles.

"It's really, case management for Medicaid is like what it is for moms and babies," said Tammy, a county public-health nurse who introduced the program and described its contract-driven scope and early operations. The county conducted its first TCM visit on June 27, 2023, and staff have been resolving billing, coding and outreach challenges since the restart.

Why it matters: TCM visits provide practical, early-childhood interventions — such as breastfeeding support, postpartum screening, car-seat checks and referrals to WIC, Early Intervention (EI) and pediatric care — that staff say can be life‑changing for families who might otherwise fall out of care while their Medicaid status is being processed.

Tammy and her colleagues said the program is small but active. The county averages about 35–50 births per month and estimates roughly 12–15 babies are typically eligible for TCM based on Medicaid enrollment. Staff described frequent delays in state reporting: if a mother signs up for emergency Medicaid only days before birth, the official records may not be completed for two to four months, making it hard for TCM nurses to locate and bill for eligible infants.

Staff also described concrete supports given during visits: a county pamphlet created for TCM families (bilingual and written at a fifth-grade level), donated diapers and small safety giveaways, car-seat referrals after observing unsafe setups and vaccine access through the county’s Vaccines for Children (VFC) activities. Karina, who assists with the program, recounted a recent visit where a baby was placed forward-facing in a booster; staff arranged a safer car-seat and follow-up.

Program limits and next steps: Tammy said the TCM contract covers "traditional Medicaid" infants only; the county currently cannot serve babies on CHIP, some high‑risk mothers, or families outside its jurisdiction, limiting reach compared with larger counties that deploy multiple nurses and community health workers. Staff recommended continuing to update the program pamphlet and to pursue additional staffing or funding so more eligible families can be found and served.

The department asked the board to support outreach and noted that keeping the TCM program funded and visible will be a budget consideration in the coming cycle.