For adults 65 and older managing chronic conditions like diabetes, barriers to preventive care compound quickly: limited mobility, fixed incomes, social isolation, and low digital access all work against standard engagement approaches. These are not members who respond to a portal notification or a text reminder. And when they don’t engage, the gaps in chronic disease management show up in Stars ratings performance.
What happens when a plan tries to close those gaps while simultaneously absorbing 156 percent membership growth? That was the question facing Coordinated Care (WellCare of Washington) in 2025. The lessons from their experience offer a practical framework for quality directors navigating similar terrain.
The population
The program served a DSNP membership with a median age of 69, managing diabetes alongside the full range of challenges that accompany aging: multiple comorbidities, transportation barriers, and limited support networks. Eligible membership grew from roughly 900 to 2,300 members, with many new enrollees arriving with unknown needs and unverified contact information, a structural challenge that has become familiar to any plan experiencing rapid DSNP growth.
Geography deepened the complexity. Four of the top five delivery ZIP codes were in central Washington, rural communities where poverty rates exceed the national average and specialty care access is limited. A fifth area, Ocean Shores, served a geographically isolated coastal population with a median resident age of 64. For older adults in these regions, “hard to reach” isn’t an engagement strategy failure. It’s a structural reality.
The approach
Rather than scaling outreach volume, the program employed Pyx Health to redesign member experience for this specific population around three elements.
Proactive, milestone-based food delivery: A “push box” model contacted eligible members in advance and informed them a fresh food delivery was coming—removing the expectation of self-initiation that often fails with older adults managing multiple health demands. Subsequent deliveries were tied to completion of specific clinical milestones.
Condition-specific education at the right reading level: Materials were health-literacy appropriate, co-branded with the plan, and delivered in the home as part of the food box delivery. The relevance and usefulness of the materials and the resource delivery reduced the friction that clinical communication alone rarely addresses, especially for members with limited digital access.
Continuous care coordination: Ongoing person-to-person touchpoints identified and resolved practical barriers like transportation, scheduling, confusion about what a test requires, and connected members back to the plan in real time. For a 65+ population, the human touchpoint wasn’t supplemental. It was central.
Results
Across 1,458 completed care tasks between June and November 2025, the program achieved a 38 percent average care gap closure rate: a 9-percentage point improvement over 2024, in a population that more than doubled in size.
Members who received care coordinator outreach closed an average 15 percent more gaps than those who self-directed, with 44 percent of outreached members completing A1c screening (vs.12 percent without outreach); 39 percent kidney health evaluation (vs. 22 percent without outreach); and 32% percent diabetic eye exam (vs. 37 percent without outreach). Twenty-five percent completed all open care gaps.
This reinforces two things: first, that aging members benefit from guided support; and second, that sustained, structured outreach is essential for moving clinical screenings across the finish line.
Member satisfaction data aligned: 86 percent said the program improved their opinion of the plan, 83 percent said it increased their likelihood to renew, and 79 percent said it helped manage their diabetes.
What quality directors can take away
Age is a complexity multiplier. A 69-year-old with diabetes in rural Washington is not the same challenge as a younger urban member. Programs designed for the average member will underserve the oldest and most complex ones. Under CMS Final Rule CY2027, those are exactly the members whose engagement determines Stars outcomes.
Tangible value builds trust faster than communication. For older adults in communities where health care has often been transactional, a food delivery that shows up does more to open a relationship and drive action than outreach alone.
Iteration compounds. The 2025 gains came directly from 2024 lessons: adjusting timing, removing low-value survey tasks, and front-loading intake screenings. Plans that treat engagement programs as fixed infrastructure will plateau.
Closing gaps in this population isn’t a messaging problem. It’s a design problem. Older adults aren’t disengaged by choice; they’re navigating circumstances that make preventive care feel inaccessible. In a Stars environment where member experience accounts for nearly half of total performance, programs that meet members inside those circumstances are the ones that protect plan revenue.