Test-Time Learning and Inference-Time Deliberation for Efficiency-First Offline Reinforcement Learning in Care Coordination and Population Health Management

Abstract: Care coordination and population health management programs serve large Medicaid and safety-net populations and must be auditable, efficient, and adaptable. While clinical risk for outreach modalities is typically low, time and opportunity costs differ substantially across text, phone, video, and in-person visits. We propose a lightweight offline reinforcement learning (RL) approach that augments trained policies with (i) test-time learning via local neighborhood calibration, and (ii) inference-time deliberation via a small Q-ensemble that incorporates predictive uncertainty and time/effort cost. The method exposes transparent dials for neighborhood size and uncertainty/cost penalties and preserves an auditable training pipeline. Evaluated on a de-identified operational dataset, TTL+ITD achieves stable value estimates with predictable efficiency trade-offs and subgroup auditing.