Uninsured patients benefit from ED referral program

Tucson center serves working poor

About 110 uninsured patients a month are being referred from a Tucson, AZ, hospital emergency department to a nearby primary care and specialty center, the result of a collaborative aimed at finding the individuals an ongoing medical home.

Between August 2006 and July 2007, there were 1,352 referrals for patients "who aren't emergencies, don't have insurance, and don't have regular medical care" from St. Mary's Hospital in Tucson to nearby St. Elizabeth's Health Center, says Nancy Johnson, RN, PhD(c), executive director of the health center.

Patients at St. Elizabeth's, which serves individuals who are not eligible for federal- or state-funded health care programs, are put on a sliding scale and pay whatever they can afford, Johnson notes.

The effort, which began as a pilot program, will be continued, she says, noting that of the patients referred to the health center, 252 "have established care" at St. Elizabeth's. "The definition of that is that they have actually shown up, registered, and had one appointment.

"Where the rubber meets the road is if they continue [to come to the health center] and we see that we don't have other hospitalizations," Johnson adds. "That is yet to be seen."

In addition to continuing the partnership with St. Mary's, she says, health center staff will be seeking out those in need of affordable care in other places. One of those locations, Johnson notes, is a small volunteer clinic in south Tucson called Clinica Amistad.

"There is no outpatient care of any kind in that area, so it's not easy [to get treatment] if you wake up in the morning and aren't feeling well," she says.

Clinica Amistad is run by volunteers, Johnson adds, and is open only on Monday evenings. "Seventeen to 30 people show up who have no physician, no money, no insurance."

"We started sending one of the community health workers from our center there to let people know we're here and to do health education with whoever shows up," she says. The plan was to encourage them to enroll at the center, Johnson adds, "and start getting them involved in preventive health care as well as acute care — things like flu shots and PAP smears."

The message her staff want to get across, she says, "is that we can offer services based on what they can pay." As a result, it is anticipated that the hospital ED will see fewer uninsured people who are not emergencies, and there will be fewer hospital admissions.

Key to the success of St. Elizabeth's programs, Johnson notes, is the support of Tucson physicians. "Our great blessing is that we have over 150 volunteer physicians who help us." Physicians donated care worth $750,000 during the past fiscal year, she adds, including expertise, X-rays, and use of the vascular lab, among other services.

Reluctant patients

One of the challenges center staff face in their efforts to provide care to the uninsured, she says, is the reluctance of many individuals to seek treatment — no matter how crucial — that they know they can't afford.

"We have one woman in for breast cancer treatment who had a palpable lump," Johnson notes. "She said, 'I don't want to leave my family with a large medical bill. I'd rather leave my savings account to them.'"

St. Elizabeth's staff were able to tell the woman about funding that is available from grants and from the Komen Foundation, she says, as well as care from volunteer clinicians.

Models integrate family, neighborhood

"The projects we work with are models that integrate family and neighborhood," Johnson explains. "If I'm hanging out with people who eat healthy and take a walk every morning, I'm not as likely to eat doughnuts and lie in front of the television. A lot of people are influenced by those around them."

The Monday night sessions that St. Elizabeth's community health workers conduct at Clinica Amistad, for example, include nutrition education and chair exercise sessions "with whoever happens to be there," she says. "It's very impromptu. They might say, 'We will talk tonight about protein and where to find it, or calcium and what foods it's in.'"

Staff might start a conversation with patients about the foods they like to prepare and suggest ways to make them healthier, or discuss stress management activities, Johnson says.

"Our education is twofold," she adds. "One [approach] is to provide health information, but another is to build trust and to convince people that [St. Elizabeth's] will be a comfortable place to get care."

Cooperation between health center and hospital employees is a continuing focus, Johnson notes "When one of our patients needs to have surgery for cancer, we call ahead to let the hospital know the person doesn't have insurance, so they can be prepared to help rather than have it be a traumatic experience."

St. Elizabeth personnel work with hospitals to set up packages and payment plans for uninsured patients, she says, including an arrangement with Tucson's University Hospital on obstetrics care.

The health center has obtained funding to establish an electronic medical record (EMR) system, Johnson says, and it is expected to be in place by the summer of 2008.

"That will help us tremendously," she adds. "We're building in some templates for all the education and health prevention [programs] we're doing."

In the case of patients who are referred from the ED, Johnson says, "we will be able to measure the power of these interventions. We might have a diabetic who has improved — his hemoglobin A1c has gone down, which is the gold standard we use for control of diabetes."

Using the EMR, she explains, the individual would be logged in as an ED referral, with notations in the record showing that he came to the nutrition class and did the chair exercise, and that those things actually impact clinical outcomes.

"Most EMRs are designed for what happens in the exam room, and that is certainly helpful, but the premise we have is that [the traditional] model of care needs adjustment and that some of the preventive intervention may affect everything else."

Physicians will be able to pull a person's record, she adds, and say, 'Oh, I see you've been going to this exercise class.'"

"We live in a really abundant society," Johnson points out, where a lot of money is channeled toward health care. "Money is spent on treatment and hospital care. It is a disease-based model. We reimburse hospitals and specialists for surgery, radiation, and chemotherapy, but we don't have a lot of funding on the front side for prevention."

If an uninsured person feels fine, she may not see spending $75 for a mammogram. "I believe there needs to be a shift to get money on the front side and help people who are working but who can't afford to pay $1,000 a month for insurance."

(Editor's note: Nancy Johnson can be reached at njohnson@ccs-soaz.org.)