Network targets barriers for unfunded patients

Strategies include paying for a lower level of care

When patients at hospitals in Seton Healthcare Network are ready for discharge and don't have funding for post-discharge services, the hospital may pay nursing homes to provide care until their Medicaid eligibility is determined or place patients in assisted living facilities temporarily until they fully recover.

"It simply does not make sense to have the bed filled with someone who does not meet acute care criteria and who can't pay the bill. Paying for the care patients need after discharge is a good move because the patient is no longer in an acute care bed when they don't need to be there, and the hospital can fill that bed with a funded patient. It allows us to increase revenue while saving costs," says Pat Beal, LCSW, case operations manager for Seton Northwest Hospital and outpatient case manager.

Austin, TX, where Seton has headquarters, has a huge homeless population. Since it's in a border state, the city also has a high number of undocumented workers, says James Brown, MD, vice president and medical director for Seton Health Plan and case management.

The health system takes a proactive approach to planning the discharge destination for homeless and unfunded patients and ensuring that they are not readmitted.

Each weekday, Brown meets with the case management and social work staff for complex discharge rounds, during which they discuss patients who have been in the hospital for at least five to 10 days. The number may be considerable. For instance, one day recently, there were 44 patients in Brackenridge Hospital whose stay exceeded 10 days.

The team identifies barriers to discharge and comes up with ways to address the issues, particularly related to unfunded and homeless patients. "We make sure we have a disposition plan and start planning a discharge destination," Beal explains.

A few years ago, Brackenridge Hospital had a lot of patients with Medicaid or SSI disability coverage pending who had extended stays because they were too sick to be discharged to home but nursing homes wouldn't take them until their eligibility for Medicaid was assured, a process that can take as long as 10 months, she says.

The hospital has arranged to pay the Medicaid TILE rate for nursing home care until Medicaid approval comes through, if a cost-benefit analysis shows that the hospital will save money by doing so. In that case, the nursing home bills the hospital monthly for what Medicaid would have paid. When the patient is approved for Medicaid, the nursing home will get a check from the Centers for Medicare & Medicaid Services for the back payments and reimburse the hospital.

"It's a great thing. It gets the patient to the proper level of care and opens up beds for patients who do need nursing care. We haven't recouped 100% of the money we've paid to the nursing homes, but we have been correct in determining that the patient will eventually be approved for Medicaid," she says.

Before the hospital agrees to pay for a patient's nursing home care, Beal does a cost-benefit analysis of moving the patient.

She determines the average cost of the patient's last six days of care, using 30% of charges as the cost basis. Beal then compares that to the cost of transporting the patient, providing medication, and the average daily rate that Medicaid will pay to a nursing home.

"The hospital's chief operating officer signs off on the transfer. It's always turned out to be a tremendous cost savings for us," she says.

Beal also compares what the hospital will be paying to the nursing home with what the hospital could recoup by putting a funded patient in the bed.

"The program has been extremely successful. It's helped us to get the patients to the right level of care and to a place where they are not susceptible to hospital-borne illnesses. The hospital has avoided being on diversion, and we can increase our revenue if we have a funded patient in that bed," she reports.

The hospital is willing to pay for the nursing home care only if there is a likelihood it will be reimbursed, she adds.

Paying for home care

The hospital has a partnership with an acute rehabilitation facility which offers two acute rehab charity beds each day, with the stipulation that the patients need to be in rehab only two weeks. In addition, the hospital pays for whatever equipment unfunded patients may need in order to go home. For instance, the hospital has rented wound vacs or provided special mattresses so patients can be discharged.

Each hospital in the Seton Healthcare System pays for the cost of its patients' home care if they lack resources.

"Paying for home care makes good financial sense because the patient is no longer in an acute care bed when they don't need to be there," Beal says.

When patients are too sick to be on the street but not sick enough for skilled nursing care, the case managers sometimes can find them a place at a community facility to continue their recovery.

The Salvation Army sick bay will accept some patients for a limited amount of time. The City of Austin operates The Arch, with a six-bed infirmary where homeless patients can get care.

"On very rare occasions, we have discharged a patient to a hotel and arranged from them to have meals from a soup kitchen. This is only in cases where the patient needed bed rest for a short time, such as recovering from a sprained or broken limb and there is no other placement option available," she says.

When patients need long-term care and don't qualify for disability because they are going to heal, the hospital contracts with assisted living facilities or group homes where they can get their meals and receive home health services if necessary.

These may be patients with two broken legs or those who need IV antibiotics. "The ones we can't do anything about are IV drug abusers who need IV antibiotics. We can't send them out with an open line so they're here for the duration of the IV antibiotic therapy," Beal says.

Seton Healthcare funds and operates three primary care clinics for indigent patients in parts of the city where there is a need, Brown says.

The clinics help keep nonemergent patients out of the hospital and provide continuity of care in management of chronic conditions such as high blood pressure and diabetes.

"When patients come to the emergency department for primary care, they are treated by whoever is available. When they go to our clinics, they see the same provider over and over. We hope that we can manage the care for patients in our clinics and help them ward off costly complications of their chronic diseases," Brown says.

When indigent patients present at the hospital, they go through a screening process to determine what kind of aid they might qualify for, such as Medicaid or one of the federally and county-funded programs in Austin that provide care for unfunded patients.

If they don't qualify for any other care, when they are discharged, they are referred to a Seton clinic to use as their medical home. They pay a nominal fee for their care, based on their income and other resources.

To accommodate the burgeoning numbers of indigent patients, Seton Healthcare has expanded its clinic hours to give patients a chance to come into a clinic in the evening hours, instead of using the emergency department for primary care.

The clinics are funded through the health care system's charity care funds and donations from the community.

In addition, the hospital has arranged for specialty providers in the city to provide free care for indigent patients. The hospital provides hospital and ancillary services for these patients.

Approximately 5,000 of the uninsured patients using the Seton Clinics for primary care have been enrolled in a health plan "look-alike," according to Brown. They pay a nominal amount for office visits and prescriptions, based on a sliding scale according to income.

"We manage the patients who use our clinics as if they have health insurance. They get a card that they present for treatment. Our goal is to manage their care, to prevent readmissions, and to try to educate them not to use the emergency department as their only source of care," he explains.

(Editor's note: For more information, contact Pat Beal, LCSW, at e-mail: