Program for uninsured saves $4.56 million

Social workers target frequent ED users

A program that provides support for uninsured patients has saved $4.56 million over 18 months at Memorial Hermann Healthcare System in Houston.

Patients in the Community Outreach for Personal Empowerment (COPE) program had a 34.7% decrease in emergency department visits and a corresponding 31.6% decrease in cost from the implementation of the program from October 1, 2009 through March 31, 2011. In the same time period, inpatient visits for the same population dropped by 40.6%, for a savings of 40.4%, and observation stays declined 18.7% and decreased in cost by 13.6%, according to Pat Metzger, BSN, MSA, FAACM, FABC, system executive for care management at the health system with 11 hospitals serving the greater Houston area.

Located in a metropolitan area with a 34% rate of uninsured citizens, Memorial Hermann started the COPE program to help the large number of uninsured patients using the emergency department as a primary care provider find a more appropriate way to obtain healthcare, says Paula Lenhart, RNC, MSN, FAACM, FABC, system director of care management. "As a result of patients with non-emergent needs seeking care in the emergency centers, we were experiencing long wait times and overcrowded emergency centers," she says.

The program focuses on patients who are uninsured and who frequently use the emergency department for primary care. The program is staffed by two social workers who rotate between the hospitals in the system and intervene to help patients access more appropriate primary care. As soon as a patient who has been identified as eligible for the COPE program visits the emergency department, the healthcare system's electronic system triggers a notification to a social worker. Whenever possible, the social worker visits the patient in the emergency department or in the hospital if he or she is admitted. If the patient presents to the emergency department when social workers are not on duty, a social worker contacts the patient by telephone the next business day to follow up on the reason for the visit and to provide whatever assistance the patient needs for follow up care.

"We find that it's more effective for the social workers to visit the patients in person whenever possible because they establish a rapport. Often it takes several contacts with a social worker before the patient engages in self-care," Lenhart says.

When the social workers meet with the patients the first time, they complete a comprehensive psycho-social assessment that looks at their coping behaviors, social support systems, barriers to compliance with health management, and belief systems. They also determine the patients' financial status and screen them for eligibility for state, federal, and county government assistance programs.

"The majority of people use the emergency centers because they don't know what resources are available to them in the community or where the clinics are located where they can receive care. The social workers have been able to improve the lives of our patients by helping them access primary care providers where they can receive ongoing care so that when they come to the emergency room, it's truly for urgent care," Lenhart says.

The social workers educate patients on the importance of regular primary care and refer them to community clinics that provide free or low cost care. They match the patients and their needs to the culture of the clinics and inform them of the fee schedule (a flat fee or sliding scale) of the clinics. Some patients are eligible for the Harris County Hospital District, the Houston area's safety net healthcare system, but are having trouble filling out the applications. Others are referred to non-profit clinics for immediate care.

One patient in the COPE program has three chronic diseases that drive her into the emergency department almost weekly. The COPE social worker helped her with the Medicaid application and interview process, as well as the process of signing up for Medicare when she became eligible. "We are trying to help her access community services to provide the care she needs," Lenhart says.

Lack of transportation is one of the biggest barriers that prevent patients in the COPE program from receiving care at a primary care provider. Some even call 911 for transportation to the emergency department when they are sick, Lenhart says. The social work team helps patients access community agencies that will provide transportation to physician appointments and sign up for programs that provide assistance with medication.

Patients with diabetes or heart failure can choose to be in Memorial Healthcare's chronic disease management program and receive telephonic case management to help them cope with their disease. The program targets Medicare, Medicaid, and uninsured patients.

When eligible patients with either of the two chronic diseases have been hospitalized or received care in the emergency room, a Memorial Hermann case manager contacts them, tells them about the program, and enrolls them if they agree. The nurse case manager completes a comprehensive assessment using proprietary software that drives the questions based on the patient's understanding of the disease, compliance, and lifestyle. The software stratifies patients into risk groups, which drives the coaching plan. The nurse case manager makes coaching telephone calls to help the patients adhere to their treatment plan.

When patients are hospitalized, the case managers screen them for barriers to compliance and contact them within two days of discharge to confirm their understanding of the discharge instructions, ensure that they have an appointment with a primary care physician for follow up, and then follow them on a regular basis.


For more information, contact:

Paula Lenhart, RNC, MSN, FAACM, FABC, System Director of Care Management, Memorial Hermann Healthcare System, Houston, TX. E-mail: