As Healthcare Becomes Value-based, Hospital Partners With the Community for Patient Care
Two projects aim to fill gaps in care for the uninsured and Medicaid patients
EXECUTIVE SUMMARY
Spartanburg (SC) Regional Healthcare System is partnering with providers at other levels of care and in the community to improve care for Medicaid patients and the uninsured.
- Access Health focuses on low-income and uninsured people who frequently use the ED for primary care issues. Many patients also have behavioral health issues.
- Access Health includes eligibility specialists, RN care navigators, social worker care navigators, and volunteers from the AmeriCorps program to connect patients with primary care providers who charge a discounted rate, address their social needs, and coach them on navigating the healthcare system.
- Case management is a major component of Healthy Outcomes, a collaboration of the three hospitals in Spartanburg. The staff works closely with the patients to help them overcome the obstacles to receiving primary care, educates them on appropriate use of the ED, and accompanies them to physician visits.
Just a short time ago, Angie Roberson, MSN, RN, ACM, director of case management at Spartanburg (SC) Regional Healthcare System, was a typical healthcare case management director in a traditional role. But now, as healthcare shifts toward a pay-for-performance model, Roberson’s role has expanded and crossed over into initiatives in which the hospital partners with providers at other levels of care and in the community.
“Hospitals have to change the way they operate as the Centers for Medicare and Medicaid Services and other payers shift to value-based care versus volume-based reimbursement. We have to figure out how to make the switch and meet all the payer requirements while staying within the rules in order to stay afloat,” Roberson says.
In addition to participating in the voluntary Bundled Payment for Care Improvement initiative from CMS, the 540-bed research and teaching hospital has taken a leadership role in two statewide projects aimed at providing healthcare for the uninsured and underinsured, and preventing readmissions and ED visits for at-risk Medicaid patients with chronic conditions.
The hospital kicked off its first bundled payment initiative in July 2015 as part of the CMS voluntary initiative.
“Bundled payments provide a great platform for moving into the new era of healthcare. The initiative requires hospitals to reach out to other providers and work together to provide high-quality, cost-effective patient care,” Roberson says.
The health system has a post-acute division that includes a long-term acute care hospital, a skilled nursing facility, home health, and hospice services.
“Working within our own system has helped us understand how providers across the continuum work. We’ve also been working with skilled nursing facilities outside our hospital system for many years, and meet with them quarterly. These experiences are helping us move forward,” she says.
Spartanburg Regional Healthcare System was the first system in South Carolina to sign up for the Access Health program, a project sponsored by the South Carolina Hospital Association to encourage community organizations to collaborate on ways to provide healthcare for the uninsured and underinsured. The health system began the program six years ago as part of its goal to connect low-income patients to healthcare.
“AccessHealth has given us a chance to explore community partnerships and collaborations, and to develop the relationships we need to provide the best care for our patients,” Roberson says.
The program links uninsured patients to primary care providers who have agreed to provide free or low-cost ongoing care. The staff works closely with the patients to help them overcome any obstacles to leading a healthy lifestyle.
“Our mission is to provide preventive care and treatment for clients who are uninsured. The challenge and the ultimate goal for us is, ‘How do we collaborate to effectively hand off patients from the inpatient setting to the ambulatory setting and connect with all of the entities in the community?’” she adds.
The staff includes non-clinicians who are trained as eligibility specialists, RN care navigators, social worker care navigators, and volunteers from the AmeriCorps program.
Community partners include both hospitals in Spartanburg, a free medical clinic, a federally qualified health system, the public health department, the department of mental health, the alcohol and drug abuse commission, the county medical association, and a statewide medication program.
AccessHealth received a grant in July from the Robert Wood Johnson Foundation as part of its Transforming Complex Care initiative. The grant will help pay for a new community health worker to work closely with high-risk, high-cost individuals.
The target population is low-income, uninsured people who use the ED frequently. A large portion of the population has behavioral health issues, including mental health problems, alcohol or drug abuse, or all three, Roberson says.
“Behavioral health was one of the driving threads of AccessHealth, but many of these patients have other health issues such as diabetes and cardiovascular disease,” she says.
Referrals come from the hospital, community organizations, and through self-referrals. Participants have to meet income requirements and be without insurance.
When people are referred to the program, the care navigation team conducts an assessment to determine their eligibility for AccessHealth as well as other local, state, and national programs. “Sometimes they find that clients are eligible for Medicaid, the Supplemental Nutrition Assistance Program [SNAP], or other programs. In those cases, a care navigator helps them sign up,” Roberson says.
The care navigators screen participants for behavioral health issues and psychosocial needs, helping them access assistance from community agencies. They help participants identify a primary care provider who can meet their needs, and who has agreed to provide care for uninsured clients. They also work with the clients to set goals and support them in meeting their goals, Roberson says.
The program addresses clients’ social needs, as well as helping them navigate the healthcare system. The program cut hospital use by 31% and reduced costs by 42% among AccessHealth participants in 2014, according to AccessHealth’s report to the community.
When the care management team assessed the first group of patients, using a patient engagement scale, they found that the majority of patients scored very low when it came to being engaged in their own health. For that reason, a member of the care management team attends the first primary care appointment and the first mental health appointment with participants and may attend other appointments.
“These people have so many barriers to healthcare that there is a big risk that they won’t be successful in taking care of their own health. We coach them before the first appointment and during their encounters with providers,” she says.
The care managers spend a lot of time preparing their clients for their first physician visit. “It’s a lot of work. Most have no idea how to navigate the healthcare system. Many feel ashamed because they don’t have insurance. The care managers assist them in writing down a list of questions they want to ask their doctors,” Roberson says.
Participating physicians have expressed approval of having a member of the care management team attend office visits, Roberson says.
The program received the city of Spartanburg’s 2015 Culture of Healthcare Prize honoring communities that are improving the health of their residents, and the program was cited by the Robert Wood Johnson Foundation.
Roberson is the clinical liaison for Healthy Outcomes, a program launched in 2013 by South Carolina’s Department of Health and Human Services to reduce inappropriate use of hospital ED services and cut costs in the state Medicaid program. Participants must have one or more chronic conditions, be uninsured, and utilize the ED frequently.
“Because patients don’t have a primary care provider, they often go to the emergency center when they are sick. People with chronic conditions are among the most frequent users of the emergency center. Healthy Outcomes staff works closely with the patients to help them overcome the obstacles to receiving primary care and educates them on appropriate use of the emergency center,” Roberson says.
The program is staffed by three registered nurses, one medical social worker, and two clinical social workers. They accompany clients to physician visits, see them in their homes when needed, and help them link with community organizations.
“More than anything, the Healthy Outcomes program is about case management and transitions and value-based care that ties back to the community. We believe our system has developed relationships with community agencies that allow us to collaborate with each other on meeting the needs of the people in our community,” she says.
Healthy Outcomes is a collaboration of the three hospitals in Spartanburg, two of which are part of Spartanburg Regional Healthcare System, and is managed by AccessHealth. Roberson serves as the clinical link for the Healthy Outcomes program.
The hospitals identify patients for the Healthy Outcomes program in the ED, but typically, patients know someone who is enrolled in the program and they refer themselves, Roberson says.
“Nonprofit organizations are very familiar with Access Health. There are a lot of cross-referrals. We refer patients to the community organizations and they also refer appropriate patients to use,” Roberson says.
Spartanburg (SC) Regional Healthcare System is partnering with providers at other levels of care and in the community to improve care for Medicaid patients and the uninsured.
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