Faced with a growing indigent population, Sentara Healthcare developed a comprehensive systemwide program with post-acute providers that agreed to partner with the hospital to care for indigent patients after discharge.

“The indigent population is a group of patients with unique needs and complex conditions. Rather than each hospital in the system determining how to manage a safe transition plan for indigent patients on their own, we put together a program for the entire system,” says Teresa Gonzalvo, RN, BSN, MPA, CPHQ, ACM, recently retired vice president of integrated care management for Sentara Healthcare, a 12-hospital system serving Virginia and North Carolina.

The healthcare system began by locating post-acute providers that would collaborate on care for patients with complex post-discharge needs. “We were looking for partners who would care for patients who are not only sick but have behavioral health issues, are overweight, are homeless, who live in isolation, or who have other barriers to a safe discharge,” she says.

In the past, case managers would contact skilled nursing facilities in several states to place indigent patients, but many patients ended up staying in the hospital long after they no longer met inpatient criteria.

“Case managers always have to pull rabbits out of their hats when there are indigent patients with multiple barriers to care, such as behavioral issues and/or who are overweight. Now, if they can’t find a placement, our team follows an escalation process with management support. Eventually, the patients are escalated up to me and I call my counterparts at the skilled nursing facility and request that they reconsider the denial. Part of our success is that we have ongoing communication and maintain good relationships with our colleagues at other levels of care,” she says.

Sentara began building relationships with post-acute providers by organizing the Sentara Hampton Roads Long Term Care Council four years ago. The council includes representatives from the hospital’s care coordination department and skilled nursing facilities, as well as long-term acute care hospitals in the Hampton Roads area, including those not affiliated with Sentara. There are about 40 members on the council, which meets every other month to brainstorm ways to facilitate smooth transitions. Part of the meeting is devoted to education on topics such as readmissions, advance care planning, palliative care, and hospice.

The purpose of the council is to facilitate the transition of patients from Sentara acute care to long-term care facilities and back to acute care when appropriate, and to effectively share information as patients transition, Gonzalvo says.

When the program for the indigent began, the health system negotiated contracts with skilled nursing facilities, personal care agencies, transportation providers, and a durable medical equipment company to cover the needs of indigent patients. Sentara’s home care agency provides home visits for patients who need them.

The health system offered the post-acute providers a competitive rate that was determined by Sentara managed care division, based on the rates being paid for complex patients by commercial payers, Medicare, and Medicaid.

Now, when unfunded patients need post-acute care, the cost is covered by the health system’s indigent care fund. “Our focus is on the patient and making these investments for the patient’s benefit. In the long run, the patient is cared for in the appropriate level of care and we maintain our fiscal responsibility. It’s a win-win situation,” Gonzalvo says.

For instance, if an indigent patient needs a piece of equipment, such as a cardiac chair, the indigent fund pays for it. “We know it will be better if the patient goes to the skilled nursing facility with the needed equipment and doesn’t come back to the emergency department,” she says.

Identification of indigent patients begins in the ED where the registration staff flags patients identified as self-pay.

“‘Self-pay’ may not mean ‘indigent.’ It could be someone who owns a company and is self-insured. The registration questionnaire includes a lot of other questions that help us determine the financial needs of our patients and who would qualify for charity care,” Gonzalvo says.

Case managers or social workers assess unfunded patients in the ED if it is likely they will be treated and released. They identify what the patients will need in the community and refer them to one of Sentara’s post-acute partners.

The biggest hospital in the system, Norfolk General, has a case manager or social worker dedicated to the ED. ED staff at other Sentara hospitals alert the unit-based case manager who also is responsible for covering the ED.

Case managers on the unit complete an assessment of indigent patients who are admitted to determine their transition needs and if they are eligible for Medicaid.

Patients qualify for indigent care if they don’t qualify for Medicare or Medicaid and don’t have other insurance. People who are ineligible for Medicaid include undocumented immigrants or tourists from other countries who are traveling through the area, Gonzalvo says.

If patients are likely to be eligible for Medicaid but have not applied, the case managers refer them to an outside company that has contracted with Sentara to assist eligible patients in signing up for the program.

The health system closely manages the resources used to treat patients who are not likely to be eligible for Medicaid or other financial assistance. The system has established a centralized process with one accountant in the finance department assigned to track the cost of care for ineligible patients being treated at all hospitals in the system.

“In this day and age of tight budgets, we have to be very judicious in our spending. With patients who may never be eligible for Medicaid, we pay the contracted fee for post-acute care and look for other financial assistance sources while they are in the skilled nursing facility. We work with our post-acute providers to find the most cost-effective options for care,” Gonzalvo says.

For instance, the health system assisted with the transportation needs of a patient when it appeared that the best and most cost-effective option for care would be to transport the patient to China, she adds.

Case managers on the unit determine patients’ transition needs and work with the post-acute providers to cover them. The goal is to move patients to a lower level of care when they no longer meet inpatient criteria.

Depending on the contract between Sentara and individual facilities, the case manager, with the approval of the manager, arranges a transfer to a facility that can meet patient needs for a specific period of time. While the patient is in the facility, the director of nursing sends the referring hospital a report of the patient’s clinical progress. The hospital case manager and the facility staff collaborate on a plan to meet the patient’s needs in the community.

Sentara’s home care agencies provide care for indigent patients who can be discharged to home. “Their priority is to take care of the indigent patients’ needs so we don’t have to worry about negotiating,” she says. In addition, the organization has partnered with a durable medical equipment company to provide whatever equipment patients need.

Case managers line up personal care for patients who can be safely discharged if they just need someone to help with bathing, meals, or other day-to-day activities. “We have a contract to provide this level of care so we can safely discharge people instead of keeping them in the hospital because they can’t take care of their personal needs,” she says.

A taxicab company that serves seven Hampton Roads hospitals contracts with Sentara to provide transportation for patients who need a ride home from the hospital or for follow-up physician visits. The company set up a toll-free number that is dedicated to Sentara patients.

The healthcare system team also is working with a company that provides transportation for people in wheelchairs, and with a local nursing home that has wheelchair-accessible vans.

If patients don’t have a physician, the case managers can refer them to Sentara’s clinics that keep slots open for indigent patients. They can arrange for prescription assistance through Sentara’s charity care program.

“We try to cover all the bases and optimize care for our indigent population. Our philosophy is that it is the responsibility of all organizations in the community to make sure our residents are getting the care they need. It’s all about collaboration among the community providers and agencies,” Gonzalvo says.