Follow-up care helps avoid readmissions

Team helps patients navigate health care system

With the number of uninsured patients increasing rapidly, the case management and social work staff at North Broward Medical Center are faced with the challenge of making sure patients receive the follow up they need to stay healthy and out of the hospital.

"In North Broward County, our hospital case managers and social workers work with the district clinics and other providers to make sure our patients have continuity of care after discharge. We try to focus as much as possible on preventive care so these patients manage their health care and reduce readmissions," says Gavin Malcolm, LCSW, coordinator of social services and trauma social worker at the Deerfield Beach, FL, medical center.

The hospital has seven full-time social workers, an emergency department social worker, and a trauma social worker, in addition to 20 case managers.

"We work as a team. The case managers and social workers are unit based and work together to determine the patients' needs and how to meet them," he says.

Non-compliance with follow-up care is a huge issue with uninsured patients for many reasons. One issue is that people don't want to go to a clinic and wait for hours, Malcolm says.

South Florida has a large population that doesn't speak English. The hospital has some bi-lingual staff and uses a telephonic certified service to talk to people who do not speak English.

After the hospital implemented a process improvement project to increase compliance with follow-up visits, the percentage of uninsured patients who follow up with their scheduled initial appointment with the clinic rose from 7% to 15%.

"It's still miserably low but it has doubled," he says.

The social workers and case managers use a central scheduling line to set up a primary care appointment before people leave the hospital.

"Because of sheer numbers, there is a long wait for appointments so we try to set an appointment as early in the process as possible. Once they get established in the clinic, they can go there for medication refills without having to have an appointment," he says.

The social workers obtain contact information at assessment and confirm it at discharge so the clinic can call to confirm the appointment, but often, the patients can't be contacted for follow-up.

"Contact information can change on an almost daily basis," he says.

If preventive care is not possible, Malcolm encourages patients to go to an urgent care center, where care may be covered by tax funds, instead of coming to the emergency department. The urgent care centers and primary care clinics result in lower financial burdens on the patients and focus more on the patient's history while the emergency department has to stabilize the patients as efficiently as possible, he says.

"When we make the follow-up appointments, we give the phone number of the patient to the clinic so they can call to confirm the appointment," he says.

Malcolm talks to patients about the benefits of seeing a primary care physician, rather than visiting the emergency department for treatment.

"I point out that they will rarely get the same doctor or the same treatment at the emergency department and that a physician who is familiar with them will give more consistent care. I also point out that the cost of follow up at the emergency department is more than at a clinic," he says.

Once patients get established in a clinic, they tend to follow up at the clinic, rather than going to the emergency department, Malcolm says.

"The health care system is confusing for people who work in it every day. It's totally bewildering to other people, especially if there is a language barrier. Giving them education and connecting them with community resources keeps them out of the emergency department and keeps them from being readmitted," he says.

Any patient who indicates he or she is self-pay is screened to determine if he or she is eligible for Broward County Tax Fund assistance, a program that provides medical care for patients who do not have any type of health insurance, including Medicaid.

"It can take up to six months to get a patient approved for Medicaid. This makes it difficult to discharge patients in a timely manner. The county programs can issue approval the next day so we can ensure that patients have follow-up visits whether it's with the cancer center, a primary care physician, or a specialist," Malcolm says.

In addition to the financial and medical requirements, to qualify for Medicaid, a patient has to prove residency for five years. The Broward County Tax Fund requires the same financial information but proof of only 30 days residency in Broward County for people to qualify for the Star Card assistance program, he says.

"For people who have immigrated and lived here less than five years or who are undocumented, the Star Card would be the primary option," he says.

The program covers people whose income is up to 300% of the poverty level. Patients pay copays based on their income level.

The benefits include assistance with medications and outpatient, inpatient, and acute rehabilitation services and provides home health through a partnership with a home infusion and home health care agency.

"It's essentially set up like an HMO once they qualify," he says.

People are ineligible for Medicaid if they have savings or other assets, he adds.

"In addition, people have to have medical issues before they can apply for Medicaid. The Star Card fills that gap. When I'm meeting with families, I encourage them to apply for the Star Card and get care at the clinics before they get so sick they have to be hospitalized," he says.

If people are undocumented, they can apply for tax fund assistance but not Medicaid.

"When a patient is in the hospital, I try to talk to the whole family. I tell them that I'm not interested in their immigration status, I just want to get them resources," he says.

Malcolm reports varying degrees of success in trying to help undocumented workers. Many times people say they don't remember their address or how long they've lived in the area for fear that they will be turned into the Immigration and Naturalization Service.

With the exception of people who have both criminal and medical issues and patients with tuberculosis or other public health risks, hospital staff do not notify the authorities of a patient's immigration status.

In the past year, there's been a huge increase in self-pay patients who previously had insurance, Malcolm says.

"People who were doing OK a year ago have lost their jobs and they are scrambling to find health care for their families. And, there are a lot more people who are just one paycheck away from being homeless," he says.