Indigent patients present multiple challenges

Psychosocial needs often impede recovery

The approximately 4,000 indigent patients in the University of Iowa Hospital and Clinic’s Care Management program (CMPUI) in Iowa City make up 3% of patients but utilize 6.5% of hospital resources and represent 6.4% of acute admissions.

The typical patients have a variety of chronic illnesses such as diabetes, hypertension, and cardiac diseases. In addition to poverty, the patients often have a history of substance abuse, family violence, and a history of mental health problems.

Many have had limited access to primary care in their communities and often visit multiple specialty clinics or the emergency department (ED) for their primary care needs.

"We have found that medical and psycho- social problems are intrinsically linked, and in most cases, it’s most efficient to have both a social worker and a nurse comanage the patient," says Cynthia Doyle, MSN, CS, ARNP, Cm, team leader and nurse practitioner case manager of the CMPUI.

A subgroup of patients presents symptoms in a challenging or confrontational way, which is very time-consuming to providers. In these cases, the social workers are able to help coach these patients on how to better communicate with their providers to achieve their desired outcomes.

The nurse practitioners who act as case managers and the social workers collaborate on care for the patients to get them to the right venue of care and to make sure their treatment or discharge goes smoothly.

Patients are referred to the program by county relief workers, specialty physicians who believe their patients don’t need specialty care, by nurses, social workers, and by the patients themselves. When a patient is referred to the program, the case managers call the patients if they have a telephone and come up with a care plan.

"We give them sort of a road map of where they need to go inside the institution and what kind of community resources we think will be beneficial," Doyle says.

The nurses typically get the patients established with a family care physician in the clinic and meet with the patient and the physician.

"We often have information about the patient that the physician does not have. We collaborate with them on what is appropriate for their care," she adds. They collaborate on discharge planning to make sure the patients can go home on time. For instance, if the patient is likely to have problems finding a way to get home, the social worker arranges transportation in advance.

Durable medical equipment issues often slow down discharge because the patients may not have any funding for them. In that case, the nurse practitioners work with the social workers and local agencies trying to find resources for the patients. "Without our interventions, many of these would have gone home without their needed supplies," Doyle says.

The program has resulted in a significant reduction in ED visits for the population. "In the past, they were discharged with a prescription to take home but no way to get it filled, or they didn’t have the supplies they needed. In a short time, they were back in the emergency room in crisis again," Doyle says.

The patients once used the ED as their primary care physician. Now that they have a primary care physician, they don’t access the ED as often.

"We review all emergency room visits very closely. When they are not appropriate, we contact the patient and find out the reason they went to the emergency room," she says. "The social workers help the patients to improve communication so they can help with their treatment," Doyle adds. The number of patients in the program has slowly increased over the years, and Doyle expects the trend to continue.

"As the economy gets worse, we can foresee that our clients will have more difficulty accessing community resources. Our social workers are magicians when it comes to helping patients access the services we need. That’s why we believe it is so valuable to have social workers who can address these kinds of issues," she says.