Community wide effort assists uninsured, homeless

Providers, agencies team up to provide care

In its efforts to ensure that the uninsured and homeless receive the healthcare services they need, Carondelet Health Network in Tucson, AZ, has developed a list of community resources and partnered with community agencies to provide care for patients underserved patients. (For more details, see related story, below.)

Using a $2 million donation, the health system has brought together a number of community agencies to create the South Arizona Health Village for the Homeless, a virtual village that provides services for homeless residents. "We are trying to bring together everybody who works with the homeless so we can provide the services our community needs without duplication," says Donna Zazworsky, RN, MS, CCM, FAAN, vice president of community health and continuum care for Carondelet Health Network in Tucson, AZ.

The organization purchased a 38-foot recreational vehicle, equipped it to provide mobile medical services and named it the Van of Hope. The van is licensed through a federally qualified health center and staffed by a nurse practitioner, a medical assistant and a community health outreach worker, and provides health assessments, medical treatment, medications, case management, specialty care, and tele-behavioral healthcare in the community. It travels to 19 different locations, including churches and shelters, on a schedule that is publicized in the communities and distributed to community agencies, case managers and emergency department staff in local hospitals.

The organization created respite care beds in two shelters for the homeless, and is able to fund home health visits when patients need them. When homeless patients need post-acute services, the hospital case managers can place them in the shelter beds and arrange for a home health agency to provide services. "If the nurse practitioner on the van finds homeless patients who are on the edge and could end up being hospitalized, they can put them in respite care beds in a shelter, to stabilize them so their conditions don't get worse," she says.

The health system has set up preferred provider agreements with local skilled nursing facilities that agree to follow Carondelet's quality guidelines. In return for referrals from patients who can pay, the nursing facilities agree to take the uninsured patients at a discounted rate. The health system also contracts with other nursing facilities to take patients on an individual basis, paying different rates for basic care, moderate care, and high care. The hospital case managers work with assisted living centers that will take uninsured patients at a discounted rate for a short-term stay. "We are looking at developing preferred provider arrangements rather than negotiating on an individual basis," Zazworsky says.

ED Navigator helps patients find a PCP

Pilot steers patients to appropriate level of care

When patients without a primary care provider come into the emergency department at St. Mary's Hospital in Tucson, AZ, Renee Perez, the hospital's community health outreach coordinator/emergency department navigator helps them get follow-up care.

The initiative is a pilot program begun by Carondelet Health Network in late 2011 that primarily targets frequent flyers who use the emergency department for primary care, says Donna Zazworsky, RN, MS, CCM, FAAN, vice president of community health and continuum care for Carondelet Health Network in Tucson, AZ. Emergency department physicians and case managers refer patient to the navigator who works with them to identify a medical home and make an appointment. "Most of these patients do not realize that there are other resources out there where they can receive care at a reduced rate," Zazworsky says.

Perez adds that the navigation program is an adjunct to the health system's long-standing initiative to help the uninsured identify and sign up for healthcare assistance programs. Many of the patients Perez assists in the navigation program use the emergency department for primary care. "We want to help them find a medical home so they don't come to the emergency department for a non-emergency situation," she says.

Perez receives referrals from the physicians and case managers in the emergency department. If patients are uninsured, she screens them for eligibility for assistance programs and sets an appointment for them at a clinic that offers primary care at no cost or on a sliding scale. The key to the success of the program is not just making the appointment, but following up to make sure the patient is seen by the primary care provider in a timely manner.

If patients are insured but don't have a primary care provider, she helps them identify a provider and make an appointment. "The patients get the care they need in the emergency department, then I coordinate the follow up appointment with a primary care provider. Some patients need follow up the next day; others can wait longer. I call the clinics and make sure they get an appointment in a timely manner," she says.

Zazworsky adds that if patients have a primary care physician but all the appointment slots are booked, the emergency department navigators try to get the primary care office to work the patient in. If that doesn't work, they refer the patients to walk-in clinics operated by the health network's medical group to take care of their immediate needs while they wait for an appointment with their primary care provider. "It's all about access to care," she says.

Perez works closely with the clinics and calls to make sure the patient showed up for follow-up care. If not, she calls the patient and offers to reschedule the visit.

"It's too early to have data, but when but we are documenting every visit and we're seeing good success with patients following up with the clinic," she says.


  • Renee Perez, Community Health Outreach Coordinator/Emergency Department Navigator, St. Mary's Hospital, Tucson, AZ.