System links providers throughout the continuum

Community network provides care for uninsured

Communication between hospitals and the primary care providers in the community is essential in managing the care of the uninsured, asserts Diana Resnik, vice president of community care for Seton Healthcare Network in Austin, TX.

"One of the biggest challenges at our clinics has been that we don’t know if our patients have been to the emergency room unless they tell us. Nobody is accountable because nobody knows what is going on," adds Resnik, who manages three community clinics that provide care for 5,000 members of the working poor.

Many of the uninsured who come into the hospital emergency department (ED) have no medical home. Others have a primary care provider but go to the hospital instead.

In Austin, an Internet-based electronic record system links all providers that treat the uninsured population, creating an easy eligibility process and facilitating the management of the patients’ care.

The Indigent Care Collaboration (ICC), a private-public partnership created to manage the care of the uninsured, created the system with a Community Access Program grant from the U.S. Department of Health and Human Services that was matched by Ascension Health. All of the hospitals and clinics that treat the poor in the Austin area are part of the collaboration.

"It’s a work in progress. We have assembled a number of players who are dividing and conquering. The important thing is that we are all working together and the payoff is the savings," she says.

The ICC was formed to take some of the burden of providing care for the uninsured off the hospitals.

"Traditionally, what happens is that the hospital sees the uninsured as their problem and only their problem. We are trying to collaborate here and say that even if you’re the hospital safety-net provider, you shouldn’t take the burden of care on all alone. Other community clinic providers should bear part of the burden," Resnik says.

The shared database is the foundation of what the ICC hopes will provide data to help create care management across the continuum and beyond the boundaries of every system, she says. The database tracks demographic and encounter information at present and eventually will include laboratory and pharmacy interfaces and the patient’s medical record.

"The ICC members are trying to case manage in the primary care arena. The incentive is that if we all save money from managing their care, we can reinvest and add more care managers and see more uninsured," Resnik says. Having the data to identify the people whose care needs managing and to track their interventions is crucial, she adds.

The members of the ICC try to filter everybody who is uninsured through the system and either care manage them through a community clinic program or help them get enrolled into Medicaid or the Children’s Health Insurance Program (CHIP) through a community outreach group.

Through the electronic system, all eligibility screeners can ask the same question and assess the patients the same way. The screening tool helps identify if the patients are eligible for a government payer source or what charity agency might fund their care, Resnik says.

"We literally hold their hands through the enrollment process, and if they don’t qualify, we direct them to a safety-net provider," she says.

The system already has been successful in identifying patients who have a medical home at a primary care clinic but still use the ED as a primary care provider.

"If a patient has a medical home, that medical home should be getting reports on a monthly basis about the frequent fliers through the emergency room. The medical home should be working them into appointments and seeing what are the issues that direct them to the emergency room," she says.

The Seton Community Health Centers have piloted this system with 5,000 lives and, over the past two years, have reduced the list of frequent fliers into the ED from 30 pages to two pages.

When the clinic staff find out someone has been using the ED for primary care, they call the patient.

"It’s not a threatening call. We ask what the problem is and how we can help them get to the clinic instead of the emergency room. With most of these people, it’s a matter of education," she says.

The pilot program has made a lot of progress on the primary care side, Resnik says.

"It’s not just the hospital going out and doing more than they’re responsible for. Everybody takes on their appropriate role and scope of managing the uninsured," she adds. "We hope to expand the learning of this pilot out to the other clinics in the ICC and, using the ICC database, build a best practice for managing the care in the community clinics."

If families that enter the Seton Healthcare System don’t qualify for Medicaid or CHIP, they qualify for care at the Seton Community Clinics.

"We manage their care in these clinics. We watch the data and find out when they are using the emergency room. We try to make sure everybody who needs care uses us," Resnik notes.

All of the community providers and clinics in the ICC have a sliding payment scale. The upfront payment can be as little as $5. When patients go to the ED, they are expected to pay $25 or more.

The next step is to get a list of all the chronic patients and start managing their care, following the same practice ideas, she says.

"This is a huge reason for people to use the emergency department, and it’s the most expensive reason. One diabetic can rack up a huge price tag by being admitted, released, and getting complications that lead to readmission. We want to educate them to manage their disease," Resnik adds.