Discharge Planning Advisor - Clinic serves as a model for care of the uninsured

Volunteers play key role

In April 2002, Donna Zazworsky, MS, RN, CCM, FAAN, director of grants, partnerships, and policy at St. Elizabeth of Hungary Clinic in Tucson, AZ, got a telephone call from a case manager at a local hospital who wanted to know if the clinic had a hospital bed it could donate for use by a 17-year-old patient who was being discharged.

"She said they had a young man who was not insured, with a gunshot wound to the head, who had been stabilized after several weeks in the hospital, but who was paralyzed and still had a tracheostomy tube and a gastrostomy tube," Zazworsky explains.

The boy’s mother was coming to take care of him, the case manager explained, but a hospital bed was needed, and she wondered if there was one available from the clinic’s medical equipment loan chest.

"I said I could probably get a bed," Zazworsky recalls, "but then I asked her, Who is going to oversee his care?’"

That question, and its answer, set in motion a series of events, she says, that has everything to do with how discharge planners and case managers need to approach the problem of getting care for uninsured patients.

What the case manager told her, Zazworsky says, is that the young man had an appointment to come back and see a neurosurgeon in two weeks.

"Inside, I went nuts," she adds. "I said, Who is going to be there for the mother? She’s the one giving care, and he has a trach tube, a G-tube, and a three-inch hole in his head? They need backup support. No one at the neurosurgeon’s office is going to provide that.’"

While the Emergency Component of the Arizona Health Care Cost Containment System (AHCCCS), the state Medicaid program, had paid for the patient’s initial care because his condition was life-threatening, Zazworsky learned, he didn’t qualify for home health services because he was an undocumented immigrant. There was no primary care physician in the picture, she notes, because he had never needed one before.

"I told the case manager to have his mother come to the clinic, bring the papers we need — proof of work or a utility bill to show residence here and a photo ID — and said I would go out and do a home visit," she explains. Without her intervention, Zazworsky says, "I can guarantee you that he would have been in the emergency department [ED] in two days."

Instead, the coordination she provided through the clinic — using a myriad of carefully developed resources and affiliations — resulted in a program of care that was not only cost-effective, but far superior in quality to the reactive, stop-gap measures that otherwise would have comprised the young patient’s follow-up treatment.

"The bottom line with discharge planning if somebody is not uninsured," she says, "is you need to really work on connecting people with a medical home that will provide primary care and case management to help people get through the system and to get them set up with a follow-up visit."

St. Elizabeth of Hungary Clinic, a nonprofit primary and specialty care clinic operated under the auspices of Catholic Community Services, serves individuals who are not eligible for federal or state-funded health care programs, Zazworsky explains. "They are the working poor, the recent immigrants and refugees." If the clinic’s coordinated approach to care were used universally for the uninsured, she suggests, ED visits and overall costs would be reduced dramatically.

In the case of Daniel, the 17-year-old gunshot victim, if she had not intervened, "the neurosurgeon would have followed through in some way, shape or form," Zazworsky says, "but what happens when I take over is that I start working with our volunteers. We got it done more efficiently and affordably."

Without that coordination, she adds, "he would have been in and out of the hospital many times, racking up a lot of bills."

In arranging care for the more than 18,000 active patients who are seen annually at the clinic, Zazworsky notes, she draws on not only an in-house administrative/provider staff of 52, but on 150 volunteer physicians, dentists, nurse practitioners, and nurses from throughout the Tucson community.

These volunteer practitioners, she says, either come to the clinic to provide care or donate slots of their office time. Among other arrangements with community providers, Zazworsky notes, a teleradiology set-up with radiologists at a local hospital allows St. Elizabeth’s to send the day’s X-rays to the hospital, where the physicians read the X-rays for free on their lunch hour and send them back to the clinic.

St. Elizabeth’s contracts for laboratory services with another hospital, which maintains a drawing station at the clinic and gives its patients a discount, she adds. "They can get the lab done right there during their visit," Zazworsky says, after which the lab technician coordinates regular pickups of the specimens and takes them to the hospital and then sends back the results.

The ability to have laboratory services performed during a primary care appointment is an example of the kind of accommodation that is important in caring for the uninsured, she points out. "Most of our patients work low-income jobs and cannot afford to miss an hour or two. They might even be fired if they have to miss work. So one-stop shopping must be addressed."

Patients at St. Elizabeth’s "have to pay for care," Zazworsky emphasizes. "It might be a $10 administrative fee. That’s a big, important thing to get across. People need to keep their dignity for their well-being."

Fees are based on a sliding scale and are negotiated with the patient, she says. "We will bill them over time — even if they pay $5." In Daniel’s case, for example, the family paid the $52 per round trip it cost for a specially equipped van to take him back and forth from the clinic.

The clinic gets some primary health care funding from the state: "a flat amount of money to provide care for the uninsured" that amounts to maybe $70 per patient (this includes the provider visit, lab, and other services), Zazworsky says. "It usually runs out in March or April, so from that time until about the end of June (the end of the fiscal year), we might bump up the fee."

"What happens," she adds, "is that you see our visits go down, because it’s harder for people to pay, and ED visits go up." At present, Zazworsky adds, the evidence of that link is mostly anecdotal, but a local group of hospital administrators and business leaders is looking at doing an analysis of ED visits that would substantiate it.

"People can’t be turned away at the ED," she notes. "They’re either going there for a primary care visit that could have been done at the office; or they’re not being cared for at all, and something more serious has happened; and they’re going for that."

A cautious start

When Zazworsky left St. Elizabeth’s to make that first visit to Daniel’s home, she recounts, she took along the clinic’s medical director, who looked at her and said, "Donna, we can’t do too many of these." He was referring to the likelihood that the case would be very complex and require many resources, she adds, "and that was true in the first month. I made visits two or three times a week, and the medical director went weekly."

When they arrived at the tiny home in South Tucson, Zazworsky says, they found the mother, who speaks only Spanish, and her son, head bandaged, unable to turn on his own, and with the eyes of a deer caught in headlights. But having thought they might find the young man in a coma, she adds, they were thankful to see that "He was all there."

Zazworsky set about coordinating some care into the home, she says. "The mother knew how to manage the wound and was somewhat comfortable with the tubes but certainly not independent. I called a home health company I know, and they sent out a respiratory therapist who put in a talking trach. So then he could talk to us."

Discovering that Daniel could not yet tolerate bolus feeding, whereby a cup of tube feeding is put directly into the stomach through the G-tube, she asked for a nutritionist and a kangaroo pump that would deliver the food slowly in measured amounts.

"We needed to find out if he would have enough calories and fluid for healing," she adds. "He was on a variety of medications, so we needed to see if changes should be made based on the G-tube route. I coordinated and oversaw all that."

Physical and occupational therapists, volunteers of the clinic, came out to do an evaluation, she says, and gave Daniel’s mother instruction on basic exercises that should be done daily to reduce muscle contractures that occur when muscles are not used because of paralysis.

His mother, meanwhile, was calling the clinic regularly because she understandably had a lot of questions, says Zazworsky, who ended up giving the woman her cell phone number to facilitate the communication.

To make it easier to oversee Daniel’s care, she asked the Arizona Telemedicine Program — which provides services to communities throughout the state from its base at the University of Arizona College of Medicine — to set up a unit in the home "so we could call him up and I could assess him from the clinic," she notes. "He thought that was so cool. He said, Donna, it’s like [the television show] Big Brother.’"

When she discovered that the family had only a cell phone, Zazworsky adds, "I had to back up a few steps and call the telephone company and get a phone jack put in."

Once the telemed was put in, Zazworsky adds, "they managed very well. I went out every other week and then monthly. The medical director would come out if needed."

When she wanted to have Daniel hospitalized to have his tracheostomy and gastrostomy tubes removed, AHCCCS couldn’t pay for it because it wasn’t an emergency, she says. So Zazworsky arranged to have the procedures done by volunteer physicians at an outpatient clinic.

Later, she was able to get Daniel a "scholarship" through the foundation of a local rehabilitation facility, she notes. "They gave him five inpatient days where they taught him and his mom how to work better together — how to transfer from bed to chair, how to dress, daily living skills."

After Zazworsky made some contacts and assisted with paperwork, Daniel was able to enroll in classes through the home program of the local school district, she adds, using computer, television, and the Internet to keep up with his studies.

Daniel’s case "is such a classic story of how you have to work the system," she says. "He was somebody who could easily have been dropped. We picked up [his care] in April 2002, the tracheostomy and gastrostomy [procedures] happened that April and May, and then we got his head closed that August. Now we don’t have to spend much time on him. He’s a healthy young man — he just has this brain injury — and the most amazing person."

Although St. Elizabeth’s is a faith-based clinic and currently does not qualify for federal funds, Zazworsky points out, there are more than 700 federally qualified community health centers throughout the country that receive money from the federal government to care for the uninsured (http:ask.hrsa.gov/pc).

In most cases, she adds, the clinics have a case manager who knows how to leverage funding for optimal benefit.

"[Hospital] case managers need to learn where the resources are," Zazworsky stresses. "Caring for the uninsured takes a lot of coordination, a lot of support from people in the community."

(For more information, contact:

Donna Zazworsky, MS, RN, CCM, FAAN, Director, Grants, Partnerships, and Policy, St. Elizabeth of Hungary Clinic, Tucson, AZ. E-mail: DONNAZAZ@aol.com.)