Discharge Planning Advisor

Program targets uninsured, underinsured patients

Goal: Establishing 'home' at nearby center

Self-pay emergency department patients who have no primary care provider are being referred to a nearby primary care and specialty center under a program in place at St. Mary's Hospital in Tucson, AZ, part of the Carondelet Health Network.

The majority of the patients involved are uninsured or underinsured working people who may have already applied for help through the Arizona Medicaid program, known as the Arizona Health Care Cost Containment System (AHCCCS), says Cassandra Pundt, RN, PEN, emergency services patient representative. "They make a little too much money [to qualify] or have had AHCCCS but haven't kept it up."

The referral "gets them into the loop" to receive primary care services at St. Elizabeth's Health Center, she adds. "Our goal is to get them follow-up care and [do the] paperwork. If they get a health care home, they will use ED services less.

"Our [ED] volumes are overwhelming, especially in the winter," Pundt says. "Once we get into the winter crunch, we can have 20 or 30 people waiting for an ED treatment bed, although they are triaged immediately."

The process, which began in August 2006, works as follows, she explains: "Our [registrar] gets the demographics and data needed for our Meditech [registration and patient logging] system, which logs the patient visit, including the insurance provider if the person has one.

"Our information systems staff have programmed the registration system to spit out the names of patients who meet the criteria — self-pay, no insurance provider," she continues. At 6 a.m. each morning, Pundt says, she receives the report on the previous day's patients.

As of April 2007, there is a new twist: The patients are divided into those with addresses and those without, she notes, in order to direct the latter to a clinic that now specifically addresses the needs of the homeless population.

Pundt says she can distinguish between the two groups because registrars know to enter the hospital's address for those who don't list a residence. At that point, she faxes the appropriate face sheets either to St. Elizabeth's or to El Rio, the clinic handling the homeless population.

"Our social worker tends to get involved with the homeless anyway," Pundt notes. "There are several brochures we have about services. Before this program, all these people were slipping through the cracks."

All of the individuals referred to the two clinics have been discharged from the ED, she points out. "Some of them may not need follow-up care, but we still want to refer them so that if they need a flu shot or get sick again and have a minor problem, they will call St. Elizabeth's or El Rio."

In addition to the daily screening of face sheets, Pundt adds, ED staff can alert her or the social worker if they think a patient has a particular need or can benefit from referral to one of the two clinics.

If that happens, she says, "I make sure they get sent over and I also make a follow-up phone call. Anything brought to my attention today, I will deal with."

While it's difficult for nurses — who are focused on clinical issues — to consistently screen for likely candidates, Pundt notes, educating staff to pass on information about specific cases to her or the social worker is one of the goals of the program.

In one instance, Pundt recalls, a young man with a dislocated shoulder made several visits to the ED and was ultimately referred to St. Elizabeth's for orthopedic care. A self-employed construction worker, the man originally didn't meet the criteria.

"He couldn't work and he couldn't make money, but then [he qualified] when he got down to having no money," she says. "The only way he could get back to work was to get his shoulder fixed. Everything was going well the last time I talked to him."

Another case recently brought to her attention involved a woman who came in to be treated for one condition, but during triage also was found to have extremely high blood pressure. "When she was asked what she took for that, she said, 'Nothing — it's too expensive.' The [triage nurse] alerted me, I got her connected with St. Elizabeth's, and she is now on medication."

Another goal of the referral effort, Pundt notes, is to identify children who might qualify for Kids Care, an arm of the AHCCCS program.

"Say an adult comes in, but in a follow-up phone call to the person, we find out he has a family," Pundt says. "We may find that the parents make too much money to get total AHCCCS [coverage] for themselves, but the kids are eligible."

Local school systems also help identify children who are eligible for the program, she adds.

During the 14-month period between August 2006 and October 2007, there were 1,325 referrals for patients "who aren't emergencies, don't have insurance, and don't have regular medical care" from St. Mary's Hospital to St. Elizabeth's Health Center, according to Nancy Johnson, RN, PhD(c), executive director of the health center.

Center uses sliding fee scale

St. Elizabeth's serves individuals who are not eligible for federal- or state-funded health care programs, Johnson notes. They are put on a sliding scale and pay whatever they can afford, she says.

The effort, which began as a pilot program, will be continued, she says, noting that of the patients referred to the health center, 327 — including some family members — were successfully registered, and about 132 "have established care" at St. Elizabeth's.

"The definition of that is that they have actually shown up, registered, and had one appointment with a primary care provider," Johnson adds.

"Where the rubber meets the road is if they continue [to come to the health center] and we see that we don't have other hospitalizations," she notes. "That is yet to be seen."

Further breaking down the number of referrals, says Pundt, 91 people have had more than one appointment at St. Elizabeth's, and 159 individuals received help through the center's prescription assistance program.

"The numbers keep whittling down, but they are for a program that is not much more than a year old," she adds. "We are still learning how to promote it to the community."

Of the 1,325 referrals to St. Elizabeth's, Pundt says, staff were unable to reach 178 people because they had given their names or other information incorrectly.

Various locations help initiative

Between April 2007 when St. Mary's began its program with El Rio and July 2007, about 160 homeless individuals were referred to that clinic, Pundt notes. "They only made contact with 16 people who followed up. There were a lot they just couldn't track down."

In addition to continuing its partnership with St. Mary's, Johnson says, St. Elizabeth's staff will be seeking out those in need of affordable care in other places. One of those locations, she notes, is a small volunteer clinic in south Tucson called Clinica Amistad.

"There is no outpatient care of any kind in that area, so it's not easy [to get treatment] if you wake up in the morning and aren't feeling well," she says.

Clinica Armistad is run by volunteers, Johnson adds, and is open only on Monday evenings. "Seventeen to 30 people show up who have no physician, no money, no insurance.

"We started sending one of the community health workers from our center there to let people know we're here," she says, "and to do health education with whoever shows up." The plan was to encourage them to enroll at the center, Johnson adds, "and start getting them involved in preventive health care as well as acute care — things like flu shots and PAP smears."

The message her staff want to get across, she says, "is that we can offer services based on what they can pay." As a result, it is anticipated that the hospital ED will see fewer uninsured people who are not emergencies, and there will be fewer hospital admissions.

Key to the success of St. Elizabeth's programs, Johnson notes, is the support of Tucson physicians. "Our great blessing is that we have over 150 volunteer physicians who help us." Physicians donated care worth $750,000 during the past fiscal year, she adds, including expertise, X-rays, and use of the vascular lab, among other services.

One of the challenges center staff face in their efforts to provide care to the uninsured, she says, is the reluctance of many individuals to seek treatment — no matter how crucial — that they know they can't afford.

"We have one woman in for breast cancer treatment who had a palpable lump," Johnson notes. "She said, 'I don't want to leave my family with a large medical bill. I'd rather leave my savings account to them.'"

St. Elizabeth's staff were able to tell the woman about funding that is available from grants and from the Komen Foundation, she says, as well as care from volunteer clinicians.

Models 'integrate family, neighborhood'

"The projects we work with are models that integrate family and neighborhood," Johnson explains. "If I'm hanging out with people who eat healthy and take a walk every morning, I'm not as likely to eat doughnuts and lie in front of the television. A lot of people are influenced by those around them."

The Monday night sessions that St. Elizabeth's community health workers conduct at Clinica Amistad, for example, include nutrition education and chair exercise sessions "with whoever happens to be there," she says. "It's very impromptu. They might say, 'We will talk tonight about protein and where to find it, or calcium and what foods it's in.'"

Staff might start a conversation with patients about the foods they like to prepare and suggest ways to make them healthier, or discuss stress management activities, Johnson says.

"Our education is twofold," she adds. "One [approach] is to provide health information, but another is to build trust and to convince people that [St. Elizabeth's] will be a comfortable place to get care."

Cooperation between health center and hospital employees is a continuing focus, Johnson notes. "When one of our patients needs to have surgery for cancer, we call ahead to let the hospital know the person doesn't have insurance, so they can be prepared to help rather than have it be a traumatic experience."

St. Elizabeth's personnel work with hospitals to set up packages and payment plans for uninsured patients, she says, including an arrangement with Tucson's University Hospital on obstetrics care.

The health center has obtained funding to establish an electronic medical record system (EMR), Johnson says, which is expected to be in place by this summer.

"That will help us tremendously," she adds. "We're building in some templates for all the education and health prevention [programs] we're doing."

In the case of patients who are referred from the ED, Johnson says, "we will be able to measure the power of these interventions. We might have a diabetic who has improved — his hemoglobin A1C has gone down, which is the gold standard we use for control of diabetes."

Using the EMR, she explains, the individual would be logged in as an ED referral, with notations in the record showing that he came to the nutrition class and did the chair exercises, and that those things actually affect clinical outcomes.

"Most EMRs are designed for what happens in the exam room, and that is certainly helpful; but the premise we have is that [the traditional] model of care needs adjustment and that some of the preventive interventions may affect everything else."

Physicians will be able to pull a person's record, she adds, and say, "'Oh, I see you've been going to this exercise class.'

"We live in a really abundant society," Johnson point out, where a lot of money is channeled toward health care. "Money is spent on treatment and hospital care. It is a disease-based model. We reimburse hospitals and specialists for surgery, radiation, and chemotherapy, but we don't have a lot of funding on the front side for prevention."

If an uninsured person feels fine, she may not see spending $75 for a mammogram. "I believe there needs to be a shift to get money on the front side and help people who are working but who can't afford to pay $1,000 a month for insurance."

(Editor's note: Cassandra Pundt can be reached at cpundt@carondelet.org. Nancy Johnson can be reached at njohnson@ccs-soaz.org.)