Each Sunday, the Daily News will take a closer look at a topic important to the community.
Some of the highest health insurance costs are bore by those who least can afford it: uninsured, lower-income patients with chronic conditions who often forego regular treatment and end up in the hospital as a result.
“Unfortunately, people without insurance or who are low income sometimes do not go to their primary care provider or primary physician on a routine basis and only go to the doctor when their sick or to get their (prescription) script refilled,” said Debra M. Davidson, Ph.D., chief operations officer for Neosho-based ACCESS Family Care. “They’re using the emergency room for primary care, in essence, when they could come to us on a more routine basis and at a much lower cost. We could help prevent an exacerbated situation for the patient.”
It’s a recurring problem seen too often by hospitals and medical clinics such ACCESS Family Care, a federally qualified health center founded in 1996 for the purpose of increasing access to health care for those who lack medical insurance coverage. To assist in its work with the chronic-condition population in Southwest Missouri, a grant has been awarded to ACCESS, which provides medical, dental and pediatric care on a sliding-scale fee at clinics in Neosho, Anderson, Joplin, Cassville and Mount Vernon.
New York-based RCHN Community Health Foundation has awarded ACCESS Family Care $150,000 to support a project to help diabetic and other patients discharged from the hospital to better manage their condition.
Diabetes is considered acute in the area, where 14 percent of the organization’s 20,000 patients, roughly 2,800, struggle with the chronic condition, compared to 9 percent of people nationwide.
“Rising numbers of people with diabetes is leading to higher rates of avoidable emergency department visits and hospital admissions,” said Venice Green, RN, ACCESS quality assurance manager. “This grant will help us to streamline patient care from hospital to home and community, lower ER visits and hospital admissions that can be avoided with preventive care and improve our capacity to serve as a comprehensive health home for our patients.”
Hospital partnership
ACCESS is partnering with Freeman Health System, Mercy Hospital and the Missouri Primary Care Association on the initiative. Called ACCESS Comprehensive PCMH Integration, it will assign a community resource coordinator (CRC) to serve as a liaison with local hospitals to identify discharged patients with poorly controlled diabetes and connect them to services to better manage their condition. PCMH stands for patient-centered medical home.
Davidson said working more closely with hospitals will ensure that “it’s a smooth, working process that’s not burdensome for the hospitals” when alerting ACCESS of patient admissions and discharges. “We have a very good working relationship with all of the hospitals. This will help connect the dots a little bit more.”
National Committee on Quality Assurance standards, in which ACCESS adheres, require a 72-hour follow up when patients are discharged. The CRC will help make that happen, Green said. “We are hoping that the coordinator we are going to hire will build a relationship with the hospitals to identify those patients and follow up with them within 72 hours of the hospital stay.”
Benefits of community resource coordinator
ACCESS is in the process of hiring the CRC, who will expand on efforts of clinic care team members’ efforts to reach out to patients, because “there’s only so much nurses can do from the clinic,” Davidson said. That’s where the CRC will enter the picture to help educate patients and seek solutions for patient barriers such as lack of transportation.
“We can offer our patients additional educational opportunities and benefit them in ways such as how to eat more healthy and how to find different places to go for assistance when they need to purchase better food items at a reduced cost,” said Green, who will supervise the CRC.
“Having a grant to be able to afford an additional staff person is a very big benefit for us,” Davidson said, “because then we can concentrate focus so that one person can be that liaison and the conduit between these hospitals. If the process isn’t working quite right, this person can figure out who to go talk to and see where they are sending the information that maybe isn’t getting to the right people on our end. Now we’ll have a detective to figure that out and make the process seamless, smooth and timely to benefit our patients.”
In addition to hiring a CRC, grant funds will be used for training to help clinical staff reach patients with motivational interviewing and teaching better self-management goals, Green said. Funds also will be used to purchase teaching supplies.
Grant criteria
To fulfill grant requirements and possibly receive second-year funding, Green said, ACCESS must meet several deliverables that show improvement in tackling problems faced by the patient population served by the initiative. For example, there is a quarterly goal to increase by 10 percent hospital notifications when patients are discharged.
“We are failing to know when they have been discharged. We have a lot of groundwork to do there,” she said.
Other goals include improving outcomes of patients by decreasing hemoglobin A1c levels and rates of hospital admissions and ER visits.
The initiative will focus first on patients served out of the Joplin clinic, Davidson said. “That’s our biggest population of patients.”
After working with the Joplin clinic for several months, the goal is to expand to other clinic locations. What is used and learned in Joplin, however, will benefit all facilities, according to Green.
“If we get (hospital) notifications in Joplin, it’s going to improve notifications at our other locations because we do send patients to Freeman and Mercy from our other four clinics,” she said.
Diabetes intervention
While the initiative will reach patients with other chronic conditions such as hypertension and asthma, Davidson said, diabetes is the main focus because it’s particularly widespread among older adults and in low-income, minority and other vulnerable communities, where access to healthy foods or an ability to afford ongoing medications can be a challenge.
“They often tell us that they can eat or take their medicine,” Green said of low-income patients choosing between the two.
The intervention program aims to improve patient education and to identify services to help diabetic patients overcome barriers to controlling their condition, while strengthening the health centers’ systems of care.
“We at the practice can notify the patient, have them come in and reconcile any medications that the hospital put them on with what they’re already taking,” Davidson said.
Funding source RCHN Community Health Foundation is a not-for-profit foundation established to support community health centers through strategic investment, outreach, education and health policy research. It’s the only foundation in the country dedicated solely to community health centers.
“A critical part of improving our nation’s health is to more effectively reach and care for those who face cultural or systemic barriers that limit their access to care and ability to lead healthier lives,” said Feygele Jacobs, RCHN president and CEO. “Our foundation is pleased to support innovative projects to improve the health of vulnerable populations and share lessons learned on how to deliver health care that works better for our communities.”
ACCESS Family Care is one of six grantees in five states that will receive $150,000 each to develop and launch a population health-focused program. Other projects include initiatives to improve pediatric care management and reduce child and teen ER visits, reduce smoking among Asian-Americans, increase colon cancer screening rates, improve cervical cancer screening rates in health center communities and establish a medical home for the homeless.
“Being one out of six in the United States chosen by this particular foundation,” Davidson said, “is pretty amazing.”