Dr. Feldpush says her group’s hospitals work hard to reach the uninsured. South Florida’s Memorial Healthcare System (MHS) created the Health Intervention with Targeted Services (HITS) Program, an outreach initiative that links patients with insurance programs or medical homes.3 The HITS team used a geographic information system map to target 15 neighborhoods with the highest rates of hospitalized, uninsured patients. Over a six-month period, the team approached these neighborhoods using various outreach strategies, such as health fairs, educational workshops, and door-to-door visits.3
Approximately 6,910 HITS participants have been enrolled in Medicaid, Florida’s children’s health insurance program, or an MHS community health center. Over a three-year study period, MHS saved $284,856 in the ED, about $2.8 million in inpatient costs, and roughly $4 million overall.3
Barriers to Follow-Up Care
Whether you are looking to help uninsured patients, those without a PCP, or both, the key is to try to fill in the gaps.
“As hospitalists, we need to work with pharmacists, case managers and social workers, and others to identify affordable and effective ways to provide care,” Dr. Englander says. “Interprofessional team members, community partners, and family members can help hospitalists understand patient and population health needs and available resources.”
In an effort to close transitional care gaps, OHSU developed the C-TRAIN program, a multi-component transitional care intervention that includes four main elements:
- Transitional care nurse who sees patients in the hospital, makes home visits, and helps coordinate care 30 days post-discharge;
- Inpatient pharmacy consultation and prescription medications at discharge from a low-cost, value-based formulary;
- Medical home linkages, whereby OHSU partners with and provides payment to three community clinics to provide primary care for uninsured patients; and
- Monthly implementation team meetings that convene diverse healthcare stakeholders to integrate elements of the healthcare system and engage in ongoing quality improvement.
The Schumachergroup has also found an effective solution.
“The department head of our case managers and social workers made an agreement with a local multispecialty group,” Dr. Merchant says. “The group agreed to take all discharged patients and be their PCP for 30 days, even if the patient couldn’t pay, in exchange for receiving all patients who had good insurance but did not have an established PCP.
“This has worked well. Every patient discharged from our facility has a PCP listed at discharge, and the unit clerk makes an appointment and documents it in the electronic medical record.”
Sound Physicians has set up a service line, called transitional care services, to smooth transitions of care after discharge for up to 90 days, depending on their clinical needs. It hires providers who work in post-acute facilities and who can also visit patients at home. After discharge, a nurse practitioner will visit the patient, connect him or her with a PCP, and get the patient access to care.
“Smaller hospitalist groups could set up post-discharge clinics,” Dr. Sears suggests, “so when they discharge a patient without a PCP, [the patient] could return to see one of the hospitalists there.”
Mount Carmel East Hospital, a Sound Physicians’ hospital in Columbus, Ohio, has a financial assistance program.
“The case management department provides community health resources to patients who are insured but have no PCP,” says Shelli Morris, RN. “We also have a hotline that patients can call for a list of PCPs that are accepting new patients.”
When a patient lacks insurance or a PCP, Morris is contacted by the physician or case management to provide a referral to a neighborhood health clinic. “Then, as a courtesy, we set up a post-hospital follow-up appointment,” she says.