Dignity Health program reduces inappropriate use of the emergency department
By JULIE MINDA
When Medicaid-insured and uninsured patients seek primary care in the emergency department, the uncompensated costs of their care can be significant for hospitals.
Data from four Dignity Health hospitals in Sacramento, Calif., show that 59 percent of all visits to their emergency departments are for nonurgent needs; and 97 percent of those nonurgent visits are by people insured through Medi-Cal, California's Medicaid program, and by the uninsured.
In 2012, the four hospitals incurred over $103 million in uncompensated care expenses for such visits.
To help get at the root of the problem, Dignity Health's Sacramento regional hospitals and two partners created a program that places patient navigators in the emergency departments, to meet with Medi-Cal insured patients and uninsured patients and assist them in accessing care in the appropriate venue.
Patient Navigator Silvia Dominguez, left, meets with client Marion Shaw, who is a patient of Dignity Health's Methodist Hospital in Sacramento, Calif.
The navigation program is the subject of an Innovation Forum session at the Catholic Health Assembly June 22-24 in Chicago. The session is called "Creating an Integrated Patient Navigation Model through Hospital, Health Plan and Community Collaboration."
Silvia Dominguez is one of six patient navigators who serve four Dignity Health hospitals in Sacramento County, Calif. Those hospitals participated in a successful pilot of the navigation program. They are: Mercy General Hospital of Sacramento; Mercy San Juan Medical Center of Carmichael, Calif.; Methodist Hospital of Sacramento; and Mercy Hospital of Folsom, Calif.
"I spend a lot of time educating patients on how to get health care services and advice outside of the ED. I teach them the benefits of having a primary care doctor and why this is important," Dominguez said.
Climbing Medicaid rolls
The pilot began in late 2010 with one navigator conducting all outreach by phone with select emergency department patients of the four hospitals. The hospitals implemented it full-scale last year by adding more navigators responsible for both face-to-face interaction with patients and phone follow-up when appropriate. Dignity Health started the program in response to "an alarming increase" since around 2009 in the number of Medi-Cal-insured patients, in addition to uninsured, who are turning to the emergency department for basic and nonurgent medical needs, according to Rosemary Younts, director of community benefit for the Dignity Health Sacramento service area. It is more than four times more expensive to treat nonurgent needs in these emergency departments than in a primary care setting, said Younts, who is one of the presenters at the assembly session.
Younts said that with Medi-Cal rolls expected to climb by more than 200,000 people in the Sacramento region under the Affordable Care Act's Medicaid expansion, hospital leaders felt new urgency in finding ways to steer people to care venues appropriate to the acuity of their conditions.
To create the navigator program, Dignity Health partnered with the nonprofit community organization Sacramento Covered and the Medi-Cal managed care provider Health Net. Dignity Health developed, implemented and manages the program. It compiles and analyzes data and provides operational support. Sacramento Covered — which is partly funded by grants from Dignity Health — employs the navigators, who provide patient assistance, and provides insurance enrollment assistance when patients need it. Health Net provides funding for the program and educates the navigators on how health reform impacts beneficiary services and on how to address related questions from patients.
Ashley Brand, manager of community benefit for Dignity Health's Sacramento service area, and an assembly session presenter, said, "We have a promising model for the care coordination system that is missing within our community's safety net — one that could be replicated in full or part by other health providers."
Education at a crucial time
Under the model the partners have now implemented, the bilingual navigators meet face-to-face with Medi-Cal-insured patients and uninsured patients who have come to the emergency department with a primary care diagnosis. The navigators meet with patients after they have gone through triage and treatment, received information from patient registration about the navigator program and agreed to participate in the program.
While the patients are still in the hospital, a navigator talks to them about personal barriers they face in trying to access primary care. The navigators identify a primary care provider for patients if the patients don't have one, set up an appointment for them and help troubleshoot problems that could prevent patients from keeping their appointments. When appropriate, navigators also make patients aware of chronic disease management programs available in their area, including at Dignity Health locations.
Navigator Dominguez said, "A typical day for me would consist of speaking to five to six patients face-to-face and calling different clinics to make them follow-up appointments, and also making follow-up and reminder calls to patients I have served previously." Dominguez and the other navigators also provide first-appointment transportation if it is needed and link patients with community resources, such as programs for low-cost prescriptions. Patients can call navigators on a direct line.
Kelly Bennett-Wofford is executive director of Sacramento Covered and an assembly presenter. She said the navigators are reaching people when they have a medical issue with vital education on how to access primary care. The navigators have prior experience with health insurance enrollment and benefits, clinical outreach and patient education.
Surmounting obstacles
Dominguez and Bennett-Wofford said there are many reasons that people avoid the primary care setting for nonurgent medical needs. Many have trouble finding primary care providers who have timely appointments available for Medi-Cal enrollees. Patients may have trouble keeping appointments, often because they don't have the transportation to get there. Some people aren't aware of benefits in their health plan that can assist them in avoiding the emergency department — benefits like a 24-hour nurse call line.
"We help them figure out how to establish a better relationship with a primary care physician. We show them how to access a system that isn't always set up to be easily accessible and friendly," said Bennett-Wofford.
Marion Shaw, 41, of South Sacramento benefitted from Dominguez' navigation services late last year after several visits to the emergency room for nonurgent care and a few hospitalizations at Dignity Health's Methodist Hospital, including for pneumonia and a gallbladder issue. Shaw, who is unemployed and on disability, said in the past she had automatically gone to the emergency department for health concerns because when she was sick, she didn't have time to look for a doctor. Also, she didn't want to return to the primary care doctor she'd seen because she felt he was uncaring and inattentive. She does not have a car and relies on family and friends for transportation.
Late last year, Dominguez helped Shaw find a primary care doctor near her, helped her schedule follow-up appointments and arranged transportation to the appointments.
Broken safety net
Younts said it has been important for the partner organizations and the navigators to understand the barriers Medi-Cal and uninsured patients have when trying to access health care and to become familiar with the providers who can serve them and the resources that can help them.
Despite their familiarity with the system, the navigators, too, have challenges. Younts said safety net providers have capacity limits and may have many patients with special needs, and so it is difficult to determine exactly who can serve new patients, and when, said navigator Dominguez.
And Bennett-Wofford said currently, navigators are able to find clinics including federally qualified health centers that are able to take new Medi-Cal patients. However, with more and more people signing up for Medi-Cal, she believes there will be capacity issues with these clinics in the future. But, she said, the data the three partners are collecting in connection with the navigator program will help them to understand their population and their population's needs better, so that it will be easier to determine how to help them.
"At the end of the day," Younts said, "the program is contributing to our mission. We are helping those in need find timely, regular care and services."
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