By JULIE MINDA
Dawn Diaz, a patient advocate at Mount Carmel West Hospital in Columbus, Ohio, talks to patient Levi Bell in the emergency department, about a follow-up medical appointment at Lower Lights Christian Health Center.
Patient advocates in two emergency departments in the Mount Carmel Health System in Columbus, Ohio, are learning what motivates patients to go to the emergency room for nonemergency conditions as they work to connect these patients to primary care medical homes. "This is the right thing to do for our patients — to get them into a patient-centered medical home environment, establish a long-term primary care relationship and to refocus them on health and wellness as opposed to episodic care," said Beth Traini, senior vice president and
chief transformation officer for the four-hospital Mount Carmel system.
Another benefit, Traini said, is that as Mount Carmel's parent, CHE Trinity Health of Livonia, Mich., prepares "to move from the old paradigm of being a collection of hospitals and facilities to being a company whose business is managing the health of populations, this is a perfect starting point for us to identify a population that was misusing a very expensive resource for episodic care when they were not feeling well and moving them instead in a population health management world."
In this world, she said, the focus shifts "to how to keep people well, and how to do more preventive care."
Group effort
The patient advocate program began at Mount Carmel St. Ann's hospital in the Columbus suburb of Westerville, which has a large population of Somali refugees. Several years ago, the hospital was exploring solutions to the problem of inappropriate use of the emergency department for nonemergency care. Hospital leaders suspected a cultural disconnect was at the root of the problem and so St. Ann's partnered with Columbus' Community Refugee and Immigration Services agency to hire in December 2012 a bilingual Somalian with a background in community health as a full-time patient advocate in the emergency department.
The advocate talks to patients who have come to the emergency department for nonemergency needs about how they're accessing the health system. He uses information about their location, culture, language and health needs to identify a primary care provider who would be a good match for them. With the patients' permission, he schedules appointments with the providers. He helps the patients with paperwork, transportation, financial issues and other concerns that could keep them from accessing primary care.
Cross-cultural education
Last year, Mount Carmel partnered with a federally qualified health center in Columbus called Lower Lights Christian Health Center to hire a full-time, bilingual Spanish speaker as a patient advocate for the Mount Carmel West emergency department. Brian Pierson, Mount Carmel's director of community outreach, said initially, the two hospitals funded most of the program's cost with foundation and grant dollars. Now the partners — Community Refugee and Immigration Services and Lower Lights — provide most of the funding, with Mount Carmel hospitals providing the rest.
Traini said the program has different dynamics at each site. "I think from the Somali population what we can infer is that all they needed was information. … They weren't aware of primary care access that could be made available to them and that there were alternatives to the emergency department for primary care."
Patient Advocate Dawn Diaz, left, discusses a patient case with Jill Parak, a nurse practitioner in the emergency department at Mount Carmel West Hospital. Diaz is tasked with helping vulnerable patients, including some who may be accustomed to using the emergency department for nonemergency care, to access appropriate community-based health care and social services.
She said that knowledge gap "was quickly resolved by putting someone in place as an advocate for them, who understood their culture, could speak the language and who could make available to them resources."
Breaking generational habits
Pierson said, "Our bigger challenge is those folks who have been in this country for many, many years and many generations and are part of the generational poverty culture."
Traini explained, that's "a very different demographic — much more of a vulnerable population in terms of income level and education level — at Mount Carmel West hospital, and we are finding different results with that patient advocate.
"There, it is not as much about (patients) not knowing what was available, it's about finding appropriate access and then being willing to access those resources. They're more focused on convenience, and they'd rather just wait in the ED than make an appointment and follow through. So it's culturally different what we have to do to address appropriate use with that population," Traini said. She said the goal is to break the behavior cycle and help these patients appreciate they have control over the situation and can act proactively to address health concerns.
Dawn Diaz, the advocate at Mount Carmel West, tries to do this by functioning like a case worker. She talks in-depth with about 15 to 30 patients a day about the many different concerns they're facing. Many lack housing, transportation, money, proper identification for accessing services.
She refers patients to social service agencies including Lower Lights for nonmedical needs. For primary care, she usually refers them to the Lower Lights clinic, but she can refer them elsewhere if they prefer.
Educating the newly insured
According to Pierson, the two advocates have had more than 6,400 patient encounters since the first advocate was hired in 2012 (with a 5 percent to 10 percent repeat rate). About 70 percent of the advocates' clients were uninsured or "self-pay" patients (the advocates help get them enrolled if they are eligible for any subsidized insurance coverage). The remaining 30 percent were insured through Medicare, Medicaid or commercial insurance (Ohio is among the states that is expanding Medicaid enrollment under Affordable Care Act provisions).
Pierson said just because someone has insurance, that "doesn't mean they have a relationship with a primary care provider, and it doesn't mean they know how to get one."
He said many people newly enrolled in insurance through the health insurance marketplace come to the emergency department inappropriately because they don't know how to access the system. "Even once we get someone insurance, if they've never had it before, if this is something novel to them, if we don't properly educate them, there's no reason for us to expect them to change their behavior pattern.
"So that's another important reason to have an advocate and educator in the emergency department," he said.
Leg up
Pierson and Traini said they are still determining how best to assess the advocates' impact — it is a challenge to track how well clients are staying connected to primary care.
With regards to financial impact on the hospitals, initial analysis shows the program is helping the hospitals avoid the cost of delivering care in the least cost-efficient venue for primary care.
Randall Ryder, 48, is a patient success story. He was jobless, homeless, without insurance and without a primary care provider when he arrived at the Mount Carmel West emergency department. Diaz and Lower Lights assisted him in enrolling in Medicaid and connected him with a primary care provider. "I found out I was diabetic, and that scared me. So, I have been consistently keeping my appointments," Ryder said, and added that he is in the process of getting permanent housing and applying for Social Security disability assistance. Diaz has maintained a relationship with him and has assisted with the steps Ryder has been taking.
He now has hope that he will be able to get a car and perhaps reconnect with a daughter and granddaughter he lost touch with while homeless.
"I have been picking myself up off the ground, and Dawn has helped so much," he said.
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