Meeting the Healthcare Needs of Underserved Communities

With each passing week, tens of millions of lower-income Americans without adequate health insurance face challenges accessing appropriate and affordable resources for preventive and primary care. Consequently, medically underserved populations often neglect to seek out basic services, leading to undiagnosed and/or untreated health conditions that put them at risk for serious illnesses and acute episodes that must be treated in intensive, high-cost settings. In this HFMA Executive Roundtable, sponsored by Walgreens, healthcare executives share key strategies for meeting the needs of this important patient population.

What ara soma of the most successful programs you have to treat underserved patients?

Scott Goodin: I think it largely starts with simply making sure people are aware of the services available to them. People may not realize they can access coverage and services in affordable ways or, in some instances, without charge.

Focusing on affordability is crucial. We have certified enrollment counselors for Covered California, the state's health insurance marketplace, to bring awareness to low-cost health plans. For those without financial resources, we charge a basic sliding scale of $30, $40, or $50 for office visits, regardless of the intensity or comprehensiveness of the reason for the visit.

Also, we recognize the importance of being flexible. A patient coming in twice a week for a blood test to check anticoagulant levels may not be able to afford the typical cost of $60, which can result in them not coming in, creating potential for a significant-and likely far more costly to treat-health problem. We discovered that if we drop the fee to $5, then we have much better compliance. The test is simple and quick, and making it more affordable is not only the right thing to do for the patient's health but also overall cost of care.

We're doing many of these types of common-sense initiatives that improve quality and overall cost of care, from offering health screenings to providing free immunizations. If these programs can prevent visits to the emergency department, then that's a huge win for everyone.

Ed Cohen: My organization provides traveling wellness support for the needs of urban and minority communities that experience disproportionately high rates of preventable diseases. We staff a fleet of buses with nurse practitioners and physicians assistants to provide the community visited with free tests, risk assessments, and counseling, as well as vouchers for reduced prescription costs and free/low-cost immunizations for influenza and other preventable diseases, such as pneumonia. The program, Way to Well, is funded through a multiyear, $100 million grant from our charitable foundation. In the past several years, we've had 8,800 event days, where we have seen 830,000 people and performed nearly 5 million tests.

We also operate a separate program that involves distributing vouchers to underserved populations for low-cost or no-cost flu vaccinations. All of our pharmacists are trained to immunize customers whenever the stores are open, so participants don't have to plan their visit around normal office hours; they can select a time for immunization that is most convenient for them, whether an evening or weekend or even a holiday.

Lisa Daigle: Diabetes is a major driver of health issues in large segments of our patient population, so we formed a partnership with Scripps Whittier Diabetes Institute to help meet associated needs. They send out RN specialists and nutritionists on our behalf to provide screenings, education, and consultations. Instead of a quick 15-minute visit, our patients get a one-hour initial appointment and receive follow-up care from a nurse who is a certified diabetes educator. Patients also can receive free or discounted medications, such as insulin, during the appointment.

Also, one area that can be overlooked is the importance of behavioral health. At each of our clinics, we have a psychologist on site. When a patient comes in for a medical appointment but also presents mental health issues, we can do a "warm hand-off" and have the provider bring the onsite behavioral health consultant into the exam room to meet with the patient for an assessment and brief intervention. Even though we can't bill for two visits in the same day, supporting this extension of care can be very important for the patient. The patient can establish a relationship with the behavioral health provider and schedule a future appointment. At the same time, the patient's medical provider is able to better focus on the patient's physical condition.

Denise Barton: We've partnered with Baptist Health Care to establish a medical home. Escambia Community Clinics is now a federally qualified health center with service sites in six locations that will provide more than 100,000 social, medical, and dental encounters this year. Twenty-two percent of our community is uninsured and 46 percent are at or below federal poverty levels, and these are the patients that are seen in the medical home. Our organizations mutually support the program through $525,000 in community benefit grants that are leveraged to secure local and federal match funding. This enables Escambia Community Clinics to take a larger number of uninsured patients, nearly three times the average federally qualified health center. More than 60 percent of the Escambia Community Clinics' patients are uninsuredthey are largely made up of the region's working poor.

David Sjoberg: Many of our health improvement programs are incubated and operated through a community health coalition, Partnership for a Healthy Community, which was founded 20 years ago. One program the coalition supports is our LiveWell Northwest Florida initiative, which includes access to care and self-care management as key focuses. With the initiative, we have successfully provided community-based care management for chronic diseases, which contributed to a 28 percent reduction in emergency department visits and avoidable inpatient stays. We also offer a pharmacy assistance program that secures no-cost medications and a generic formulary for maintenance medications associated with chronic illnesses. The financial benefit of these programs to our organizations as well as the community is significant. The pharmacy program alone has provided more than $6 million in free medications since its inception.

Why Is serving uninsured or underinsured patient populations the right thing to do-not only lor patients, but lor the bottom line as well?

Daigle: It starts with the fact that preventive and primary care are the least-costly ways to treat patients. Preventive and primary care services keep people healthy and less likely to need care in more intensive settings, such as the emergency department. As healthcare reform continues to focus on payment structures that support better outcomes and shared savings, the financial incentive for providing these services for the medically underserved will only continue to grow.

Larry Flick: Recognizing the importance of primary care is one of the reasons HealthNet has partnered with Indiana University Health to jointly fund staffing for a HealthNet representative, who is co-located in the emergency department of Indiana University Health Methodist Hospital. The HealthNet representative directs patients with non-urgent needs to the HealthNet network or to other providers in the community. We encourage these patients to break the habit of coming to the emergency department for routine care by helping them get reacquainted with their physician or scheduling an appointment if they are assigned to a HealthNet physician. Educating patients to access appropriate levels of care this way is smarter for the immediate bottom line, and helps patients better manage their own care for the long term, which can improve their health and reduce future demand for more intensive services. At the same time, emergency department resources are better available for those truly in need.

Cohen: Improving access to primary care isn't the only way to minimize emergency department strain from those with non-urgent needs. Many clinical care providers are beginning to work with community pharmacies as well. This low-cost setting can often be better leveraged within the care continuum for non-urgent services, such as immunizations or walk-in clinic care. With access to community-based care available seven days a week and some locations available 24 hours a day, the community pharmacy is often the first point of contact for the underserved population.

When H comes to wellness, routine checkups and immunizations are often cornerstones. What advice would you offer to others when it comes to providing these services to the underserved?

Cohen: Our success focuses on three areas: expanded immunization options, broad access, and a consistent message to bring awareness to patients.

Flick: I think for us, it begins with staff education and training. You want to create a wellness-focused culture that emphasizes treating the patient, not the illness. We promote well-child checkups, for instance, which pay significant long-term dividends with respect to patient health, and create improved ongoing relationships between patients and their providers and staff.

In terms of executing, we added one Saturday per month at some of our busier locations with a focus on well-child visits and immunizations. Since Medicaid managed-care organizations are evaluated on clinical outcomes, there are often financial incentives to integrate these types of focused events as well.

Barton: In our communications, we strive to have a personal touch. Standard materials and brochures are well and good, but without creating a connection with patients during one-on-one encounters, you cannot activate patient engagement. In our experience, feeling connected to a care provider who you trust and who can navigate you to necessary resources is foundational to achieving the patient's personal health goals and to improving the collective health of the community.

Of course, patient engagement alone isn't enough. For instance, it's all too common for patients to be willing to come in for services but lack the transportation to do so. We're working to overcome such barriers and meet residents where they live, work, and pray. We have a pretty robust faith-community nursing program in more than 20 churches where volunteers provide services and support to their congregants and neighbors. And we also have another simple strategy that's effective: When we identify an uninsured resident in the emergency department who could have been treated in a physician's office, we pay for the first visit to an Escambia Community Clinic. Doing so removes at least one key barrier as individuals consider accessing care.

Daigle: Although we don't incentivize immunizations or checkups, we have taken a longer-term perspective by emphasizing the importance of a primary care medical home. With a specific physician identified and a supportive care team to manage the patient's health, we're seeing much better rates of checkups, immunizations, and other preventive care. Performance is documented on provider report cards, so leadership can identify the effectiveness of interventions: What percentage of patients are up to date on immunizations? How many patients with diabetes have A 1C rates in the recommended range?

And as payment shifts away from fee-for-service to the quality of overall outcomes, providers have incentives to get behind this strategy as well. This is new for us, but it's really spurred some thinking about how to best manage the patient.

Also important for wellness is proper management of chronic illness. What key strategies would you recommend to providers to assist the medically underserved in this regard?

Daigle: Our diabetes management program that I referenced earlier, where we provide outreach in the community and encourage follow-up visits and medication compliance, is a good example of an effective way to help a patient population manage chronic conditions. And this style of care turns out to be a great gateway for transitioning into a true form of primary care medical home. To carry efforts even further, we're currently creating care transformation teams and panel managers.

You mentioned encouraging medication compliance. What are some of the key strategies healthcare providers can use to help ensure that prescriptions are filled, particularly for patients with chronic conditions?

Daigle: Sometimes it's not easy to know what happens once that patient leaves the treatment room, so we're going to pilot a program, starting with our diabetic patients at one of our health centers, to start monitoring prescription compliance. At every contacteven if it's for an unrelated issue-we will ask about medications. The pharmacists on site will meet with patients, help manage medication and timings, and educate on the importance of compliance. And we'll follow up with at-risk patients, discuss any challenges with following the medication regimen, and even schedule a follow-up visit, if necessary. Obviously, this isn't a funded initiative-you can't bill for a pharmacy consultbut we think it's an important service to provide.

Goodin: We participate in HRSA's 340B Drug Pricing Program, so we can provide medication to our patients at subsidized rates that they can't get anywhere else. We also took our 340B program even further, by putting pharmacies in two of our clinics. That presence increases drug compliance, because patients don't have to travel to get their first prescription filled. Patients can walk out of the exam room, down the hall, and fill their medications. Based on data in our electronic health record, we've seen a 70 percent increase in patients' compliance with starting prescriptions since making this change.

Barton: We developed a community wide pharmacy assistance program among safety-net clinics. The program includes common policies, a prescribing formulary, and a software platform that completes the paperwork to secure the free medications from pharmaceutical companies. This pharmacy software system is integrated into a community health information exchange that can assist a provider in understanding the patient's medication compliance. We have also done several studies on the factors associated with noncompliance. The results were surprising: The most common reason for noncompliance is a lack of understanding about how to take medications. This knowledge has allowed us to develop no-cost interventions by working with physicians to improve patient education. *

Walgreens is a leader in providing forward-thinking solutions for health systems/health centers that target pressing needs to decrease avoidable réadmissions, administer complex programs like 340B Complete®, manage more patients and reduce chronic condition costs. Through transition-of-care solutions, Walgreens coordinates with staff to expand community outreach and maximize outcomes.

This published piece is provided solely lor informational purposes. H FM A does not endorse the published material or warrant or guarantee its accuracy. The statements and opinions by participants are those of the participants and not those of HFM A. References to commercial manufacturers, vendors, products, or services that may appear do not constitute endorsements by HFM A.

PARTICIPANTS IN THIS HFMA EXECUTIVE ROUNDTABLE

Denise Barton is chief business development officer for Sacred Heart Health System, Pensacola, Fla.

Ed Cohen is senior director of clinical solutions for Walgreens, Deerfield, III.

Lisa Daigle is CFO for Neighborhood Healthcare, Escondido, Calif.

Larry Flieh is CFO for HealthNet, Indianapolis, Ind.

Scott Goodin is CFO for Marin Community Clinics, San Rafael, Calif.

David Sjoberg is vice president of strategic research and community health for the western Arizona hospitals of Baptist Healthcare, Pensacola, Fla..