Primary Access To Health (PATH) Program

State: FL Type: Model Practice Year: 2013

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In 2009, the Brevard County Health Department established a part-time clinic, Primary Access to Health (PATH) to address the needs of the underinsured/low income residents of Brevard County. The county has a unique lay of the land; it spans 70 miles in length from north to south and 20 miles in width from east to west and has a population of over 550,000 persons in which approximately 82,000 residents are without healthcare benefits, including Federal and State funded insurance plans. The clinic was established to address the disparities for quality medical care and for affordable healthcare coverage for the underinsured/low-income adults in Brevard County. The primary mission of PATH was to provide a medical home for eligible adults, provide continuum of care and to move healthcare from a sick care model to a disease management model providing preventative care and education.

 

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Brevard County Health Department
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Primary Access To Health (PATH) Program
In 2009, the Brevard County Health Department established a part-time clinic, Primary Access to Health (PATH) to address the needs of the underinsured/low income residents of Brevard County. The county has a unique lay of the land; it spans 70 miles in length from north to south and 20 miles in width from east to west and has a population of over 550,000 persons in which approximately 82,000 residents are without healthcare benefits, including Federal and State funded insurance plans. The clinic was established to address the disparities for quality medical care and for affordable healthcare coverage for the underinsured/low-income adults in Brevard County. The primary mission of PATH was to provide a medical home for eligible adults, provide continuum of care and to move healthcare from a sick care model to a disease management model providing preventative care and education. The Board of County Commissioners funded the program for $347,415; no funds from the health department trust fund were used. The clinic was staffed with a medical doctor, registered nurse and health support technician and support from Volunteer Primary and Specialty Physicians and in- kind donations from local hospitals and diagnostic centers. The primary objectives and goals were to provide access for underinsured/low income residents to receive quality medical care at no charge, recruit and retain a network of specialty providers and reduce the number of unnecessary emergency room visits and preventable hospitalizations. As the unemployment rate grew in Brevard County to 11.6%, it was determined that services need to expand to address the continued need for providing quality medical care to the underinsured/low income residents. Research indicated that the largest municipal in South Brevard County, the city of Palm Bay with 100,000 residents in South Brevard County exceeded the combined unemployment rate and was at 11.9%. This further diminished the healthcare dollar for residents already being serviced through the PATH Program. In December 2010, a Low Income Pool Grant (LIP) from ACHA was awarded to the PATH Program. The monies awarded were used to expand the current services in Central Brevard County from 108 scheduled appointments per week to 180 or by 60% and to open a satellite clinic in South Brevard County to accommodate 108 scheduled appointments per week. The original objectives continue to evolve by helping to decrease local emergency department visits/hospital admissions, create a support system for Emergency Department diversion and increase access to care which can be done at the fraction of the cost of an Emergency Department visit; the program has successfully decreased these visits by 71%. Ability has been gained to support and identify persons with known health risk factors that contribute to increased hospital admissions and increase enrollment for eligible Brevard County residents. In addition, several target areas have been identified for the high population of those afflicted with chronic health conditions. According to the Centers for Disease Control and Prevention, 9.5% of the population of Brevard County has been diagnosed with diabetes. Primary Access to Health Clinic (PATH) recognizes that co-morbidities exist among such diseases as diabetes, cardiovascular illness and chronic obstructive pulmonary disease and will include conditions that increase risk factors such as nutritional insufficiencies and obesity. Other diseases targeted through this program are hypertension, pulmonary disease and hyperlipidemia. Health outcomes of the clients have greatly improved. Close monitoring of diabetics Hemoglobin AI-C has been drastically reduced from critical high of 16 percent to 7 percent or lower. By reducing their AI-C levels, we have also decreased their risk for other diseases such as cardiovascular disease and hypertension. This correlation is directly related to increased access to care, medications, i.e. insulin and testing supplies, and by knowledge gained through Diabetic Education Classes and grant funds allowed for a full-time case manager to monitor chronic health conditions. By providing a medical home and an alternative to emergency department visits and hospitalizations, the PATH Program has provided a medical home to 4300 clients and provided over 42,000 services at no cost to the client; these include, but not limited to Primary Care Visits, Specialty Referral and Diagnostic Testing. Sequentially, the Low Income Pool Grant has been renewed and now entering into the third year of funding. In October 2012, the PATH Program was awarded a LIP Expansion Grant for 2012-13 to provide services in North Brevard County. Through the power of community partnerships, the program continues to evolve and expand to create a network of health and wellness throughout the community.
Responsiveness The public health issue that this practice addressesPrimary Access to Health Clinic was established in response to the medical needs of the less fortunate in our community. The current unemployment rate in Brevard County is 11.6%, which diminishes the health care dollar. Approximately 26% of the current populations in Brevard County who are below 100% of the Federal Poverty Guidelines and who are without health care coverage routinely use the local emergency departments for Primary Care. Many clients have the mindset that the emergency department (ED) is the portal to health care because it is looked upon as a site guaranteed where treatment and care will be rendered, however, with a high price tag. Not only are the emergency departments used for primary care they are also used for subsequent follow-up visits within 48 to 72 hours that normally would be seen in a Primary Care office when clients do not have access to care. The PATH Program provides health care for non-emergency acute and chronic health conditions, disease management and education, diagnosis, treatment and follow-up care, basic laboratory services and in-house ultrasound and EKG testing. With the establishment of a Primary Care Clinic, the underprivileged residents of Brevard County can now have a medical home and receive services at the fraction of the cost of an emergency department visit. A priority in services includes local hospital emergency department diversion. Diversion from the emergency department is accomplished by the PATH Clinic by providing increased access to health care for treatment, evaluation and follow-up care, discounted medications or enrollment to pharmaceutical medication assistance programs, disease management and education and with incorporation of a PATH Case Manager being assigned to their case. The process used to determine the relevancy of the public health issue to the communityThe PATH Program Director networks with local agencies, specifically Housing and Human Services, to identify clients and provide outreach to community organizations who serve low- income groups. Neighborhoods targeted are those who demonstrate the highest amount of underinsured/low-income and exhibit specific chronic health issues, such as diabetes and cardiovascular disease. Also, monthly data collection from the Housing and Human Services and from the Brevard County Unemployment Agency are used to continuously monitor and assess the current needs of the unemployed, underinsured/low income population of Brevard County. The PATH Program has taken an active role in the community as liaison between local hospitals, Volunteer Providers, the Brevard Medical Society, the Brevard County Health Forum and a North County hospital that just recently closed their low-income hospital community health centre. The PATH Program is also actively involved with the Brevard Health Care Forum to recognize current issues that affect access to health care; i.e. primary care providers in the community, high unemployment rate, mental health issues, chronic health conditions and access to dental care among the underinsured/low income adult population of Brevard County. Statistics received from the Health Council of East Central Florida 2009 Community Health Survey was also used to help identify community needs among residents of Brevard County. How the practice addresses the issuesThe PATH Program was instrumental in recognizing the need for increased services for Primary Care among the underinsured/low income adult residents. The PATH Program wrote and secured a grant to help address. The PATH Program has been able to increase the capacity of clients seen weekly from 108 scheduled appointments to 180 appointments or by 67 percent. A goal of the clinic is to accommodate all clients within a reasonable amount of time. Increasing services will allow increased access to primary care, decrease emergency department and hospital admissions. In addition, the opening of a satellite program in South Brevard County has increased access to health care by 100%. Health care is now being addressed and accomplished at the most appropriate venue with the least amount of time and expenditure. These services can be done at a fraction of the cost of an emergency department visit. Health outcomes of the clients have and will continue to be greatly improved with expanded access to Primary Care. Close monitoring of diabetics Hemoglobin AI-C has been drastically reduced from a critical high of 16 percent to 7 percent or lower. This can be contributed directly to increased access to health care, medications, i.e. insulin and testing supplies, and by knowledge gained through routine clinic visits. By reducing their AI-C levels, we have also decreased their risk for other diseases such as cardiovascular disease and hypertension. In addition, by having access to laboratory services on site, turn around times of laboratory values are within one to two days. This allows for successful management of their disease process by adjustments in medications.   Innovation Evidence based strategies used in developing this practiceThe PATH Program used USPSTF (www.thecommunityguide.org) Guide to Clinical Preventive Services and has implemented their standard of care. Recommendations on screening, preventive medication and counseling. The providers and case managers have access to their web version clinical pocket guide http://www.ahrq.gov/clinic/pocketgd1011. This allows reinforcement of our providers for recommendations to our clients and helps identify effective programs in the community in which to refer clients for additional education and support. The Florida Area Health Education Centers (AHEC) Network smoking cessation hotline at 1-877-848-6696 or www.flahec.org. provided and standards of care are followed. A second evidence-based strategy used is Wolters Kluwer Health Up-To-Date online resource. Clinicians working in Primary Care have access to Evidence-Based Decision Support at the Point of Care (www.uptodate.com). This practice is a creative use of an existing tool or practice. Process used to determine that the practice is a creative use of an existing tool or practiceThe Primary Access To Health (PATH) Program is not completely new to the field of public health. It had previously existed within the county in a very limited capacity and evolved further after the advent of Federally Qualified Health Centers (FQHC). In reviewing the literature, most community clinics are either under a FQHC, a hospital base, or a public foundation. The PATH clinic is unique in that it improves access to care to clients who fall through the gap by not having access to the FQHC in a timely fashion, establishes a medical home for those who utilize the emergency department as their medical home, and does so with the LHD being the primary source of care. Through networking in the local community planned partnerships were developed. The PATH Program was innovative in developing relationships with local county government via Housing and Human Services, the Brevard Board of County Commissioners, all seven local hospitals, private diagnostic centers, local laboratories, and a network of Primary Care Providers and Specialty Providers to provide quality medical care to the underinsured/low income at no charge to the agency or client. Partnership development is an ongoing process and essential in today’s fiscal crisis. From the outset, the vision for this center and practice was the driving force behind the program and the MAPP process was utilized extensively to achieve the necessary results. Tool or practice used in a creative way to create this practiceWe began the MAPP process by asking strategic questions to help clarify the vision of the program and the likelihood of success. Could we add additional quality services without duplicating existing service? Would this practice benefit the underinsured/low income residents of Brevard County by providing services not available? Was implementing the program considered a valuable service that would be of tangible benefit to both the community as well as to the agencies involved? Given the economic challenges and grant constraints, was it possible to achieve the desired results? Once these strategies were answered yes, it was easy to proceed to partnership development and visioning. Much of our focus was on partnership development uniquely aimed at bringing in county level government, all hospital systems, diagnostic providers (imaging and laboratory), specialty service providers, pharmaceutical providers and the local health council. Using the forces of change assessment, and with a strong partnership base we were then able to easily proceed through the process enabling the achievement of the results we had envisioned. Unique as well, was the fact that the local HD took the lead, secured the startup funds, networked the participants and orchestrated the deliverables as well as providing the operational support. How this practice differs from other approaches used to address the public health issueImproving access for eligible clients is considered a balancing act between the supply and demand for services, which means there is no delay when the demand for services is warranted and service is delivered. By establishing equilibrium between supply and demand, access to care was increased. The mission of the PATH Program is to provide quality service at no charge to the client and to meet demands of the counties disparities. The PATH Program has streamlined eligibility for the client; a short self declaration at the initial visit is accomplished without a formal eligibility intake appointment needed and then completed yearly. If the client is found to be over income, above 100% of the Federal Poverty Level on the initial visit care is not denied and is seen by a qualified provider. The client is then referred to the case manager to help direct the client to other options available for care within the community. Clients who are not eligible for the PATH Program are counseled to apply for Medicaid and/or Social Security Disability if applicable. In addition, the PATH Program works with local Volunteer Urgent Care Clinics to be an extension and provide health care for overflow of clients daily, after hours and weekend care. These services are provided at no charge to the client or health department.
Local Health Department and Community CollaborationPrimary StakeholdersBrevard County Health Department, Brevard County Board of Commissioners, Housing and Human Services, Brevard Health Care Forum, University of Central Florida School of Nursing, eligible clients, seven local hospital emergency departments, private primary and specialty volunteer providers, free standing diagnostic centers, private laboratory centers and urgent care clinics.LHD RoleThe Primary Access to Health (PATH) manages the health care needs to eligible adult Brevard County residents. The PATH program provides health care for non-emergency acute and chronic health conditions, disease management and education, diagnosis, treatment and follow-up care, basic laboratory services and in-house ultrasound and EKG testing. Services are provided by the Brevard County Health Department facilities. The PATH clinic is staffed with Brevard County Health Department personnel. The clinic staff consists of a Medical Doctor, Registered Nurse and Health Support Technician. In addition, auxiliary support staff from medical records and appointment center assists in the daily operations of the PATH Clinic. The Brevard County Health Department PATH Clinic Director has taken an active role in the community as liaison between Volunteer Providers and with local hospitals. Recruiting and retaining Specialty Providers has been instrumental in providing continuum of care to clients. The PATH Director uses diagnosis to seek out Specialty Providers specific to a disease process. In the process of recruitment of specialty physicians, partnerships have been established to reciprocate care to clients. Examples are with Circles of Care. They provide mental health visits for our clients and in turn we become their Primary Care Provider to manage their acute and chronic health conditions. Specialty Providers are extended Sovereign Immunity for providing services to clients. Stakeholders/partnersThe PATH Director continually recruits physicians, hospitals and diagnostic centers for volunteer time. The success of the current model being used assists in the attract ability for future providers. The end result is a collaborate relationship among health care providers in Brevard County.The PATH Director networks with the local agencies, specifically Housing and Human Services, to identify clients and provide outreach to community organizations who serve low-income groups. Formative evaluation is ongoing with Housing and Human Services to ensure needs of the less fortunate in the county are met. The Brevard Board of County Commissioners plays a significant role in the PATH Program. Meetings between the Commission and Brevard County Health Department Director are ongoing. The PATH Director communicates closely with all specialty providers and local hospitals to ensure that all clients are receiving quality medical care. Bi-monthly meetings are scheduled with local hospitals to discuss ways to help improve health care among potential PATH Clients and established clients. The PATH Director makes frequent visits to local specialty provider’s private offices to give pertinent updates and to ensure that both the Provider and the client’s needs are met. A commitment to collaborative partnering, an active program coordinator, and alignment with health care goals will allow the program to gain momentum and provide the services needed necessary to sustain the program.The Brevard County Health Department PATH Clinic Director has taken an active role in the community as liaison between local hospitals, Volunteer Providers, the Brevard Medical Society, the Brevard County Health Forum and a North county hospital that just recently closed their low-income hospital community health centre. Relationships also exist with local pharmacies who give discounted rates to PATH clients. In addition, recruiting and retaining Specialty Providers has been instrumental in providing continuum of care to clients. The Director communicates closely with all specialty providers and local hospitals to ensure that all clients are receiving quality medical care. Bi-monthly meetings are scheduled with local hospitals to discuss ways to help improve health care among potential PATH Clients and established clients. The PATH Director makes frequent visits to local specialty provider’s private offices to give pertinent updates and to ensure that both the Provider and the client’s needs are being met. A commitment to collaborative partnering, an active program coordinator, and alignment with health care goals in the community will allow the program to gain momentum and provide the services needed necessary to sustain the program.Lessons LearnedKnowing how the service or product will benefit each partner is essential. For emergency department diversion, it is helping to eliminate the unnecessary overcrowding for services that are better served in a physician’s office. Face to face communication with local hospitals, primary and specialty providers, diagnostic centers and urgent care clinics has been found to be the most effective communication tool. The LHD found they needed to be a team player with the community whenever possible. The barriers encountered were busy schedules, hesitance among specialty providers to volunteer their time when they are already overwhelmed in their private practice and local hospitals not overstretching their funds already compromised by services they already provide through other charitable donations.   Implementation Strategy Specific TasksThe Brevard County Health Department in response to the current unemployment rate in Brevard County collaboratively formed a partnership with the Brevard County Board of Commissioners to establish a medical home for the underinsured/low income population within Brevard County. In June 2009, a strategic planning meeting with the Brevard County Board of Commissioners, Brevard County Housing and Human Services, Director of the Brevard County Health Department and the Primary Access to Healthcare (PATH) Coordinator. The goals and objectives from each of the agencies was the focal point on how to structure the Program. What would be the benefit to the client and health system for underinsured/low income population? What do we want to accomplish with this program? Where will residents receive care? Is the project doable? In addition, funding, community partnerships, location for services, type of services to be offered and specific goals were addressed. The agencies involved determined the project feasible and of great benefit to the community. July 2009 – funding was assured from the Brevard County Board of County Commissioners, Housing and Human Services and the Brevard County Health Department. August 2009 – partnership with local hospital system was agreed upon to provide in-kind services for diagnostic procedures at no charge to the client or Brevard County Health Department. September 2009 – laboratory services were added through state contract agreement with local facility already providing laboratory testing for the Brevard County Health Department. October 2009 – partnerships with local specialty providers was established to provide services at no cost to the client or the Brevard County Health Department. June 2011– Re-evaluation of the Program by the Brevard County Board of Commissioners and funding secured for fiscal year 2012-13. The Low Income Pool has sequentially been renewed through June 2013 and an additional grant for expansion has been awarded through June 2013.Meetings with local hospitals were held to recognize the PATH Program as a medical home for the underinsured/low income residents of Brevard County. Local hospital emergency departments and in-patient facilities utilize PATH for emergency department diversion. Recruitment and retention of specialty providers is ongoing. Time FrameAt the strategic planning meeting it was hopeful that the Program would be open within three months of the first meeting (August 2009) given the securing of finances, facility accommodations, training of staff and other various challenges and nuances encountered by each agency involved. The planning and implementation of policy and procedures took two months and PATH was operational by August 2009. After the Low Income Grant was awarded in December 2010, the period to expand services occurred on January 20, 2011, with the part time clinic converting to full time and a part time satellite clinic in South Brevard County opening its doors to the underinsured/low income population of South County. Expansion to North County will occur in November 2012.Outline of steps takenIn June 2009, a strategic planning meeting with the Brevard County Board of Commissioners, Brevard County Housing and Human Services, Director of the Brevard County Health Department and the Primary Access to Healthcare (PATH) Coordinator. July 2009 – funding was assured from the Brevard County Board of County Commissioners, Housing and Human Services and the Brevard County Health Department. Training of medical provider, registered nurse and health support technician for PATH Clinic. August 2009 to present– partnership with local hospital system was agreed upon to provide in-kind services for diagnostic procedures at no charge to the client or Brevard County Health Department. September 2009 – laboratory services were added through state contract agreement with local facility already providing laboratory testing for the Brevard County Health Department. October 2009 to present - partnerships with local specialty providers was established to provide services at no cost to the client or the Brevard County Health Department. The clinic was fully functional by October 2009. August 2010 to October 2010 – Low Income Pool Grant written and submitted. December 2010 – LIP Grant Awarded for expansion of services in Central Brevard County and establishment of new clinic in South County. January 2011 – Full-time Case Manager was hired to cover both clinics, full-time medical provider for Central County was hired, registered nurse and health support technicians for both facilities hired and trained. June 2011 – year two funding was assured from LIP Grant, the Brevard County Board of County Commissioners, Housing and Human Services and the Brevard County Health Department. August 2011 – full time Med Net Navigator was hired, trained and services implemented, second Case Manager for South Brevard county Clinic was hired. Trained and implemented. January 2012 – a third case manager was hired. June 2012 - year three funding was assured from the LIP Grant, Brevard County Board of County Commissioners, Housing and Human Services and the Brevard County Health Department. Expansion LIP Grant was written and submitted. October 2012 – Expansion Grant awarded, strategic planning started for expansion of services to North Brevard County. Lessons LearnedThe PATH Program found that by obtaining funds from the Brevard Board of County Commissioners was a priority. Working with a $375,000 budget in 2009-10 to pay salaries, overhead, laboratory and diagnostic testing would only allow a small percentage of eligible clients a medical home. Funding from other sources would need to be secured; the rapid growth of the program was exceeding available funds. To adhere to the grant specifications, augmentation of staff were needed in all areas including clinical staff, case management and medication assistance. Recruitment and retention of volunteer specialty providers and local hospitals to provide in-kind services was a full-time job for the PATH Director. The Program transitioned from the Director being over day- to -day clinic functions and staff to the onsite clinic supervisor. The PATH Director would oversee the Program and the subordinates in case management, medication assistance, administrative assistants and account analyst. With this restructuring of duties, the Director is able to take a more pro-active role in the community.Cost of ImplementationThe initial PATH Program operated on a budget of $375,000. Funds were used for physician, PATH Director and assistant salaries and basic clinic services. The Brevard County Health Department provided in-kind costs in the form of the existing clinical facilities and their related overhead costs to house the programs. Existing administrative support services, such as Information Technology, Personnel, Purchasing, Accounts Payable, Payroll, Accounting, Facilities, Utilities, Custodial services, etc. were provided at no additional charge to the Path program. PATH expanded the program in Viera and a new clinic in Melbourne was initiated with a total cost the first year of $938,052 in 2010. The County partnered by providing a match of $254,212, and the State’s Low Income Pool program providing the remaining $683,840. The Brevard County Health Department provided in-kind costs in the form of the existing clinical facilities and their related overhead costs to house the programs. Other in-kind costs totaled $501,545 which included free medications obtained by the use of the MedNet Navigator for clients whose low income level qualified them for complimentary prescriptions from various pharmaceutical manufacturers, donated equipment and in-kind donations from local hospitals. Another form of in-kind costs were from services provided by volunteer physicians and nurses from the community. Existing administrative support services, such as Information Technology, Personnel, Purchasing, Accounts Payable, Payroll, Accounting, Facilities, Utilities, Custodial services, etc. were provided at no additional charge to the Path program.
Objective 1:PATH clients will have access to quality health care by providing a medical home for underinsured/low income residents of Brevard County. Through increased access to care, health outcomes will be improved of the population served. Performance measures:1. The Program enrolled 425 clients in 2009-10. The goal for 2011 was to enroll 1400 clients in the program and by the end of year 2012 grown to 2200 clients with a growth rate of approximately 50 patients per week to a maximum capacity of 3000 clients per year based on current funding and staffing.2. Goal is to reduce number of clients with Hgb A1C > 9% from 90% of clients to less than 50% of clients with aHgb A1C>9%. Clients will be trended over a 12 month period of time. Data Collection: Data is collected by PATH Accountant Analyst on a weekly basis using the Brevard County Health Department (BCHD) Health Management System (HMS) Ad Hoc Portal Report system. The data collected includes unduplicated client base, services provided, laboratory results, number of emergency department diversion and diagnosis codes. Compiled data is then submitted to the PATH Director and shared with all partners. Formative evaluation of clients served is ongoing through an electronic survey at the end of each clinical visit; including where service was received, overall length of visit, type of service and overall experience of the visit. Evaluation Results: The PATH Director uses the data collected on an ongoing basis to determine needs of the program. Expansion based on client needs were been implemented based on the rapid growth of the program. Actual enrollment of 4325 clients has far exceeded the projected growth by the end of the third year of operation. To keep customer satisfaction above 70% and to keep the client base returning for continued care, staffing throughout the program was re-evaluated. Surveys indicate that 80% of clients felt their wait time to see a clinician was acceptable; less than 30 minutes and 82.9% indicated that they would continue to use the PATH Clinic as their medical home; 76.2% of clients survey indicated they do not know where they would receive quality medical care if the PATH Program were not available.These indicators surpass expectation and to continue the quality of care acceptable to clients, staffing in all areas of the program were increased; addition of a volunteer provider to work collaboratively with the paid provider, additional nursing and case management staff was implemented. . Through intensive case management, results exceeded the goal by reducing HgB A1C>90% from 90% of clients to less than 30% of clients having a Hgb A1C>9%. When factoring in that these clients typically frequent the emergency department at four visits per year, the net annual savings is greater than $796,000: 299 clients (90% of 332) reduced to 100 (30% of 332 clients) = 199 clients at 4 visits to the ED each = 796 visits per client x $1000/visit = $796,000 saved. A total cost savings to the community is valued at $2.2 million yearly for all services provided. Direct correlation of improved health outcomes can be attributed to individualized care, increased access to care, education and the quality of medical care received. Feedback: The Coordinator submits quarterly reports to all partners. The Director of Housing and Human Services uses this information to reinforce to the Brevard Board of County Commissioners the impact of the PATH Program; i.e. the PATH Program is effectively utilizing funds and providing quality medical care for the underinsured/low income residents of the county. The Program is filling a void within the community, has, and will significantly continue to help to improve the quality of life of those clients served. At a clinic level, feedback from staff was positive with the addition of a volunteer provider within the clinic and with increased nursing and case management staff. The clinic staff felt they were able to spend more quality time with the client to manage their care more effectively; able to give more 1:1 individualized attention to clients needs. Positive feedback from customers is optimal. Clients now have a clear choice where they want to receive quality medical care. Local emergency departments have seen a decrease in chronic health clients presenting for routine care. This has helped to decrease the ratio of uncollected reimbursement to payable sources and to help lower rates for emergency care. The objective has been met above what was anticipated. Objective 2:To recruit and retain volunteer specialty providers to provide service both in the PATH Clinic and in their private offices at no cost to the PATH Program or client. Performance measures: 1. Specialty provider recruitment was to have 20 participants by end of 2009-10. The target was to increase specialty by 50% annually. 2. Goal to increase specialty visits from 500 visits per year to 1000 visits per year. 3. Maximize cardiology specialty provider referrals – establishment of a Coumadin Clinic to accommodate clients who only need weekly, biweekly or monthly Protime/INR and medical management. This reserves cardiology referral for more intensive needs. The goal is to stabilize the client and within a six week time period be stabilized in therapeutic range. Data collection: Data is collected by the Accountant Analyst on a weekly basis using the HMS Ad—hoc Portal Report System to track all specialty referrals. This module gives a detailed list of referrals made, completed and failed. This information is provided to the PATH Director and shared with all partners. Specialty Providers complete quarterly satisfaction surveys to determine if referrals are appropriate to the specialty field, client compliance, the ease of working with the PATH Program and areas needing improvement. The PATH Director reviews all data for weaknesses and strengths and ways to improve the program. Formal and informal meetings are held with local hospitals emergency department physicians and staff. This helps to identify specialist in areas that are high in demand; cardiology being a top referral from emergency departments. Recruitment of specialist are dependent on the current trends of emergency department referrals. Year ending 2012 data indicated that 1300 specialty visits were completed. Data is collected through electronic medical records by the case manager for management of the Coumadin Clinic client. The provider and case management use the collected data to medically manage the client. Evaluation: The PATH Program Director uses the data collected to target areas of specialty need. Data indicates that high number of specialty services recommended are in the areas of cardiology, orthopedics and for specialized diagnostic testing; with focus placed on highest priority of specialty need. A recruitment obstacle is that specialty providers feel they already provide free care by taking emergency department call for unassigned clientsBy showing specialist concrete data that emergency department visits are down among PATH clients, patient compliance is trending upward and utilizing the specialty referral for recommendations after seeing the client one time only to the Primary Care Provider which allows for better medical management. Specialty referrals through the PATH Program resulted in a reduction of emergency department by 40% which equates to savings of over $620,000 per year - 620 clients referred (40% of 1300) at $1000 per visit equals $620,000. This has been receptive and recruitment and retention of cardiologist and other specialist has increased. Patient compliance for keeping Coumadin Clinic appointments and up to date demographics was a challenge. A client agreement was initiated and compliance is at 90%. This objective has been met above expectations. A special clinic was set-up to accommodate only clients needing weekly Protimes/INR’s. This ensures clients are in therapeutic levels and have access to their Coumadin. Standing orders have been established by the cardiologist for the PATH medical doctor to follow. This reserves referrals to the cardiologist for more intensive needs. The goal of the clinic was within six weeks of enrollment into the program to have the client be in therapeutic range. Of the initial 23 clients enrolled, 81% of the clients were in compliance by the sixth week, the 19% out of range were within compliance after 16 weeks. Feedback: Positive feedback has occurred from all stakeholders and clients served. Clients report they have been treated professionally and with the upmost respect to their current financial conditions. Specialty providers receive feedback based on responses, both favorable and unfavorable. Specialty Providers are an advocate to enroll colleagues into the program. A positive change implemented by the specialty providers is to allow certain clinic days and hours for PATH clients. This allows for streamlined scheduling and tracking of number of clients seen per month. Local emergency departments have expressed a positive feedback in relationship to decreased emergency department visits for PATH clients. The objective has been met. Objective 3:Decrease Emergency Department Admission rates to local hospitals for the underinsured/low income population of Brevard County. Performance Measures: 1. Reduce the number of emergency department visits for non-emergent visits by 10% yearly from 2010 to 2012. Currently, the emergency department diversion rate is at 40%. Long term goal for 2012-13 is to decrease emergency department visits by 65%. 2. Expand available appointments for emergency department diversion specifically by 15% by October 2012. Clinic appointments will be blocked to allow access only for clients who need care and are diverted from the local emergency departments. 3. The coordinator meets quarterly, both formal and informal, with the discharge planners, emergency department leaders and emergency department physicians to continuously monitor if emergency department diversion is successful and to determine areas of improvement. Meetings are held at three major hospital systems within the county. Data Collection: Data for emergency department diversion is collected by the PATH Accountant Analysts through the HMS Ad-hoc Portal Report System and reported to the PATH Director. Data includes number of clients appointments for emergency department diversion, referral hospital and if client was scheduled or a walk-in to the PATH Clinic. This data is graphed and the information is shared with all partners at quarterly meetings. Data is also collected from clients after their clinic visit using an electronic survey. Clients complete a survey indicating the clinic they received service, type of service, satisfaction with wait time and where medical care would be obtained if the PATH Program services were not available. This data is shared with all collaborative partners. Evaluation: A reduction in emergency department visits has decreased by 40% among the PATH eligible clients. . In 2010-11, only 5% of the emergency department diversion appointments were available, as of October 2012, 15% of the available appointments in a scheduled clinic, an increase of 10%. An average clinic visit is 60 minutes or less, compared to an average emergency department visit of six hours or more at a fraction of the cost. October 2011 to October 2012, 321 clients sought care through PATH by referral from local hospitals as emergency department diversion/post hospital discharge.Based on an average PATH Program cost per visit is $30.76 compared to an average basic emergency department visit of $1000, a cost savings of $311,126 to the local hospitals. Cost comparison has allowed the PATH Program to solicit in-kind donations from local hospitals for diagnostic procedures. In 2010, the PATH Program started with $5,000 in-kind donations and has substantially increased by October 1, 2012 to $40,000. Survey of 100 clients indicated that 15.9% would have sought medical treatment at the emergency department and 55.6% indicated they would not have known where to receive care if the PATH Program were not available; this can be interpreted as a potential emergency department visit. Increased education of the patient and family members to know when emergency department visits are warranted has alleviated clients using the emergency department as the portal to healthcare and the PATH Program has given them another option for medical care. Feedback: Local hospitals have reported a significant decrease in emergency department and hospital admissions with the implementation of the PATH Program. Through quarterly meetings with local hospital emergency department management, there were disconnects with the emergency department staff and physicians to once the client was deemed not emergent, life-threatening and not needing treatment in the emergency department, to refer to the PATH Program for further care. Through networking and open discussion to include staff and physician input at quarterly meetings, a process was implemented to include the PATH Program as a formal referral option in their discharge instructions. This objective is ongoing and is being met above expectations to help reduce the overall cost to the community of clients using the emergency department as primary care.
It is with 100% certainty that this practice will continue with the current stakeholders who are committed to the Program. The cost savings, community benefit and positive satisfaction resulting in the medical care of those in need exhibit this. The agencies involved have a high level of commitment to the Program to help provide a medical home for the low income/underinsured residents of Brevard County. The local hospitals have recently increased their in-kind diagnostic donations based on the evidence that providing a medical home for the underinsured has decreased their hospital emergency department and hospital admissions significantly. Volunteer Providers also have evidenced positive feedback to the program as they have the ability to refer their underinsured/low income patients to PATH for Primary Care. The Low Income Pool Grant has been awarded for a third year and an expansion grant was approved in October 2012. The Brevard County Health Department is strongly committed to the Program as it has virtually remained budget neutral requiring no funds be used from the General Trust Fund. Adequate funding is the primary concern for a program of this magnitude to continue. The Low Income Pool grant funds have been allocated to assist through December 2012 and funding from the Brevard County Board of Commissioners will continue through October 2012. The funding adequately covers salaries, supplies, diagnostic and laboratory services and medical equipment. Agreements between local hospitals will continue with in-kind donations as long as due diligence is exhibited by continued emergency department diversion and decrease hospital admissions by providing a medical home. The Program has been extremely creative in utilizing available resources in fulfilling its role and responsibilities by keeping cost low and within budget without jeopardizing health outcomes. Efforts are being made to leverage other funding sources in addition to the Low Income Pool Grant. It is with firm affirmation that the Board of Brevard County Commissioners, Brevard County Health Department, Brevard Medical Society and other community medical providers will continue to sustain this successful partnership to serve the underinsured and low-income adult residents of Brevard County.
 
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