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Service Delivery Innovation Profile

Community Health Collaborative Reduces Inappropriate Emergency Department Use by Providing Access to Health Care, Social Support for Low-Income Clients


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Snapshot

Summary

CHOICE Regional Health Network uses Health Resources Coordinators (similar to community health workers) to help vulnerable populations in urban and rural areas apply for insurance coverage and access health care services. CHOICE also serves as the administrative hub for care coordination interventions for a subset of clients who have a history of frequent emergency department visits, those receiving mental health services from a free clinic, and those with specialty medical needs. CHOICE programs have helped thousands of individuals secure and retain health insurance; connect to a medical provider; and provide necessary health supports, such as low-cost prescription drugs. The agency has also increased provider revenues, reduced emergency department visits, and led to high levels of clinician satisfaction.

See the Description section for information regarding new programs related to emergency department care and support for people with specialty medical needs, the Results section for new evaluation data related to emergency department visits and information related to provider engagement, and the Resources section for updated staffing and cost information (updated September 2012).

Evidence Rating (What is this?)

Moderate: The evidence consists of post-implementation data on insurance coverage rates and provider satisfaction, post-implementation estimates of incremental provider revenues generated by the program, and before and after comparisons of ED utilization and charges.
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Developing Organizations

CHOICE Regional Health Network
Olympia, WAend do

Date First Implemented

1997
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Patient Population

Race and Ethnicity > Hispanic/latino-latina; Vulnerable Populations > Immigrants; Impoverished; Mentally ill; Non-english speaking/limited english proficiency; Rural populationsend pp

Problem Addressed

Compared with urban and suburban dwellers, individuals living in rural areas have access to fewer health care resources and are more likely to be poor, to have chronic health conditions, and to have limited options for primary care needs.1 Certain racial and ethnic groups, such as Latino populations, suffer from even greater disparities.
  • Barriers to access: Individuals living in rural areas, especially poor rural areas, have access to fewer health care resources.2
  • Higher health risks: Individuals living in rural areas are more likely to be poor and/or uninsured;2,3 poor or near-poor individuals experience higher rates of chronic health conditions, including those related to mental health.3 Hispanic individuals experience even greater disparities, with poverty, lack of insurance, inadequate access to preventive care, and language/cultural barriers being associated with poor health outcomes in this population.4

What They Did

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Description of the Innovative Activity

CHOICE Regional Health Network uses Health Resources Coordinators (similar to community health workers) to help vulnerable populations in urban and rural areas obtain insurance coverage and access health care services. CHOICE also serves as the administrative hub for programmatic interventions for a subset of clients who have a history of frequent emergency department (ED) visits, those receiving mental health services from a free clinic, and those with specialty medical needs. Key elements of CHOICE client services include the following:
  • Outreach to target population: CHOICE client services targets uninsured and underinsured individuals living at or below 250 percent of the Federal poverty level. Roughly half of clients have incomes below 65 percent of the poverty level, and more than half are Latinos with limited English proficiency. Health Resources Coordinators (HRCs) aggressively recruit potential clients through schools, providers, state agencies, hospitals, and other community organizations. They also attend community events and meetings. Many referrals come through word of mouth and through physicians and social service agencies.
  • Initial telephone contact: Interested individuals call CHOICE’s toll-free telephone number to schedule an in-person meeting with an HRC at community locations, such as local health departments. When a potential client is referred by a medical or social service provider, the HRC calls the client. Although the call is primarily administrative, the HRC also screens for urgent needs, access to medical care and food, and sources of income/employment. The goal is to obtain basic details to make the in-person meeting (see below) more productive.
  • In-person meetings: The HRC meets with the client, performing a more thorough assessment and providing any or all of the following services:
    • Program referrals: HRCs screen for various programs and help clients complete necessary paperwork or provide referral information in order to enroll.
    • Insurance enrollment: HRCs help clients understand available health coverage options, including prescription drug coverage, from Medicare, Medicaid, other State-sponsored programs, and private organizations (e.g., pharmaceutical assistance programs). They help clients complete applications and other necessary paperwork, and interact with State agencies and other organizations to facilitate enrollment, resolve problems, and appeal coverage denials.
    • Care coordination: HRCs provide care coordination services, including helping clients select a primary care provider, assess their eligibility for community health programs, and identify appropriate support groups and health education services. They also provide referrals to relevant social service agencies related to needs such as housing, food, and employment.
  • ED Consistent Care Program: Beginning in 2008, CHOICE had arranged for more intensive services for clients deemed to be particularly vulnerable because of factors such as medical or mental illness, extreme poverty, language barriers, or excessive ED use. Information provided in September 2012, however, indicates that this intensive care support was phased out in 2010; CHOICE perceived a broader impact to the patient population by coordinating care among medical and behavioral staff associated with the patient through the ED Consistent Care Program. In this program, a multidisciplinary team coordinated by CHOICE, operating out of EDs at local hospitals in the region, work together to identify, triage, and develop a plan of care for those who make frequent and inappropriate use of the ED. Each hospital shares and receives data through the Emergency Department Information Exchange (EDIE), which delivers automated, real-time utilization and treatment histories when a patient presents to any participating ED. The program’s success is in setting boundaries with patients through care plans developed by the multidisciplinary team and redirecting care back to the patient’s primary care provider, who can more appropriately monitor care to achieve better health outcomes.
  • Support for those with mental illness: CHOICE and volunteer licensed mental health professionals staff a weekly free mental health clinic for uninsured or underinsured adults experiencing anxiety or depression. An HRC helps these clients receive other needed health or social services, such as prescriptions or food stamps.
  • Support for those with specialty medical needs: Information provided in September 2012 indicates that CHOICE administers Thurston County Project Access, a program connecting uninsured patients experiencing an acute or urgent need to specialty care provided by donating physicians. HRCs coordinate referrals from primary care to the needed specialty and facilitate enrollment and monitoring of patients who are to receive care.
  • Community outreach: HRCs conduct active outreach for CHOICE services and community referrals, including distribution of educational materials/flyers, participation at community events ("tabling"), and active networking with other service organizations. Outreach efforts to enroll children in Medicaid have included data-sharing agreements under which school districts provide contact information for followup with families that express interest in health coverage for their children when they apply for free and reduced price meals. Other benefits programs wrapped into this integrated outreach have included adult Medicaid, breast and cervical cancer screening, prescription medication assistance programs, and the Basic Food (food stamp) program, as well as screening for CHOICE-administered client service programs. In 2011, CHOICE’s contract to provide children’s Medicaid outreach through the school districts was canceled because of state budgetary constraints. Similarly, in 2012, the breast and cervical cancer outreach and screening contract with CHOICE was suspended for lack of funding.

Context of the Innovation

CHOICE is a nonprofit consortium of public and nonprofit hospitals, local health departments, family practice residency programs, clinicians, schools, and community members covering five counties (four rural and one urban) in central southwestern Washington State. CHOICE’s mission is to jointly plan and act to improve the regional health care system to benefit patients, organizations, and the broader community. Approximately 180,000 low-income individuals live in CHOICE's five-county area.

Did It Work?

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Results

CHOICE HRCs have helped thousands of individuals secure and retain health insurance; connect to a medical provider; and receive necessary health supports, such as low-cost prescription drugs. The agency has also increased provider revenues and reduced the number of ED visits.
  • Increased coverage: The program has helped thousands of individuals obtain health insurance coverage since 1998. In addition, applicants who received CHOICE services were also likely to return when their eligibility review and renewals were approaching, preventing lapses in health care coverage. More recently, severe deterioration in the availability of subsidized coverage options owing to the recession has reduced CHOICE's success rate in securing coverage for clients.
  • Enhanced provider revenues: Hospitals receive higher revenues, because previously uninsured patients now have coverage. In the program's early years (between October 1998 and September 2001), area hospitals received an estimated $4.8 million in additional reimbursement because of the program. In more recent years, although these benefits have declined, they remain substantial. In 2009, incremental revenues are estimated to have been $285,000, with all hospitals that financially support the consortium realizing a minimum 200-percent return on their investment. Despite serious reductions in the subsidized coverage that CHOICE can offer clients (owing to governmental program cuts), member hospitals were projected to receive a 150-percent return on their annual dues payments to participate in the program in 2010.
  • Fewer ED visits: In 2010, an evaluation at the hospital that has participated in the ED Consistent Care Program the longest found that ED utilization had declined by 55 percent among participating patients, while ED charges had fallen by 54 percent. Similar findings were observed in numerous subgroups receiving different combinations of program interventions.5 Information provided in September 2012 indicates that an internal evaluation performed in 2012 using data from three participating hospitals confirmed earlier results, with a 52-percent reduction in the number of ED visits and an average 59-percent reduction in ED charges, roughly $10,000 per patient in the program.
  • High physician and therapist satisfaction: In a survey of providers, both ED and primary care physicians indicated satisfaction with CHOICE’s ED Care Coordination Program. An informal survey of volunteer mental health therapists produced positive feedback about the program to assist mental health patients, including a willingness to continue volunteering. Information provided in September 2012 indicates that more than 200 primary and specialty care physicians participating in Thurston County Project Access continue to pledge their services, with more than $3.4 million in donated care delivered in 2011.

Evidence Rating (What is this?)

Moderate: The evidence consists of post-implementation data on insurance coverage rates and provider satisfaction, post-implementation estimates of incremental provider revenues generated by the program, and before and after comparisons of ED utilization and charges.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Designing the program: CHOICE staff and members held meetings to discuss program design with the executive director and a client services staff playing a major role in developing programs and services.
  • Soliciting donations: CHOICE solicited substantial financial support from its hospital members, including dues for general organizational support and separate fees to support the program in each hospital’s service area. "Associate" members contributed noncash support; for example, health departments donated the space used by CHOICE staff to meet with clients.
  • Defining the HRC position: Initially, no job description existed for community health worker-type positions. Over the years, one has been developed and revised periodically to incorporate more varied and complex client assistance and bilingual requirements.
  • Adding language capacity: CHOICE added bilingual staff and deepened collaborative relations with organizations that serve as primary points of access for people with limited English proficiency.
  • Collaborating with community organizations: CHOICE staff meet regularly with local social or health services agencies, giving customized presentations to facilitate collaborative efforts and engaging in discussions on how to solve program-related problems. This process allows programs to evolve and expand.
  • Training staff: Training varies by program focus. In general, new employees begin with one-on-one instruction; self-study about coverage programs, community resources, Internet resources, and program procedures; shadowing; and supervised client assistance.

Resources Used and Skills Needed

  • Staffing: Information provided in September 2012 indicates that the agency includes two community health workers whose work focuses primarily on connection to services; three individuals facilitating enrollment into mental health and specialty care; a customer service (telephone response) representative; and other individuals serving in community development, administrative, and managerial roles. A college degree is not required, but is highly desired, as much of the work is administrative and communicative in nature. Four staff are bilingual in English and Spanish.
  • Costs: Information provided in September 2012 indicates that annual operating costs total approximately $1.3 million, the bulk of which consists of salaries and benefits.
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Funding Sources

Robert Wood Johnson Foundation; CHOICE Regional Health Network; Washington State Department of Social and Health Services
Ongoing funding comes from membership dues paid by the hospitals, behavioral health centers, community health centers, and local health departments. Other sources include Federal, State, and local government grants and service contracts (some requiring a substantial local match), along with foundation grants.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Estimate return on investment for sponsors: Return on investment calculations can be based on enhanced reimbursement as previously uninsured patients obtain health care coverage, reductions in cost to health care providers as inappropriate or excessive service utilization is redirected in ways that meet underlying health care needs, and other benefits that funders agree are subject to monetary valuations.
  • Begin with enrollment activities, expand over time: Insurance enrollment can quickly improve access to health care; once these activities are in place, consider expansion to care coordination and other services that can further improve access to medical and social services.
  • De-emphasize traditional advertising: Advertising through brochures and radio announcements often proves less effective than recommendations from a satisfied client. Focus initially on serving customers; over time, word-of-mouth advertising will help the program become well-known in the community. Consider expanding to the Web; the Internet is often a first step for individuals and partner organizations to understand services.
  • Establish community-based sites: Because inperson interviews tend to be more successful than telephone contact, establish offices or appointment sites in convenient community locations.

Sustaining This Innovation

  • Link new programs to funding sources within the reformed health care system: Collaboration with the community's health care system can help improve the long-term sustainability of new programs.
  • Develop targets and monitor success in meeting them: Documenting improvements in outcomes can help to secure ongoing funding from potential donors in the community. Seek opportunities to develop relationships with these organizations. For example, approach local foundations about holding community forums on enhancing coverage and access for the uninsured.
  • Raise awareness with potential referral sources: Reach out to schools, public health agencies, and family support service organizations that serve uninsured families. Developing relationships with these agencies and then delivering results to their clients can help to create a trusting, long-lasting partnership.
  • Document activities related to community benefit: When pertinent, document activities in a way that meets Federal tax requirements for demonstrating that nonprofit hospitals provide "community benefit."
  • Show how activities meet Federal health care reform requirements: Program activities may help in meeting the goals and requirements of health care reform, including those related to service delivery and financing.
  • Be flexible: Program offerings will depend on funding. Over time, certain aspects of the CHOICE program (including several outreach initiatives) had to be cut because of funding limitations. To sustain the program over time, program developers must prioritize the most critical aspects of the program and identify those to be retained in the face of limited financial resources; actively seeking new sources of funding will also help decrease the likelihood that cuts will have to be made (added September 2012).

More Information

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Contact the Innovator

Libby Weisdepp
Communications and Operations Manager
CHOICE Regional Health Network
1217 4th Avenue E. Suite 200
Olympia, WA 98506
(360) 539-7576 ext.120
E-mail: weisdeppl@crhn.org

Innovator Disclosures

Ms. Weisdepp reported that CHOICE Regional Health Network received payments for work related to this profile as part of a contract with the Washington Department of Health and Human Services that covers services (e.g., food education, outreach, and subcontract administration) and reimbursement of travel-related expenses.

References/Related Articles

CHOICE Regional Health Network Web site: http://www.crhn.org.

CHOICE Regional Health Network. Impacts of the Regional Access Program. Available at: http://www.cjaonline.net/events/roci/documents/RAP%20Report%208-27-03.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Rogoff D. Measuring the Return on a Community’s Investment (ROCI) in Health Care Resulting from Providing Access to Affordable Health Coverage. Community Health Leadership Network. July 2003. Available at: http://cjaonline.net/Documents/ROCI_by_DavidRogoff.pdf.

Footnotes

1 2006 National Healthcare Disparities Report. Rockville, MD: U.S. Department of Health and Human Service, Agency for Healthcare Research and Quality; 2006. AHRQ Publication, no. 07-0012. Available at: http://archive.ahrq.gov/qual/nhdr06/nhdr06.htm.
2 Probst JC, Samuels ME, Jespersen KP, et al. Minorities in Rural America: An Overview of Population Characteristics. Columbia, SC: South Carolina Rural Health Research Center, Department of Health Administration, Norman J. Arnold School of Public Health, University of South Carolina; 2002. Available at: http://rhr.sph.sc.edu/report/MinoritiesInRuralAmerica.pdf.
3 National Center for Health Statistics. Health, United States 2007: With Chartbook on Trends in the Health of Americans. Hyattsville, MD: Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 2007. DHHS publication, no. 2008-1232. [PubMed] Available at: http://www.cdc.gov/nchs/data/hus/hus07.pdf.
4 Wallace SP, Gutiérrez VF, Castañeda X. Health policy fact sheet. Health service disparities among Mexican immigrants. UCLA Center for Health Policy Research and California-Mexico Health Initiative, 2005.
5 CHOICE Regional Health Network. April 2010. Emergency Department Consistent Care Program at Providence St. Peter Hospital: An Evaluative Report.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: January 19, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: December 18, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: December 05, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.