Problem Addressed

• High numbers of uninsured, even among employed individuals: An estimated 50.7 million people lack health care coverage, representing 16.7 percent of the U.S. population.¹ The situation in Texas is bleaker: in 2007, 5.8 million,² or approximately 24 percent of all Texans, did not have health insurance, with 79 percent of the uninsured working either full- or part-time. In Dallas County, 25.6 percent of residents lack insurance.³
• Link between uninsured status and poor access and health outcomes: An analysis of recent health services research identified a strong link between health insurance coverage and access to preventive care, primary care, acute care, and chronic illness management; the analysis also found that being uninsured increases the risk of adverse health outcomes, such as health and functional decline, the existence of preventable health problems, advanced disease at time of diagnosis, and premature death.⁴
• Link between poverty and poor health outcomes: Individuals living in poverty tend to have more chronic illnesses and health complications, and make greater demands on the health care system. Dallas County hospitals have experienced a surge in emergency department (ED) patients, particularly among the uninsured.

Description of the Innovative Activity

• Provider participation: Participating physicians agree to provide care at no cost and indicate how many patients they are willing to treat each year. Participating community clinics, hospitals, pharmacies, laboratories, and other ancillary providers also agree to provide services at reduced or no cost, and indicate how many patients and/or what volume of services they are willing to provide as part of the program.
• Covered services: Covered services include primary episodic and preventive health care services; limited diagnostic tests, laboratory work, and x-rays; limited pharmacy benefits at participating pharmacies; access to community health navigation/care coordination services; and access to specific disease management services for diabetes. 
• Patient eligibility: Enrollees must be Dallas County residents (U.S. citizenship is not required); must not have or be eligible for health insurance of any kind; must have a household income of less than 200 percent of the Federal poverty level; and must have someone in the household working.
• Patient enrollment process: Patients enroll in Project Access Dallas through providers at EDs/hospitals, community clinics, or private physician practices. Participating sites agree to complete the enrollment process as specified by Project Access Dallas. During this process, the following takes place:
  • Enrollment-related paperwork: Enrollees receive a card that identifies them as a Project Access Dallas enrollee and a pharmacy card to be used at participating pharmacies. Information provided in March 2012 indicates that initial enrollment is for a 1-year period; patients may extend enrollment pending continued eligibility.
  • Assessment of nonclinical needs, barriers: Staff work with enrollees during enrollment to complete a Patient Needs Assessment, designed to screen patients for social, financial, and educational barriers that may negatively impact their ability to be compliant with care and/or participation in the program.
  • Assignment of medical home, scheduling of first appointment: Each enrollee receives assignment to a medical home, even if only specialty care is initially required. A medical home might be a charity clinic, a community clinic, or a private physician who has agreed to participate in the program. In addition, a "mobile medical home" provides care to approximately 70 homebound patients with multiple chronic diseases who cannot travel due to physical or mental impairment. The first appointment with the medical home is scheduled at the time of enrollment.
• Ongoing navigation, disease management, other support: Patients whose assessment indicates a need for assistance with translation, transportation, and other barriers receive a referral to the Community Health Navigation program, which provides a community health navigator to ensure that enrollees receive appropriate care and support. Approximately 15 percent of enrollees typically require the assistance of a navigator. Key elements of this ongoing support include the following:
  • Care plan development using pathways: Project Access Dallas has developed six evidence-based care protocols, known as Health Navigation Pathways, to assist the navigators in providing care coordination services, including assistance with translation, transportation, health education, financial issues, food and housing, and referrals to other community resources. Each pathway guides the navigator through the process of developing a plan for the enrollee, including setting care-related goals, arranging needed services (including disease management programs for diabetes, depression, and other conditions), and counseling/encouraging the patient to access these services. The specific counseling and navigation services provided will depend on the individual needs of the enrollee.
  • Pharmaceutical support: Information provided in March 2012 indicates that Project Access Dallas provides enrollees with a $750 annual benefit for generic medications only, with an $8 copay for generics and a $20 copay for branded prescriptions. Once the pharmacy benefit has been used up, the navigators help to identify pharmaceutical assistance programs that provide access to affordable prescriptions.
• Data submission to aid evaluation process: Providers do not bill for visits (given that they are provided for free), but do submit claims information after each visit so that Project Access Dallas can track utilization and the value of donated services.

References/Related Articles

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Results

• Better management of diabetes: A randomized controlled trial of diabetes patients with comparable hemoglobin A1c levels at baseline found that, after 12 months, patients enrolled in Project Access Dallas' diabetes disease management program achieved an average hemoglobin A1c level of 7.27, well below the 7.82 average among nonparticipants.
• Fewer ED visits: The mean number of ED visits among Project Access Dallas enrollees was 0.93 per year, compared with 1.44 among nonparticipants. Analysis of 2005 data found that annual ED visits among program participants fell from 1.8 at baseline to 0.7 after program implementation.
• Fewer hospital days: The mean number of hospital days among Project Access Dallas enrollees was 0.37 per year, well below the 1.07 average for nonparticipants. The aforementioned 2005 analysis found that the program reduced the average number of annual hospital admissions per participant from 1.6 before program implementation to 0.4 after implementation.
• Lower costs, positive return on investment: The reduction in ED visits yielded a cost savings of $553,375 in 2005, while the reduction in inpatient days yielded additional savings of $890,897 that year. Financial analyses indicate that for every $1 invested in the program, approximately $3 in hospital-related costs are avoided.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Obtaining funding: The Dallas County Medical Society received a Healthy Communities Access Program grant from the U.S. Health Resources and Services Administration to create the program.
• Creating algorithm for services: Project Access Dallas used a portion of the grant to contract with faculty and staff at the Department of Family Medicine at the University of Texas Southwestern Medical School to create an algorithm for program services (e.g., patient enrollment forms, communication between participating sites and Project Access Dallas) and develop the health risk assessment that is administered at enrollment.
• Soliciting participation: Dallas County Medical Society advertised the program to members via mailings and at medical society meetings, highlighting the mission of donating services to the uninsured. Medical society leaders solicited participation from hospitals, clinics, and ancillary providers via interpersonal communications and networking.
• Obtaining additional funding: Project Access Dallas applied for and received a U.S. Centers for Disease Control and Prevention grant to study the effectiveness of the program in reducing health care utilization.
• Designing pharmacy benefit: Project Access Dallas contacted a pharmacy benefit management company to help develop a pharmacy benefit for program enrollees.
• Designing and redesigning pathways: Project Access Dallas, working with the Baylor Health Care System Office of Health Equity, initially developed four clinically-focused Health Equity Pathways in the areas of diabetes, depression, neurologic trauma/stroke, and heart failure, in part based on input from Mark Redding, the developer of the Pathways model. In 2009, the program reorganized the pathways into six Health Navigation Pathways to assist patients with social, economic, and educational barriers that prevent patients from achieving optimal outcomes. Pathways are currently paper based; depending on funding, pathways will be converted to an electronic format.
• Developing Patient Needs Assessment form: After the pathways had been reorganized in 2009, the program developed the Patient Needs Assessment to identify barriers to care.
• Training navigators: Community health navigators received training on use of the pathways from staff in the Baylor Health Care System Office of Health Equity.
• Expanding program: The program experienced a fivefold increase in resources in fiscal year 2009, largely due to a collaboration with five Dallas County health care systems that leveraged funding from the U.S. Centers for Medicare & Medicaid Services and the Texas Department of Health and Human Services. With the support of its partner organizations, Project Access Dallas is using the additional funds to expand coverage to a larger number of Dallas' uninsured.
• Spinning off diabetes disease management: The demonstrated success of the diabetes disease management program led to a significant grant award, which paved the way for expansion to additional clinical sites throughout Dallas County. To support this expansion, Project Access Dallas gave up formal responsibility for the program, with oversight now being conducted by a new independent management structure.

Resources Used and Skills Needed

• Staffing: As of March 2012, the program has 14 full-time employees who handle administration and management, including enrollment, referral coordination, and volunteer recruitment. In addition, 10 employees provide community health navigation services which includes transportation, translation, pharmacy assistance and assistance with health system navigation via contract with CitySquare (formerly Central Dallas Ministries).
• Costs: The annual budget is approximately $7 million to serve on average 3,100 patients a month or 4,000 unique patients per year; per-enrollee costs average approximately $1,900 per year (updated March 2012). Key expenses include approximately $2.7 million for diagnostic testing and imaging, hospital based enrollments and increased primary care access; $1 million for pharmacy benefits for enrollees; $800,000 for charitable clinic grants; and approximately $560,000 for the Community Health Navigation program. Funds are also allocated to utilization tracking and outcomes analysis.

Funding Sources

Getting Started with This Innovation

• Look for ongoing funding at program launch: Too often, Federal grants are limited to a specific time period or for a specific use.
• Build business case: Demonstrate that taking care of the underserved is not just the right thing to do but can also make good business sense by reducing utilization and costs.
• Develop systems to measure program impact: Physicians pay dues to be members of the medical society, so any society-sponsored program must be evaluated to determine if it adds value. Project Access Dallas developed and implemented mechanisms for tracking the program's impact at the onset of the program.
• Build relationships with research organizations: Organizations such as universities have the expertise and systems to facilitate outcomes tracking. In addition, academic thought leaders can enhance the reputation of a program by ensuring academic rigor in program development and measurement.
• Solicit attention from high-level local administrators: A rigorous evaluation process will help gain the support of local government leaders and hospital executives.
• Identify critical success factors for enrollees: For example, Project Access Dallas recognized that pharmaceutical access would be critical for enrollees, and therefore contacted a pharmacy benefits management company to help develop a benefit.

Sustaining This Innovation

• Continue to track outcomes: Demonstrating the positive impact of the program will encourage community providers to volunteer their time and will prompt funders to continue their support.