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Service Delivery Innovation Profile

County-Wide Collaborative Uses Pathways Model to Enhance Access to Insurance, Primary Care, and Mental Health Services for Low-Income Children


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Snapshot

Summary

Access El Dorado (ACCEL), a county-wide health collaborative, uses eight care pathways to help low-income families obtain health insurance, navigate the health care system, and access appropriate medical and mental health services for children age 18 and under. ACCEL clients also have access to specialty care services, including orthopedics and a telemedicine pain management clinic. Based on the Pathways model, these cross-agency care pathways promote healthy outcomes by using community health workers to connect at-risk individuals to care. Examples of care pathways include securing health insurance for newborns and young children, ensuring that insurance coverage is maintained over time, obtaining a medical home for newborns and children, and facilitating referrals between primary pediatric care and mental health services. To support the pathways, ACCEL also initiated strategies to expand primary care physician supply. The program enhanced access to insurance coverage, a medical home for primary care, mental health services, and specialty care services, and reduced visits to the emergency department for primary care by previously heavy users.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of emergency department (ED) use among historically heavy users of the ED and of the timeliness of orthopedic care, along with post-implementation data on the number or percentage of enrollees successfully completing various pathways (meaning that services have been received).
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Developing Organizations

Access El Dorado (ACCEL)
Placerville, CAend do

Date First Implemented

2006
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Patient Population

Vulnerable Populations > Children; Impoverished; Rural populationsend pp

Problem Addressed

Many low-income children do not have insurance coverage, leading to poor medical and mental health outcomes. Those who do have coverage face other barriers to accessing services, such as trouble navigating the health care system. 1-5
  • Many uninsured children: In 2008, 46.3 million people (representing 15.4 percent of the population) lacked health care coverage in 2008, including 7.3 million children (9.9 percent).1 Approximately two-thirds of low-income, uninsured parents have family incomes below the Federal poverty level (FPL).2
  • Poor health outcomes: A strong link exists between health insurance coverage and access to preventive care, primary care, acute care, chronic illness management, and mental health care. The uninsured are more likely to suffer adverse health outcomes, including health and functional decline, preventable health problems, advanced disease at time of diagnosis, and premature death.3
  • Barriers to access even among insured: Many low-income families do not access needed health care even if they have insurance coverage.4 Barriers to care include an inability to navigate the health care system, lack of sufficient information, lack of transportation, and difficult personal circumstances.5 The failure to access care contributes to poor health outcomes among low-income children.

What They Did

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Description of the Innovative Activity

ACCEL has developed eight cross-agency care pathways (based on the Pathways model) that use community health workers to help low-income families obtain health insurance, navigate the health care system, and access appropriate medical services. The eight care pathways are described below:
  • Newborn health insurance: This pathway assists mothers whose births were funded through Medi-Cal (the California Medicaid insurance program) in adding their child to the mother's Medi-Cal coverage by initiating the process to obtain coverage.
  • Health insurance for children: Children 18 years of age or younger without health insurance who live in a household at or below 300 percent of FPL can be referred to ACCEL by various health agencies, public schools, and through the use of a toll-free telephone line. A community health worker screens candidates and assists families with form completion. They also telephone the parent/guardian to determine interest, perform an eligibility prescreening, and schedule an inperson appointment to identify the most appropriate insurance option and complete the application and other required documents. The pathway is completed when the client obtains coverage.
  • Health insurance retention: This pathway helps ensure that families renew their children's insurance coverage. An ACCEL community health worker contacts the parent/guardian before the renewal deadline and then meets with the family to submit the application and other required documents. The pathway is completed when the parent/guardian has successfully reapplied for and received continuing health insurance coverage for the child. This one-time support/intervention serves to educate the client and reinforce the value and steps required to keep the insurance active.
  • Medical home: This pathway helps children obtain a medical home (a location where the child can receive ongoing primary care). Eligible clients are 18 years of age or younger, have no primary medical provider, and live in a household at or below 300 percent of FPL. Emergency department (ED) staff typically refer children to this pathway after they come to the ED for primary care services. Once ACCEL receives a referral, a community health worker or clinic staff conduct a telephone screening with the parent/guardian to confirm the presence of insurance coverage, educate them about the importance of a medical home and regular health assessments, provide a pediatric health assessment schedule, and match the child with a clinician based on geographic convenience, insurance type, and patient preference. They also assist parents in scheduling an initial appointment and in identifying and addressing any barriers that might prevent them from keeping the appointment. The primary care practice communicates electronically with the community health worker about both kept and missed appointments. For missed appointments, the community health worker calls the parents/guardians to encourage them to schedule another appointment and/or to discuss reasons for the missed appointment.
  • Newborn utilization of a medical home: This pathway helps low-income parents of newborns actively use a medical home (secured via the pathway described above) to receive appropriately timed well-baby care, immunizations, and care for common childhood illnesses. Physicians and hospital staff refer parents to the pathway, which serves those with newborns covered by Medi-Cal who do not have a preestablished medical provider. Once a referral has been made, a community health worker educates the family about the importance of well-baby visits and ensures that the family knows how to access the medical home. For up to 8 months, ACCEL prompts the family to schedule four well-baby appointments, reminds them to keep scheduled appointments, helps them overcome barriers to accessing medical care, and monitors the well-baby checks and immunization schedules. The pathway is completed when parents attend four well-baby visits and obtain all scheduled immunizations for the child.
  • Pediatric mental health consult: This pathway facilitates referrals between primary care physicians and county-offered mental health services for children and adolescents. Eligible clients are age 18 or younger and covered by Medi-Cal or Healthy Families insurance (a low-cost insurance option for California children and teens who do not have insurance and do not qualify for Medi-Cal). Once a referral has been made, an El Dorado County Mental Health Department staff worker, who acts as the community health worker for this pathway, contacts the parent/guardian to schedule an appointment and to identify and resolve possible barriers to keeping it. The mental health worker provides assessments and treatment (as needed) over the course of several visits, with reports being sent to the referring physician. The pathway is completed when the referring physician has received a report that mental health services have been provided.
  • Orthopedic consult: This pathway provides referrals to patients of all ages with Medi-Cal insurance who need an orthopedic consult; before development of this pathway, this population lacked access to orthopedic care. Primary care or ED providers refer prescreened patients to a half-day orthopedic clinic run by the Shingle Springs Tribal Health Program each week. Scheduling occurs after verification that the patient meets standardized guidelines for referral. Providers in the half-day clinic can access and input relevant information into the patient's electronic medical record. After the visit, the referring primary care provider receives a patient-specific treatment plan from the specialist and continues to manage the patient's primary care.
  • Pain management telemedicine consult: This newest pathway provides referrals to patients of all ages with Medi-Cal or County Medical Services Program insurance who need a pain management consult. Primary care providers refer prescreened patients to a half-day pain management telemedicine clinic run by Shingle Springs Tribal Health Program each week. Scheduling occurs after verification that the patient meets standardized guidelines for referral. Providers in the half-day clinic can access and modify the patient's electronic medical record. After the visit, the referring primary care provider receives a patient-specific treatment plan from the specialist and continues to manage the patient's primary care.

Context of the Innovation

Formed in 2004, ACCEL is a health collaborative that includes two small independent community hospitals, the El Dorado County Health Services Department (Public Health and Mental Health divisions), several rural clinics, a Federally Qualified Health Clinic, a Tribal clinic, and several private medical practices. ACCEL serves El Dorado County, a largely rural county with more than 178,000 residents located east of Sacramento, CA. ACCEL's mission is to unite community resources and connect individuals in need to services to foster a healthier community. The adoption of the Pathways model came as a result of a search by ACCEL representatives for a way to organize the collaborative's activities and facilitate clarity in coordination and handoff among participating institutions. ACCEL leaders saw the model as a tool to accomplish this goal, including use of technology to enable real-time efficient communication across agencies and standardized methods for patient navigation of the system.

Did It Work?

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Results

The program improved access for low-income children to health insurance coverage, a medical home for primary care, mental health services, and specialty care services, and reduced visits to the ED for primary care by previously heavy users.
  • More children with insurance coverage: More than 6,600 previously uninsured children and over 600 newborns have obtained coverage through this program. To ensure continuous coverage, the program assisted 526 children in the reenrollment process (updated February 2011).
  • Enhanced access to primary care/medical home: As of February 2011, approximately 83 percent of the 430 children enrolled in the Obtaining a Medical Home pathway have successfully secured a primary care provider and been seen at least once by that provider. In addition, roughly half of the 289 newborns enrolled in the Newborn Utilization of a Medical Home pathway have successfully completed it, meaning that these babies received four well-baby visits and all scheduled immunizations.
  • Fewer ED visits and associated cost savings: Only 9.4 percent of the children in the Obtaining a Medical Home pathway previously classified as moderate to high utilizers of the ED (defined as two or more visits per year) continued to be heavy users after program enrollment. Based on estimates of the average marginal cost of ED visits, this pathway saved the local ED over $95,000 in 1 year,6 a 40-percent reduction compared with what would have been spent had these patients not obtained a medical home (updated February 2011).
  • Enhanced access to mental health services: Of the 174 children enrolled in the Pediatric Mental Health Consult pathway, 53 percent have received mental health services. In addition, referring primary care providers report that they now have immediate access to mental health services for challenging cases and that they regularly receive followup consult reports and management plans. These providers previously had little or no access to county mental health services for these challenging cases. Each year, the number of newly opened cases has steadily increased, growing from 14 in the first year (2006) to 55 in the past year (updated February 2011).
  • Enhanced access to specialty care services: Since August 2009, 219 publicly insured adults received access to orthopedic specialty care. The orthopedic consult pathway reduced the time between referral and appointment by more than 50 percent, from more than 40 to 19 days. Data on the impact of the recently launched pain management pathway will be forthcoming.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of emergency department (ED) use among historically heavy users of the ED and of the timeliness of orthopedic care, along with post-implementation data on the number or percentage of enrollees successfully completing various pathways (meaning that services have been received).

How They Did It

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Planning and Development Process

Key steps included the following:
  • Community needs assessment: A community needs assessment identified several barriers preventing children living in poverty from accessing needed health care services, including lack of health insurance and a medical home.
  • Introducing model: ACCEL's program director met Mark Redding, the Pathways founder, at a Healthy Communities Access Project meeting in 2005. The program director invited Dr. Redding to introduce the Pathways concept in an ACCEL workshop in the fall of 2005. The workshop catered to a broad constituency, including medical providers and representatives from ACCEL agencies.
  • Pathway identification: At the workshop, participants identified four topics of primary importance to be addressed immediately and began to outline pathways on these topics.
  • Pathway design: Sarah Redding, the Pathways cofounder, attended a subsequent ACCEL workshop, held over several days, to help outline the initial pathways in greater depth. ACCEL then convened smaller work groups of individuals who finalized the pathways, laying out details on how they would work, who would be responsible for various components, and other issues. Each group designed the pathway on paper and developed referral tools and forms (such as patient consent forms and participant agreements) that would be needed for implementation. Cross-agency representatives met to identify patient interactions, roles, responsibilities, and appropriate patient handoff points. These discussions led to development of standardized work steps and to the assignment of responsibilities to participating agencies. In many instances, internal agency work practices had to be amended to facilitate cross-agency patient navigation.
  • Hiring and training staff: ACCEL initially hired three individuals to serve as community health workers. The county health department also reassigned an existing staff member to the program. (ACCEL now uses existing community health workers, community mental health workers, and clinic staff to support care coordination and pathways management.) Community health workers and other participants receive formal training and monitoring, using specially developed materials with global and pathway-specific features and requirements, along with customization for specific roles. New staff receive intense monitoring during the first 3 months and periodic monitoring thereafter.
  • Creating electronic format: During initial implementation in 2006, ACCEL began designing electronic support via a Web-based application. ACCEL assessed and selected a vendor, completed the procurement process, and helped design a configuration for the electronic pathways. Other activities included testing the system, developing training materials, and addressing privacy and security issues by adopting the ACCEL Notification of Privacy Practices and related policies. ACCEL went live with the application in February 2008. More recently, ACCEL developed report templates (currently being programmed into the software) so that automatic reports for each pathway can be generated to facilitate activities, such as monitoring quality and examining trends in completion rates. An Enterprise Master Patient Index has been developed to support cross-agency patient registration and facilitate the exchange of health information.
  • Developing quality assurance model: ACCEL implemented a three-tiered Quality Assurance (QA) model to help ensure data and process integrity and support continuous quality improvement. QA Level 1 focuses on providing robust support and monitoring to new users; QA Level 2 empowers each organization to manage and provide feedback to their own users; and QA Level 3 consists of multidisciplinary workgroups that review care pathway data, identify cross-agency trends, and resolve community barriers to the successful completion of pathway activities.
  • Testing and validating care coordination metrics: ACCEL recently began working with four other care coordination sites on a National Institutes of Health initiative aimed at addressing the lack of validated measures for the quality of care coordination services and the associated lack of comparative performance data, particularly for community-based organizations.

Resources Used and Skills Needed

The core resources applied to the ACCEL pathways are outlined below:
  • Staffing: Primary staff include the following:
    • ACCEL staff: A full-time ACCEL program manager executes policies, develops program plans, oversees plan execution and evaluation, identifies resource requirements (in-kind and staff), and manages internal and external relationships. ACCEL also contracts with an information technology (IT) consultant to assist with care pathways integration into ACCEL's Web-based care management tool and related technology issues. Two provider champions representing the Western Slope and South Lake Tahoe provide additional strategic and programmatic guidance and serve as a liaison to the provider community.
    • County and clinic staff: Part-time public health department staff include a supervising health education coordinator, three bilingual community health workers, and a mental health department worker. Clinic staff include referral specialists at each primary care site who assist with establishing patients in a medical home and providing patient education.
    • Nonpaid positions: Nonpaid positions include provider capacity work group members who provide input to and monitor program activity/results; steering committee members who oversee operations and business/policy decisions; QA workgroup members; and other agency representatives who participate in process review and new pathway design meetings. Local hospital IT staff provide additional support related to the ACCEL case management system.
  • Costs: Minimum operating costs are approximately $200,000 per year. This figure does not reflect development costs for building or modifying pathway specification in the electronic system.
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Funding Sources

Agency for Healthcare Research and Quality
A 2005 Agency for Healthcare Research and Quality (AHRQ) planning grant and subsequent 3-year AHRQ implementation grant (Grant #5UC1HS016129) have supported the program. Additional funders include the Blue Shield of California Foundation and the California HealthCare Foundation. Going forward, ACCEL will begin to leverage internal funding sources from member agencies to support program operations.end fs

Tools and Other Resources

Details about each pathway, including background information, flow charts, indepth descriptions of specific steps and responsible parties, and training materials are available at the ACCEL Web site: http://www.acceledc.org/Index.asp.

Adoption Considerations

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Getting Started with This Innovation

  • Standardize work processes whenever possible: Standardized systems, processes, responsibilities, and accountabilities across agencies improve efficiency and enhance the program's ability to provide services to all clients.
  • Use IT wherever possible: Technology allows patient handoffs to agency representatives to occur in real time, ensures the provision of all necessary reference information, and enables staff to easily document completion of services.
  • Formalize privacy policy: As noted, participating organizations adopted the ACCEL Notification of Privacy Practices to allow for cross-agency coordination of care and services.

Sustaining This Innovation

  • Monitor electronic system usage: Perform onsite followup to ensure that people remain comfortable with the electronic system, including how to input data correctly.

More Information

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Contact the Innovator

Christine Sison, MS
Program Manager
Access El Dorado (ACCEL)
County of El Dorado Department of Health Services - Public Health Division
670 Placerville Drive; Suite 1B
Placerville, CA 95667
E-mail: accelqa@gmail.com

Innovator Disclosures

Ms. Sison has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Access El Dorado [Web site]. Available at: http://www.acceledc.org

Footnotes

1 DeNavas-Wait, C, Proctor BD, Smith JC. U.S. Census Bureau. Income, poverty and health insurance coverage in the United States: 2008. September 2009. Available at: http://www.census.gov/prod/2009pubs/p60-236.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)
2 Schwartz K. Kaiser Family Foundation. Spotlight on Uninsured Parents: How a Lack of Coverage Affects Parents and Their Families. June 2007. Available at: http://www.kff.org/uninsured/upload/7662.pdf
3 Hoffman CB, Paradise J. Health insurance and access to health care in the United States. Ann N Y Acad Sci. 2008;1136:149-60. [PubMed]
4 DeVoe JE, Baez A, Angier H, et al. Insurance + access does not equal health care: typology of barriers to health care access for low-income families. Ann Fam Med. 2007;5(6):511-18. [PubMed]
5 Klerman, LV. Nonfinancial barriers to the receipt of medical care. U.S. Health Care for Children. 1992;2(2):173-87. The Future of Children (Princeton/Brookings). Available at: http://www.futureofchildren.org/futureofchildren/publications/docs/02_02_09.pdf
6 Bamezai A, Melnick G, Nawathe A. The cost of an emergency department visit and its relationship to emergency department volume. Ann Emerg Med. 2005;(45):483-90. [PubMed]
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Original publication: January 19, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: May 29, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: January 31, 2011.
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.