from the er to primary care: effective strategies for connecting enrollees to care

© 2016 Enroll America | StateOfEnrollment.org

From the ER to Primary Care: Effective Strategies for Connecting Enrollees to Care


Panelists Introductions:

• Lorena Sanchez, Director of Programs for Sacramento Covered

• Andrea Ravitz, Director of Marketing for Access Health CT

• Jaspreet Malhotra, Program Specialist for Michigan Primary Care Association

• Madiha Tariq, Public Health Manager for ACCESS Community Health & Research Center

Welcome and Overview


SACRAMENTO COVERED

© 2016 Enroll America | StateOfEnrollment.org 4

Sacramento Covered

Patient Navigation Program Data*

*Data is for Dignity Health Patient Navigation Program.


Sacramento Covered

Patient Navigation Program Goals

The health care industry is complex, but we keep our goals simple:

Ensure patients can access primary care Decrease dependency on EDs for primary care Improve quality of care Reduce uncompensated care costs


Sacramento Covered

Patient Navigation Program Patient Navigators in local hospital emergency departments

• Connect with people in need • Understand their needs• Take the connection one step further:

o Link to primary care & specialty serviceso Transportation needso Identify other social service needso Follow-up


Sacramento Covered

Formula for Success Innovative partnerships help residents gain access to coverage and care.

Collaborative partners create tailor-made approaches to meeting community need. Partners include:

• Local hospitals• Health plans• Medical groups• County Medi-Cal Office• FQHC’s• Providers


Sacramento Covered

More Work To Be Done… Transportation Programs• Taxi vouchers• Uber, Lyft, etc. • Organization vehicles

Clinic Partnerships• Working with local community clinics to coordinate

patients’ care


ACCESS HEALTH CT MODEL


Access Health CT


EXPANDING THE CHW ROLE TO INCLUDE ENROLLMENT ASSISTANCE


MI Primary Care Association

Integrating CHW and Enrollment Roles

Experts in System Navigation, Education, and Advocacy



Getting Started – Cross Train



Expanded Data Tracking Tools

http://www.mpca.net/OEReport

http://www.mpca.net/OEReport



PRAPARE Assessment

• Identifying root causes of poor health outcomes• Focus is on assessing and documenting patients’ risk

of poor health • Guide the patients goals and actions



AllRow Labels Not Completed CompletedEducation Interest Assessment 39 19Employment Interest Assessment 36 34Healthcare Referral 180 105Health Insurance Assistance 14 14Health Insurance Education 101Housing Referral 82 39HouseSafe Wellness Assessment 7 4Legal Referral 9 5Medication Equip Assistance 84 128Social Com Service Ref 278 193Social Network Assessment 18 2Stress Coping Assessment 130 59Transportation Assistance 99 73Veteran Benefit Edu Referral 2 3Grand Total 1079 678

Top 5Row Labels Not Completed CompletedHealthcare Referral 180 105Health Insurance Education 101Social Com Service Ref 278 193Stress Coping Assessment 130 59Transportation Assistance 99 73Grand Total 788 430

PRAPARE Data



PRAPARE Data

Education In

terest Asse

ssmen

Employment In

terest Asse

smen

Healthca

re Referral

Health In

surance

Assista

nce

Health In

surance

Education

Housing Referra

l

HousSafeW

ellnessA

ssessm

ent

Legal Referra

l

Medication Equip Assi

stance

Social C

om Service

Ref

Social N

etwork

Assessm

ent

Stress

Coping Assessm

ent

Transporta

tion Assista

nce

Veteran Benefit Edu Referra

l0

50

100

150

200

250

300

0

50

100

150

200

250

Not CompletedCompleted



Understand Coverage



Social Media Campaign



Sustainability• Continued commitment to assist consumers

access healthcare

• Improved screening of consumers for health coverage needs

• Increased capacity to address the social determinants of health and improve health outcomes


BRIDGING HEALTH DISPARITIES: THE ACCESS MODEL


ACCESS Health Coverage Initiative

• Clients Assisted: 16,162 • Language Assistance: 76%• Electronic Application Submissions: 75%• Certified Navigators: 4 FT 4 PT• Events: 233• Current weekly clients: 100-150• Weekly clients during open enrollment: 350• Off-Site Enrollment Sessions: 77• Enrollment Satellite Offices: 14• Web Based Reporting • Partnered with CMS to help translate the Coverage to Care booklet in

Arabic and were nationally recognized.

Navigator Program



Does having coverage mean we are healthier?


• Reasons why community doesn’t enroll/reenroll:

• Trust• Fear of the unknown• Cost

• Our underlying goal is improved health outcomes

• Being patient advocates




80% OF PATIENTS WILL FORGET WHAT THEIR PROVIDER SAID

50% OF WHAT PATIENTS REMEMBER IS RECALLED INCORRECTLY



Effective Health Communication is a Shared Responsibility

Patient Responsibility:To ask questionsTo provide full & honest information

Service Provider Responsibility:To provide a welcoming environment that allows patients to share information freely

ACCESS provides services to help develop skills in the client to effectively communicate with the provider



Case Study

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwix-PH74cPMAhWENSYKHTiXAJgQjRwIBw&url=http://www.debbieschlussel.com/66133/obamacare-not-working-hezbollah-muslims-hardest-hit/&psig=AFQjCNEPsy1QR593mm7DAIrUAkIplmKW-Q&ust=1462566232446897



• Navigator’s role is to address social determinants of health

• One Stop Shop• Cross Training over departments• Loyalty to agency, not just the program

Care Coordination



• Client-centered service• Care is not as valuable if social determinants of health are

not addressed• Every staff member plays a role in care• Every staff must be a community leader/advocate• Community Partnerships make our work easy• Important to capture the impact through programmatic

evaluation, community feedback and research

Conclusion


EXERCISE AND DISCUSSION


Exercise and Discussion

Participant Exercise:

Let’s say you are going to create a pilot project back home. Pick which program you just learned about and describe how you would incorporate a similar program back home. What would the structure look like for a 30 day pilot?


THANK YOU!

Contact information for today’s panelist:

Erin Knott: [email protected]

Lorena Sanchez: [email protected]

Andrea Ravitz : [email protected]

Jaspreet Malhotra: [email protected]

Madiha Tariq: [email protected]