from the er to primary care: effective strategies for connecting enrollees to care
TRANSCRIPT
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From the ER to Primary Care: Effective Strategies for Connecting Enrollees to Care
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© 2016 Enroll America | StateOfEnrollment.org
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
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SACRAMENTO COVERED
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Sacramento Covered
Patient Navigation Program Data*
*Data is for Dignity Health Patient Navigation Program.
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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
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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
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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
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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
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ACCESS HEALTH CT MODEL
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Access Health CT
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Access Health CT
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Access Health CT
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Access Health CT
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Access Health CT
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Access Health CT
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Access Health CT
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Access Health CT
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EXPANDING THE CHW ROLE TO INCLUDE ENROLLMENT ASSISTANCE
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MI Primary Care Association
Integrating CHW and Enrollment Roles
Experts in System Navigation, Education, and Advocacy
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MI Primary Care Association
Getting Started – Cross Train
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MI Primary Care Association
Expanded Data Tracking Tools
http://www.mpca.net/OEReport
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MI Primary Care Association
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
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MI Primary Care Association
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
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MI Primary Care Association
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
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MI Primary Care Association
Understand Coverage
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MI Primary Care Association
Social Media Campaign
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MI Primary Care Association
Social Media Campaign
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MI Primary Care Association
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
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BRIDGING HEALTH DISPARITIES: THE ACCESS MODEL
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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
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ACCESS Health Coverage Initiative
Does having coverage mean we are healthier?
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• Reasons why community doesn’t enroll/reenroll:
• Trust• Fear of the unknown• Cost
• Our underlying goal is improved health outcomes
• Being patient advocates
ACCESS Health Coverage Initiative
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ACCESS Health Coverage Initiative
80% OF PATIENTS WILL FORGET WHAT THEIR PROVIDER SAID
50% OF WHAT PATIENTS REMEMBER IS RECALLED INCORRECTLY
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ACCESS Health Coverage Initiative
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ACCESS Health Coverage Initiative
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
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ACCESS Health Coverage Initiative
Case Study
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ACCESS Health Coverage Initiative
• 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
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ACCESS Health Coverage Initiative
• 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
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EXERCISE AND DISCUSSION
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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?
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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]