Creativity is the key to managing the care of patients without insurance
Linking patients with primary care keeps them out of the hospital
As health insurance costs escalate and employers reduce coverage for employees, raise deductibles, or stop providing health insurance altogether, hospitals are providing care for an increasing number of patients who have no means to pay.
The federal government estimates that 47 million people had no health insurance of any kind during 2006, and all indications are that the number will continue to increase, says Donna Zazworsky, RN, MS, CCM, FAAN, director, network diabetes and outreach for Carondelet Health Network in Tucson, AZ.
The uninsured come from all walks of life, all age groups, and all educational levels, she adds. "The largest number of uninsured have less than a high school degree but there are still a large number of people with professional and graduate degrees who are uninsured," she says.
Having a full-time job doesn't guarantee access to health insurance, Zazworsky points out. In 2006, 18% of the total work force was uninsured, accounting for 28 million of the 47 million uninsured.
People whose incomes fall below the federal poverty level are the only ones eligible for federal programs; that leaves a lot of people who don't qualify for the program but can't afford the cost of premiums even if they work for a company that offers health insurance benefits.
Patients stuck in ED, acute care
Patients who don't have insurance often remain in the acute care hospital longer than necessary because they have no funding for home health or durable medical equipment. Others have extended lengths of stay in an acute care facility because facilities that can provide a lower level of care won't take patients when they won't be reimbursed for the care.
Uninsured patients, many with chronic illnesses, are flooding the nation's EDs because they can't afford treatment at a primary care provider or they have no money to fill their prescriptions.
"The uninsured aren't being connected to primary care and don't have the money for medications. Patients come into the emergency department and are stabilized but then sent home with no resources to help them manage their condition. The problem is exacerbated because people without insurance are not having regular check-ups and preventive care," Zazworsky says.
Hospital case managers are in a position to help in all of these situations, she adds, but it's a challenge they can't meet alone.
"Case managers need to know what resources are available in their area and work with community agencies and other providers to help the uninsured find a medical home so they can stay healthy and out of the hospital," Zazworsky says.
Network for solutions
In communities across the nation, hospitals are collaborating with local agencies and other providers to provide medical care for patients without funding and to create a bridge between acute care and primary care.
For instance, Harborview Medical Center in Seattle has dedicated a case manager to patients with chronic illnesses who are treated in the hospital's emergency department. "In essence, I'm a financial counselor, disease management nurse, and social work coordinator," says Audrey Paisley, RN, diabetes and asthma case manager.
If patients are uninsured, the Harborview staff try to connect them to services that can get them covered by Medicaid or the state of Washington's basic health plan, adds Daniel Lessler, MD, MPH, associate medical director.
"We work to address other psychosocial needs as well. Some of the patients are homeless and we connect them to sources that may help them find better housing," he says.
The model helps build bridges between the patients and resources in the community that can help them better manage their chronic diseases, Lessler adds.
"Health care and community-based organizations need to create new ways of collaborating to help people stay healthy," he says.
Help patients reconnect with primary care
Helping patients connect with a primary care provider should be a priority for hospital-based case managers whether they are in the emergency department or the acute care unit, Zazworsky says.
Hospital case managers should become familiar with what resources for the uninsured are offered in their community and help their patients access them.
"There are a lot of health care delivery systems in the community that can provide care for the uninsured," Zazworsky says.
Help patients find a medical home either though a federally qualified community health center, a clinic that provides free or reduced care, or a faith-based health center. Make the first appointment for your patients before they leave the hospital, she suggests.
In order to understand why patients keep returning to the hospital or the ED , case managers need to be aware of what is going on in a patient's life when he leaves the hospital, Zazworsky says. For instance, a patient may be repeatedly hospitalized for diabetes because he didn't get his medication or doesn't check his blood sugar level.
"Patients often wind up in the hospital if they can't afford their medication or if they cut their pills in half to make them last longer," she explains.
Asking patients how they perceive their health is a good way to determine who is likely to be readmitted, Zazworsky notes.
"Patients who perceive their health as being good to excellent are less likely to be rehospitalized, even if they are very sick," she says.
Identify your patients' potential health care and medication needs, benefits that are available to them, barriers to receiving care, and appropriate resources, Zazworsky suggests.
Look beyond the immediate situation to include what is going on in a patient's life when he or she leaves the hospital, she advises. Find out what kind of support system the patient has at home, financial issues, transportation problems, or other roadblocks to compliance.
Case managers should work with social workers in the hospital and social service agencies in the community to make sure their patients have shelter, food, and other basics.
Help your patients get on food stamp programs, energy savings programs, and other types of assistance.
"If someone is not living in a safe and secure environment, if they don't have food or are worrying about whether their utilities are going to be cut off, they aren't going to take care of their health. Many times people have to make the choice between paying an electric bill and getting a scan done," she says.
Determine an uninsured patient's eligibility for federal and state programs and initiate the paperwork, Zazworsky advises.
Make sure that someone is available to follow up with the patient on paperwork and their eligibility.
Case managers may want to talk to their manager or directors about setting up a program to identify uninsured patients so they can be screened for eligibility for various programs and so someone can set up the process to get them into primary care, Zazworsky suggests.
Help your patients apply for pharmaceutical assistance programs, help them obtain a supply of medication to bridge the gap until the program kicks in, and make sure that someone follows up, she says.
Patients who receive pharmacy assistance must have a medical home because the programs require that a nurse or physician distribute the medication, Zazworsky adds.
Regional health information exchanges are being created across the country so providers can share information and provide more cost-effective care. For instance, participants in the Southern Arizona Health Information Exchange include all hospitals, health plans, and providers in the area. They are working together to create an information system so that if an uninsured patient shows up at one hospital, the staff can check to see if a test or lab work has been done recently by another provider.
"This will enable them to use any current information without repeating tests or procedures and to see what the treatment is so they don't have to start over with a patient," Zazworsky says.
"Everybody has the same problem of escalating costs and how to reduce them. This will follow patients from location to location," she says.
(Editor's note: For more information, contact Donna Zazworsky, director, network diabetes and outreach, Carondelet Health Network, Tucson, AZ; e-mail: [email protected].)
As health insurance costs escalate and employers reduce coverage for employees, raise deductibles, or stop providing health insurance altogether, hospitals are providing care for an increasing number of patients who have no means to pay.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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