Securing care for uninsured: Look to community benefits for solutions
Even with no payer in sight, options still exist with creative approach
When dealing with a patient who has no insurance and isn't, at the time of hospitalization, qualified for Medicaid, social workers and case managers have to hit the ground running to piece together options for post-acute care.
Unfortunately, there's no one-size-fits-all solution, according to Donna Zazworsky, RN, MS, CCM, FAAN, director, network diabetes and outreach for Carondelet Health Network in Tucson, AZ but the answer might be right under your nose, thanks to community benefit requirements for not-for-profit hospitals.
"It's always a case-by-case basis," says Zazworsky. "But community benefit can be a really useful tool for discharge planning for these patients."
Whether the patient is an American citizen or an undocumented immigrant, frail elderly adult, underinsured worker, or child, someone with no benefits presents a challenge if he or she needs skilled nursing or assisted living after leaving the hospital.
"The pieces that hospitals get hung up on is that there's no payer, so when that happens, what's the next step?" notes Zazworsky. "The social worker starts getting involved, to see if the patient is eligible for Medicaid or emergency Medicaid; but even if they qualify for emergency Medicaid, it's only going to cover the hospital costs, and won't cover assisted living or skilled nursing."
Discharge planners get creative, get busy
There is no "typical" uninsured or indigent patient, Zazworsky points out. Communities are adding more and more programs to act as stopgaps for the underinsured, the homeless, and others, and it's an ongoing job for discharge planners to keep abreast of what their communities offer.
"It's a challenge, and ultimately, the hospital is going to be responsible" for finding answers for patients who might appear at first glance to have few or no options, according to Zazworsky.
And while the hospital has an interest in not extending patients' lengths of stay simply because there's nowhere else for them to go, don't overlook the hospital as a possible solution to its own predicament.
Zazworsky relates the case of a patient she worked with who was uninsured and for whom Medicaid coverage was still being sought. The patient was mentally incompetent, and though an American citizen, had no family in the United States.
"So because she had no guardian, we had to go through the court system and get guardianship established," says Zazworsky.
Because the patient's case manager had her paperwork underway, when an assisted living facility was located that would accept the patient once she was covered, the hospital agreed to pay the first month's costs for the assisted living placement. (Each state handles Medicaid dollars differently, Zazworsky notes; in Arizona, the Arizona Health Care Cost Containment System allocates Medicaid dollars for health care and long-term care.)
The hospital chose to do this "because it was a lot more expensive for the hospital to keep her in the hospital," Zazworsky explains.
Besides the cost savings provided by paying for assisted living rather than acute care, such a measure can be reported under the hospital's community benefit program.
"Hospitals, particularly non-profits, have to provide community benefit, and they track these activities and can write them off," she explains.
Community benefit: The benefits are shared
Community benefits are programs and services designed to improve health in communities and increase access to health care. They are viewed as integral to the mission of not-for-profit health care organizations, and are the basis of tax exemption.
Community benefit programming grew out of investigations, litigation, and ethical concerns that led state and federal lawmakers to question whether not-for-profit hospitals are indeed providing a benefit to the public, how best to measure that benefit, and whether that benefit is in line with the tax exemptions hospitals receive.
Some states have passed laws establishing a minimum level of charity care that community service hospitals must provide to maintain tax exemption. Some states also are mandating that hospitals document their community benefit activities.
According to the Catholic Health Association of the United States (CHA) and Irving, TX-based health coalition VHA, Inc., annual surveys on hospital leadership's support of community benefit initiatives indicate that support for the activities is growing. (See the CHA web site, www.chausa.org, for more information.)
Nearly half of the respondents to the 2007 CHA/VHA survey on community benefit reported an increase in programming, and responded that community benefit programs that have the greatest impact are ones that achieve increased access to care. Programs that offer health education or health promotion also ranked high, with 28% of respondents reporting those programs as having the greatest impact.
Zazworsky explains that as the impact of community benefits has expanded, so too has the recognition of its value to patients and institutions. Commercial software is available to allow hospitals to track their activities, she adds.
"So it's important that discharge planners work with their [hospital] foundations and whoever oversees the community benefit component, because activities like [the hospital paying the patient's assisted living costs] can be reported," she says.
Some solutions also have downsides
Repeating that "it's always a case-by-case basis," Zazworsky points out that even when potential aid is identified for uninsured or indigent patients who need post-acute care, that help might not be so easy to lock in.
"If the patient is undocumented and here illegally, the hospital and case manager will work with the consulate of the country the patient emigrated from," she explains. "We can try to see how to get the patient transported back to his or her home country, and that's not an easy thing."
For other patients, the problem might be establishing a "medical home" the outpatient physician or clinic where they'll go for post-discharge help and medication or applying for pharmacy assistance.
"But the question is always, 'Who is going to follow through with the paperwork?'" she suggests. "In cases where you have to go to court to establish a guardianship [in order to file paperwork seeking skilled nursing or assisted living coverage], you get into the legal issues, like 'Who's allowed to get that information since someone has to go through the patient's bank statements, that person has to be appointed.'
"It's a challenge, and it takes lots of creativity."
Source
For more information, contact:
- Donna Zazworsky, RN, MS, CCM, FAAN, director, network diabetes and outreach, Carondelet Health Network, Tucson, AZ. E-mail: [email protected].
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