An HFMA Healthcare Financial Pulse Resource
Striving to better serve the growing uninsured population in its community, North Carolina-based Duke University Health System joined other healthcare providers to create Project Access of Durham County.
The program provides free specialty medical care and surgery to low-income uninsured county residents, delivered on a voluntary basis by physicians, hospitals, laboratories, pharmacies, and other health service providers.
Project Access was started as a result of a major effort, organized by four community groups, to develop ways to improve the availability of healthcare services to uninsured Durham County residents. Many of these patients receive primary care through a community health center but they previously had no access to specialty care and procedures.
Together, the surgeons and medical specialists committed to provide more than 2,800 episodes of care in their own medical facilities to uninsured county residents. An episode of care is defined as a full range of services—physician visits, inpatient stays, procedures, images, medications, and any other related costs—incurred by a single patient during a three-month period.
Managing Chronic Conditions
In conjunction with their commitment, the physicians requested that the program must address the chronic conditions among the patients they would be serving. That’s where Bettina Karpathian, RN, comes in. She is the disease/case management provider for Project Access.
Project Access patients are referred to Karpathian for case management services if they:
- Have at least two of these chronic conditions: diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary disease, or cardiovascular disease
- Frequently visit the hospital emergency department (ED)
“The medical community said ‘Even if a person comes in for a hip replacement, if they have uncontrolled diabetes, we need to address it,’” says Fred Johnson, Deputy Director Local Access to Coordinated Healthcare (LATCH). “So we needed to bring on a nurse for that skill set. We needed the nurse to go into a chart, read the notes, understand the labs and the pharmacology issues.”
LATCH—funded by Duke Health—provides patient navigation, health education, and social services to uninsured Durham County residents. Durham residents who need specialty care and meet certain income and residency criteria are enrolled in Project Access. The administration, care management, and disease management services of Project Access Durham County is funded by state and local government grants.
Karpathian’s first goal is to help patients bring chronic conditions under control. But she finds poorly controlled health issues are often tied up with other problems so she works with a multidisciplinary team at LATCH to address the problems—including mental health issues, homelessness, and lack of transportation—that exacerbate chronic conditions.
“I find that a lot of the folks have financial issues. Their diabetes gets out of control because they can’t afford their medicines and so on,” she says. “Often I have to deal with those issues first. If you have no income and you’re just about to lose your housing, it’s not much good for me to tell you how to eat for your diabetes.”
She also works to ensure patients do not get lost in the hand-off from inpatient care to an outpatient physician. “If I find out that one of my patients is in the hospital, I call the hospital discharge planner,” she says. “That way I can keep track of when they are being discharged and make sure they follow up with their primary care doctor and get all their medications and know what to do with them.”
Increase in Medicaid Enrollees; Fewer ED Visits
Johnson, the LATCH director, says Duke Health puts no pressure on him to prove that LATCH services, including Karpathian’s case management, generate a positive ROI. That said, because LATCH patient navigators help about 48 uninsured patients enroll in Medicaid each year—and they also cut the number of unnecessary ED visits—he knows that the health system benefits financially from its funding commitment to LATCH.
“Duke Health knows it will see these patients either at the beginning in the ED or later in the hospital. So there is a benefit to engaging this population on how to use the system so as not to burden it too much,” he says.
Interviewed for this article: Fred Johnson is director of clinical services for the Division of Community Health at Duke Health in Durham, N.C. (f.johnson@duke.edu ). Bettina Karpathian, RN, is the disease/case management provider for Project Access (bettina.karpathian@duke.edu).