Team helps uninsured transition back home
Team follows up for a year post-discharge
Florida Hospital East Orlando has developed a transitional care program for uninsured patients to coordinate their healthcare needs as they move from the hospital to home.
A three-person team—a nurse, a social worker, and a lay health coordinator—follows the patients from the hospital and into the community and check on them for a year. The free program is designed to give patients the tools they need to manage their health through clinical, social, and educational support.
"Our team manages the healthcare needs of the patient in the program but we go beyond that and provide support for their psychosocial needs. We connect patients with food banks, agencies that can help with furniture or clothing, and other community resources that can help patients get what they need," says Alba Santiago, MPH, MHSA, community programs manager for the 265-bed community hospital.
Patients eligible for the program have had three or more visits in a 12-month period. Patients who are homeless, are minors, have substance abuse issues, or have serious mental health issues are not eligible. "Our focus is chronic conditions, particularly diabetes, cardiac conditions, and respiratory conditions but if patients don't have a chronic disease but meet our criteria, we see them too," Santiago says.
Each day, the team's social worker prints out the hospital's census of self-pay patients, reviews the new admissions, and determines if the patients qualify for the program. She goes to the rooms of eligible patients, introduces the program, enrolls the patients, and completes an assessment. The nurse also visits the patients, assesses their medical needs, and conducts medication reconciliation. If patients decline to be in the program, the social worker documents it in the record and gives the patients the team's telephone number in case they need assistance. If the patients are readmitted, the team approaches them again.
The transition team visits the patients daily in the hospital and collaborates with the unit case manager on the discharge plan. The social worker arranges a follow-up appointment with a primary care provider or specialist, arranges medication assistance, coordinates referrals to community resources, and follows up after discharge to make sure everything is in place.
"When the nurse and the social worker visit the patients in their hospital rooms, they identify both clinical and social needs. We collaborate with the treatment team on the discharge plan, ensure that they have follow-up appointments, and if they need more services that go beyond primary care, we link them with Orange County Medical Services for special services and follow-up with specialists," she says.
The team links patients with Central Florida Family Health Clinics, a federally qualified health center, and provides limited financial support for the patient's co-pay. The program provides bus passes so patients can get to their appointments, and helps patients enroll in prescription assistance plans. "We try to remove any barriers that would prevent patients from following their treatment plans. We make sure they have no excuses for not following up with a primary care physician or complying with their medication regimens," she says.
The hospital has set up a link so that the charge nurse at Central Florida Family Health Clinics can access patients' hospital records to ensure continuity in care and eliminate duplication of tests and procedures. The team also provides patients with the equipment and supplies they need to manage their conditions, such as a glucometer for patients with diabetes.
If patients need additional diagnostic tests, such as a sonogram or a magnetic resonance imaging (MRI), the team refers them to an imaging center that offers a special fee for self-pay patients. If they can't afford the fee, the hospital performs the test and the patient pays nothing.
The lay health coordinators make follow-up calls to the patients for a year. Initially, they call the patients frequently, then taper off to calling once a quarter. They make the first call within 48 hours of discharge and make sure the patients have their medication, remind them of their follow-up appointments, answer any questions, and address other needs. They call again a week after discharge, after the primary care appointment, and as often as needed after that.
"Every case is unique. We have a baseline and a structure for the phone calls, but the frequency depends on how the patients are responding," she says.
The patients are encouraged to attend the Chronic Disease Self-Management Program or the Diabetes Self-Management Program, both developed by Stanford University to help patients learn self-management skills and early-warning signs that could signal an exacerbation in their conditions. The six-week programs are presented in English and Spanish at the hospital.
"One of our steps during the hospital stay is to enroll patients in the educational program. We point out that we are providing assistance with co-payments, medications, and other health services and encourage them to enroll in the workshops. We know that people who have completed the workshops show an improvement in chronic conditions, and it is in our interest for them to take these classes," she says.
Many of the patients in the program have routinely visited the emergency room when they are sick rather than seeing a primary care physician. "During the year we work with them, we teach them the right way to access medical services. We encourage them to call their doctor if they feel sick and to call us for assistance in scheduling a timely appointment if they aren't successful," she says.
