1. Workshop IIIC: Helping the Un & Underinsured through the Public Health Maze LATCH Local Access To Coordinated Healthcare September 23, 2008 Susan D. Yaggy, Chief Division of Community Health Department of Community and Family Medicine Duke University Medical Center

2. Duke Community Health Created as a Division of the Medical School in 1998 with a staff of 2 Collaborative community-based services Programs created with extensive community input often a year in planning Multi disciplinary; multi-agency

3. Preceding LATCH 3 school-based clinics: 1 high school, 2 elementary Minority health careers Primary care with FQHC for homebound: diabetes, HTN, asthma Dental van with Health Dept and schools Large Medicaid care management programs: –10,500 enrollees (now 20,000) in Durham –Non-clinical staff –Deliver education, advocacy, follow-up on clinic care, navigation in homes

4. LATCH History Launched: January 2002; Healthy Communities Access Program (HCAP) funding from US Health Resources and Services Administration (HRSA.) To improve access to health services Improve health status for Durham County’s growing uninsured/ underinsured Latino immigrants. Over 300 patients waiting on opening day.

5. Open to any: Durham County residents who is un/underinsured – no means testing Referred by local health and social service providers and self-referrals Since 2002, over 14,000 referrals and nearly 11,000 enrolled patients

6. Enrollee Demographics 41% Male, 59% Female Race/Ethnicity: Hispanic/Latino (>96%) Employed in low-wage industries (construction, landscaping, restaurants, housekeeping, childcare) Average <7 years in US

7. Barriers No knowledge of health system Do not speak (any/much) English. Some speak indigenous languages Lack of available childcare Lack of reliable/available transportation Low/no literacy No phone; 30 day phone Cultural differences re: health and prevention Documentation status; fear limits care-seeking and follow- up

8. What LATCH Brings: Individual/Family Approach Case management Patient navigation – health and social services Health education Community outreach - delivered in neighborhoods and at home Care managed (electronic information system) Culturally and Linguistically competent staff Primary outreach through El Centro Hispano, a trusted community resource

9. LATCH Services Home Visits (program orientation, needs assessment and risk stratification) Health Services Orientation/Coordination (PCP/medical home, urgent care, specialty, ER) Referrals and Facilitation (appointments, directions, accompaniment) Medication Access and Compliance/education Bills Assistance (Self-Pay Payment Plan, Medicaid and Duke Charity Care applications) Some Chronic Disease Management (asthma, hypertension, diabetes, depression, pregnancy, etc.) Prevention Education Advocacy Interpretation/Translation Limited Transportation

10. Enrollment Medical and Social Service Providers Walk-in enrollment -- El Centro Hispano Self-referrals By fax, phone or in- person Fax Referral/Consent Form with patient signature

11. A Working Consortium to Resolve Access Barriers El Centro Hispano Lincoln Community Health Center Durham County Department of Social Services Durham County Health Department Planned Parenthood Catholic Charities Durham City Parks and Recreation Center for Child and Family Health Immaculate Conception Church Duke University Medical Center and Health System Duke Private Diagnostic Clinic Duke University Hospital: Latino Health Project Durham Regional Hospital

12. Some Recent Consortium Successes HIPPA firewall blocking Emergency Medicaid enrollment Billing and payment plan services not in Spanish Health Dept. pregnancy confirmation requirement by MD Literacy level on patient payment materials Transportation system issues with DSS Birth certificate—father’s ID

13. Program Support Funding: HRSA funding ended in April ’06. LATCH now supported by DUHS FY09 budget: $299K LATCH staff: –Program Coordinator –SW (DSS contract) –.5 health educator –3 CHW’s –.5 secretary –And administrative support from Division of Community Health

14. LATCH outcomes Phone survey (n=225) in summer 2005 (225 of 485 completed phone survey – 46% response rate) All participants born in Latin America and lived in US < 7 years More intensive case management going to: –Clients who lived in Durham longer (7 vs. 6 years) –Clients who needed health care but could not get it 80% reported having a “usual source of care” ED use from 2004-2005 reported decrease: 32% (unweighted) to 21% (unweighted)* after controlling for health and demographic characteristics (*p<0.01)

15. LATCH outcomes, con’t.

16. 2008: Making LATCH a Base to Grow Systems of Care for Un/Underinsured HealthNet: State grant through Medicaid Care Management: –Re-enroll 700/mo. who “fall off” Medicaid/sCHIP –Campaign for consistent surname $174K –Staff – health educator Subcontract: El Centro Hispano: SEPA $80K –Latino Stroke prevention –Screen/Educate through El Centro Hispano –LATCH to provide education/care management for patients with stroke risk factors –Staff – health educator

17. 2008: Making LATCH a Base, con’t. Project Access of Durham County: $299K – All-share system for specialty care – LATCH to provide navigation, support and disease management – New: RN, SW, CHW, p/t secretary and IT

18. In closing, we are learning The strength of our coalition and capacity to eliminate barriers The ability of our patients to adapt to a new (and difficult) environment How to pull together all local resources to focus on a population How to change patterns of care – seeking and create medical homes for un/underinsured patients

19. Thank you. Contact: Susan D. Yaggy Chief, Division of Community Health DUMC Box 2914 Durham, NC 27710 (919)681-3187 yaggy002@mc.duke.edu