Community Programs: A State Focus on Under-served Populations Sheryl Garland Administrative Director Office of Ambulatory Care Medical College of Virginia Hospitals and Physicians Virginia Commonwealth University November 22, 1999

The Challenge One of the largest challenges in the health care industry is providing care for the 43 million uninsured in the U.S.

Across the country initiatives are being developed to: Obtain coverage for the uninsured by changing institutional policies and programs Increase access to services at the local level Focus on prevention and public health “ Action Where It Counts: Communities Responding To The Challenge of Healthcare For The Uninsured,” The Access Project, June, 1999.

RWJ Access Project A recent survey conducted by the “Access Project,” an initiative of the Robert Wood Johnson Foundation, revealed that the majority of organizations engaged in healthcare access efforts at local levels are participating in partnerships or coalitions to meet their goals.

Safety Net Hospitals “Safety Net” hospitals and health systems across the country are struggling to provide quality health care to low income and vulnerable populations during an era of shrinking reimbursement and limited federal government intervention.

Community Responsibility “Safety Net” hospitals and health systems have a collective mission of providing care to patients regardless of their ability to pay. In addition, these providers often have responsibilities to their communities that go beyond the delivery of direct health care services

NAPH The National Association of Public Hospitals and Health Systems (NAPH) is an organization that advocates and represents the nation’s urban safety net providers.

NAPH members strive to meet the key needs in their communities, such as: Providing inpatient and outpatient care to Medicaid and Medicare beneficiaries, the uninsured, and underinsured Playing an essential community role in providing specialty and tertiary level services Training a large portion of the nation’s health care professionals

Initiatives Initiatives that have been implemented by NAPH members are diverse in scope and service

Initiatives include programs that: Expand ambulatory care Focus on disease management Are unique to targeted populations Represent health outreach initiatives

Initiatives include programs that: (cont’d) Deal with injury or violence prevention Address teen pregnancy Focus on process improvement and enhanced quality patient services Promote healthy communities

MCV/U.VA Uncompensated Care As you are aware, the University of Virginia (UVA) and the Medical College of Virginia Hospitals of Virginia Commonwealth University (MCVH) receive funding to provide care to the uninsured in the Commonwealth of Virginia

MCV $90 Million In FY 1998, MCVH provided over $90 million in indigent care to patients

Number of Patients (unique inpatients) by county FY98 2,740 to to8, , Inpatients Fiscal Year 1998 VCU’s Academic Health Center is a State-wide Resource

Source: MCVH Fiscal Services for MCV Hospitals MCVH and MCVP Total Costs Indigent Care Projected FY99 Entire Commonwealth by County VCU’s Academic Health Center State-wide Distribution of Indigent Care Costs Indigent Care Cost in Dollars Projected FY99 MCVH and MCVP $48,300,000 2,000,001 to10,000, ,001 to2,000, ,001 to700,000 1 to10,000 10,001 to150,000 0

Carilion Inova Sentara MCV Hospitals & Physicians 2.77% 2.30% 2.15% 3.07% 18.3% State Overall 1997 Charity Care as a Percentage of Gross Revenue VHS Cost Review Council’s Definition of Charity Care: Charity Care represents (unreimbursed) charges to individuals with incomes less than 200% of the federal poverty level and payments to or from the Virginia Indigent Health Care Trust Fund. Source: 1998 Virginia Health Services Cost Review Council Annual Report; 1998 Data for (MCV Hospitals & Physicians Unreimbursed Charges are FY 97 Data) 13.30% UVA

Carilion Inova Sentara MCV Hospitals & Physicians 1997 Percentage of Entire Charity Care for the Commonwealth VHS Cost Review Council’s Definition of Charity Care: Charity Care represents (unreimbursed) charges to individuals with incomes less than 200% of the federal poverty level and payments to or from the Virginia Indigent Health Care Trust Fund. Source: 1998 Virginia Health Services Cost Review Council Annual Report; 1998 Data for (MCV Hospitals & Physicians Unreimbursed Charges are FY 97 Data) 4.54% 10.83% 31.17% 5.44% 17.45% UVA

Community Initiatives In addition to the health care services provided by hospitals and health systems across the state, a host of community initiatives have been developed to support the needs of the uninsured population throughout the Commonwealth.

VHCF Several noteworthy projects have been identified and funded though the Virginia Health Care Foundation (VHCF).

These projects include: Free Clinics (medical and dental) Mental Health initiatives Case management for targeted populations Outreach activities Programs to assist patients in obtaining prescription medication

MCV Priority Despite the increasing demands, MCV Hospitals and Physicians continue to maintain as a priority provision of quality health care services to the uninsured of the Commonwealth.

The Headlines Richmond Times Dispatch April 11, 1999

Hayes E. Willis Health Center of South Richmond Partnership with the Richmond City Department of Public Health (RCDPH) to integrate public health clinical services into a primary care center Community-based health center that offers Family Medicine, Women’s Health and Pediatric services on-site Pharmacy that received funding support from the Jenkins Foundation Financial and Medicaid/ CMSIP eligibility screening at the Center

Hayes E. Willis Health Center of South Richmond (cont’d) Laboratory on-site, with computer linkages to the MCVH Reference Lab to obtain test results in a timely fashion The Center has grown from 8,000 patient visits, in it first year of operation, to a projected volume of over 15,000 visits in the current fiscal year Community Advisory Board provides assistance in establishing the goals for the Center

RCDPH/MCVH Clinical Services Agreement In July, 1998, the RCDPH contracted with MCVH to provide public health clinical services for Richmond City residents Communicable Disease Services (STD, TB, etc…) General Relief, Immigration and Refugee Services are provided in one location

RCDPH/MCVH Clinical Services Agreement (cont’d) Women’s, Children’s and Family Planning Services have been integrated into primary care locations A population of approximately 5,000 patients was identified and the “City Care” program was established

RCDPH/MCVH Clinical Services Agreement (cont’d) Community physicians participate in this program to offer patients the option of being cared for in a location close to their home

Goals of the RCDPH/MCVH Clinical Services Agreement To provide quality health care in the most appropriate site of service Reduce redundancy of services Reduce the overall cost of providing healthcare to residents in the City of Richmond

The Jenkins Foundation Care Coordination Program In January, 1999, MCVH and the RCDPH collectively received funding to support a partnership to coordinate services for uninsured City of Richmond residents A collaborative team of Nurse Case Managers, Care Coordinators, and Outreach Workers has been developed to “catch patients who fall through the health care system”

The Jenkins Foundation Care Coordination Program (cont’d) Populations that have been targeted are adults and children who are City Care patients or those who are diagnosed with the following: –Pregnancy-related disorders –Asthma –Diabetes –Upper Respiratory Infection –Otitis Media

The Jenkins Foundation Care Coordination Program (cont’d) Teams of health care providers are developing non-traditional interventions to support these populations

Management Strategy of the Jenkins Foundation Care Coordination Program: To link the patient to appropriate medical resources, which include but are not limited to, applying for health care benefits, selecting a primary care provider, getting the patient to the provider, encouraging appropriate use of the medical services at the appropriate time, and providing health education in order to help the patient obtain the greatest health care benefit

Management Strategies (cont’d) Directing the patient to a financial counselor for screening Identifying the Primary Care Provider Arranging transportation Directing the patient to use the appropriate level of care for the episode of illness

Management Strategies (cont’d) Helping patients understand their illness Reinforcing teaching Answering questions Clearly reinforcing treatment plan

Objectives for the Program Work with identified patient populations Care Coordination will provide a service Utilizing the Richmond City Department of Public Health Nurse Case Manager and Outreach Workers, along with community resources Manage the underinsured and uninsured Richmond City population

Program Goals Increase appropriate utilization of health care services Increase health knowledge of health care issues Build internal and external alliances to support the patient population

Alternative Care Program Established by the Division of Quality Improvement to assist patients who encounter barriers at the time of discharge from the hospital The program allocates funds to support DME needs that patients cannot obtain due to financial constraints (i.e., hospital beds, infusion pumps, etc…)

MCV Care at Home This Home Care agency was developed to support the post-discharge needs of the MCV Hospitals’ patients

Goals of the MCV Care at Home program include: reduction in the inpatient length of stay reduction in overall costs to the healthcare system provision of alternative health care options for uninsured and underinsured patients

A Health System? VCU/MCV Hospitals and Physicians are in the process of seeking approval to establish the VCU Health System

Goals of the VCU Health System Identification of mechanisms to reduce costs Development of enhanced contracting opportunities Management restructuring to reduce organizational redundancies

Managed Care? VCU/MCV Hospitals and Physicians are exploring the feasibility of developing a managed care program for uninsured patients

Survival? Like many academic medical centers, VCU/MCV Hospitals and Physicians are working to develop the ventures to ensure the survival of the organization