In accordance with the Florida Department of Health mission to reduce spending and achieve fiscal responsibility while protecting, promoting and improving the health of all people in Florida, the Florida Department of Health (FDOH-Seminole County) in Seminole County conducted reviews to assess programs for fiscal solvency.
The Refugee Health program is not a mandated service for the Florida Department of Health; however, it provides a vital service to the clients and the community by providing screening and vaccination of refugees for communicable diseases. The initial review revealed several key areas that would require improvement if this program was to become self-sustaining and fiscally solvent. As a non-mandated program requiring State general revenue for support, there was considerable concern over the county health department’s ability to continue providing these services. The team determined we needed to increase our revenue and our clientele to become self-sustaining.
The goal was to develop greater partnerships with our community referral sources. These non-governmental agencies are responsible for referring ninety five percent of our refugee health clients to us for assessments and vaccination services. We needed to improve communication and to increase the availability of appointments to achieve this. Our initial scheduling only allowed for Refugee Health visits two days a week. This schedule was expanded to provide daily appointments.
The registration process started with simple appointment setting. This process was improved by developing a notification tool that captured all the necessary information for patient registration. The length of stay for the clinic appointment was decreased by providing all services in the Refugee Health clinic, including lab, immunizations and the nursing assessment. Previously, the length of the initial visit was up four hours. The time of the visit was reduced to between one to two hours total visit time. Streamlining processes and consolidating services resulted in the provision of a thorough screening, comprehensive testing, and immunizations for an increased number of clients in a decreased length of time.
Most of the Refugee Health clients rely on the referral agencies for transportation to and from the clinic. Coordinating our efforts to receive the client referrals was necessary to be considerate of the client’s time and the transportation agency’s schedule. Reducing the appointment time is beneficial to the clients and the agency transporting. Next we identified a need for consistent and timely billing for reimbursement of services if we wanted to sustain the program and become self-supporting. This billing is now entered daily and completed for submission at the end of each week. The office of Refugee Relocation downloads this information at the end of each month to determine financial reimbursement. Prior to planning our program improvement there was no formal collection of data or statistics in the local FDOH Seminole County Refugee Health Program.
We have been collecting data since beginning our improvement efforts. As a result of our improvement efforts the Refugee Health Program at FDOH-Seminole County has increased the number of clients served and the amount of revenue by 400%.
The Florida Department of Health in Seminole County (FDOH-Seminole County) is a subsidiary of the Florida Department of Health. Located in Central Florida, FDOH-Seminole is one of sixty-seven counties that provide public health services in local communities. Seminole County has an approximate population of 431,074 residents. The total of this population that is reported at age 16 years or older is 80%. The total of this population that is reported to be living below the poverty level is 10%. The ethnicity demographics of the county includes a population of 66% White, 17% Hispanic, 11% Black, 4 % Asian, and 2% Multi-Racial. Seminole County is ranked fourth out of sixty-seven counties in the state’s County Health Rankings.Refugee resettlement is a public/private partnership. In the United States, federal and state agencies work with non-governmental organizations (NGOs) to provide effective and coordinated resettlement and integration services to refugees. Each state has a designated agency to administer and monitor refugee program activities within its jurisdiction. In Florida, the Department of Children and Families (DCF) has this responsibility, but has designated the responsibility of administering refugee health services to the Department of Health (DOH) Refugee Health Program (RHP) through a signed Memorandum of Agreement. Refugee Medical Assistance (RMA) funds are received from DCF and distributed to the county health departments (CHDs) by the Bureau of Family Health Services and the Bureau of Revenue Management. Groups eligible for refugee programs and benefits include: refugees, asylees, Cuban/Haitian asylum applicants, Cuban/Haitian entrants, Amerasians, Afghan and Iraqi Special Immigrants and certain victims of severe forms of human trafficking. In federal fiscal years 2011/2012, 177,647 refugees, entrants, and Amerasians were admitted to the United States for resettlement. Florida was the initial resettlement state for approximately 24% of these individuals, receiving more than twice as many arrivals as any other state. Four percent of these refugees were resettled in Central Florida It is imperative that communicable diseases, such as tuberculosis (TB) and sexually transmitted diseases (STDs) are diagnosed and treated promptly to protect the health of the refugees and all Floridians. It is equally important to identify chronic disease indicators and to educate clients in healthy lifestyle choices or to refer them to primary care providers for management as quickly as possible.
Refugees entering this country have 90 days from the date of arrival to receive Refugee Health Program services. Due to ineffective scheduling and decentralized services, many clients were not meeting the deadline to obtain these services in our county health department. The program was established in 2008 and had not been reevaluated since inception. Our new clinical processes are improved because they meet all expectations for timeliness and comprehensiveness. While this new process is not necessarily innovative, it is certainly evidence based and meets guidance from the Refugee Health Program for screening and assessment and the Centers for Disease Control and Prevention MMWR recommendations for communicable disease testing, management and treatment.
The goals and objectives of our practice are simple: to deliver a comprehensive nursing assessment and screening tool for communicable and chronic diseases, and to vaccinate clients to prevent the spread of diseases within our community. FDOH-Seminole County seeks to deliver this service within the 90 day requirement of the Refugee Health Program to no less than 95% of all refugees that are resettled in Seminole County. Our Refugee Health Clinic will continue to establish strong partnerships with our community nongovernmental organizations, stakeholders, and residents.Prior to our new practice, FDOH-Seminole County was screening a maximum of 100 clients per year with an average number of two to four visits per week and a length of appointment time of three to four hours. Clients would return to the clinic at least three times during the first month for follow up appointments. The potential to provide services for more clients was not being met due to a limited schedule. Services were not provided in a timely manner because clients were being directed to different clinics for portions of the visit. They went to the immunization clinic for vaccinations, and to the main clinic lab for venipuncture and testing. This reduced the number of clients scheduled and the practice was not client centered. The billing practices were without structure or deadline. Assessments were entered into the billing portal at the registered nurse’s leisure. Often times the program would be reimbursed in March for an assessment that was performed in January. The low volume of clients and inconsistent billing method resulted in annual revenue that was equal to $27,000 or one third of the registered nurse’s salary in the Refugee Health program.
The first step to improve the Refugee Health program was to expand the clinic hours to five days a week. Second, one of our small rooms was refitted with laboratory equipment and supplies for phlebotomy. The Tuberculosis (TB) nurse agreed to provide the phlebotomy for the clients. Third, vaccine was obtained from the immunization department and a refrigerator for storage and handling was procured from our warehouse and placed in the clinic. Clients no longer needed to leave the Refugee Health clinic area for any of the required services; “a one stop shop” process was created. This reduced the client visit for the Refugee Health Assessment by two hours.
Following the Refugee Health Program guidelines, the Refugee Health Assessment form was adopted and use of the previous form, that was created in house, was discontinued. The new assessment form follows the flow of the billing portal. This makes service entry more fluid and decreases the opportunity to miss entering any services that were provided.
Routine billing expectations and requirements were established. We separated the responsibilities to allow the Refugee Health Registered Nurse to perform client assessments in the morning, as the clients are fasting for labs. In the afternoon we schedule appointments for second visits, additional vaccinations and billing. Specific duties and responsibilities were further divided among the staff members to achieve this goal. The clerical and scheduling responsibilities were assigned to the support staff. The electronic lab entry was assigned to the clerical staff and the Registered Nurse enters the assessments in the Refugee Health Domestic Assessment System (RDHAS) for billing reimbursement. The billing information is entered by the registered nurse in the afternoons. The new expectation is that all billing is completed by the end of each week.When we succeeded in increasing the clinic appointment availability and decreasing our wait times the non-governmental community referral agencies became eager to bring their clients to FDOH-Seminole County for Refugee Health Assessments. In our effort to meet the demands for appointments and maintain our goal of providing services within one to two hours we developed a communication and notification tool for the referral agencies. This form was designed to capture all of the information needed to pre-register the clients and to verify their eligibility. This tool is faxed to the clerk after the appointment is made. By faxing the information prior to arrival it decreased the registration time when the clients arrive in the clinic on the appointment day. The current process provides them with an opportunity to review the information and make any corrections as needed upon arrival. The time saved is generally 30 minutes of registration time. The case managers from the nongovernmental referral agencies will call to make the appointment then they fax the completed form and all of the necessary documentation to the support staff and clerical staff. The program staff assistant enters the information we have received into the Health Management System (HMS) prior to the client’s arrival. The Staff of our program is acutely aware of the need for a strong relationship with our community non-governmental referral agencies. These agencies are the resource from which we receive the clients for assessments and services. FDOH-Seminole County understands the need to provide good customer service that promotes satisfaction. These clients are likely to continue services with our agency if they are treated with respect and value from our first encounter. We also view our referral agencies as clients. We seek to meet their needs and treat them with the same respect and value.
FDOH-Seminole County has worked diligently to establish a relationship with our community agencies. The staff insures that all calls are returned within 24 hours and confirms the clients are eligible for services prior to scheduling appointments. The Refugee Health Program in Seminole County has attained a reputation within the referral agency community of caring for the clients by making them feel at home and welcome. The refugee children are often provided with a token such as a coloring book or picture book, or even a backpack for school or other items donated by local organizations, such as bicycle helmets and additional school supplies. The Refugee Health Assessment is oftentimes the first exposure to health care in the United States for our clients. We want their experience to be a positive one so it promotes a lasting partnership with these clients and the healthcare system.
FDOH-Seminole County Refugee Health Program is currently screening up to four clients per day with an average of 40-50 clients per month. The length of each appointment is one to two hours. The clients return to the clinic only once for follow up in 30 days if all of their test results are normal. Services have been successfully provided to 100% of the clients resettled in our county and a significant number of the clients settling in neighboring counties that would not have met the deadline for assessment through their own County Health Departments.All of the adjustments and improvements made to the Refugee Health program were relative to current staff and utilized resources that already existed. No additional staff was hired and the increase in supplies is proportionate to the increase in services. Currently our billing reimbursement of services is $25,000-$30,000 monthly. The total reimbursement for fiscal year 2012/2013 was $316,195.00. This amount was enough to fully fund the Registered Nurse position, Health Services Technician position and half of the Staff Assistant position. The Refugee Health program did not utilize any general revenue for fiscal year 2012/2013. The number of clients presenting for Refugee Health Assessments has grown from an average of 10 per month in fiscal year 2009/2010 to an average of 40 per month in fiscal year 2012/2013. In addition to this the billing for reimbursement has increased from $27,000.00 annually in fiscal year 2009/2010 to $317,195.00 in fiscal year 2012/2013. This has successfully reduced the need for supplemental general revenue to support this program. In fiscal year 2012/2013, all of the expenses and salaries for the Refugee Health Program were met with the revenue generated by the services provided to the clients. The Refugee Health program has become fiscally solvent and the level of care for our clients and our community has been elevated in the process.
Providing communicable disease screening for these recent immigrants provides a vital service to our community and our citizens by keeping them safe from infectious diseases. Providing immunizations to these clients also has universally accepted economic benefits as it reduces the potential for communicable disease outbreaks which are costly for State Health Departments. In addition, Dr. Edward Armstrong notes, “one single case of measles is estimated to cost 23 times the amount spent to vaccinate one child and for every dollar spent on diphtheria-tetanus-accellular pertussis vaccine, more than $24 dollars is saved .” In fiscal year 2011/2012, 150 Tdap vaccinations at a cost of $30 each were administered, equating to $4,500 spent and $108,000 potentially saved. The Refugee Health Assessment also screens for chronic diseases through routine lab work and body mass index calculation. Early detection and management of hypertension, diabetes, and high cholesterol can result in substantial savings to the state in future health care costs. Florida ranks among the top states with the highest incidence of deaths due to the five major chronic diseases. Our county and community stakeholders benefit from this process directly and indirectly. The reduction in general revenue funding to support the program positively impacts state taxpayers and the state budget by reducing expense. By vaccinating the new immigrants according to the current CDC recommendations and identifying chronic disease indicators for obesity, diabetes and heart disease; communicable and chronic diseases can be effectively reduced through prevention and early intervention.
The success of the Refugee Health program in Seminole County is greatly attributed to our relationship with the referral agencies. Our willingness to accommodate their needs and provide comprehensive timely service makes FDOH-Seminole County their first choice when scheduling clients for Refugee Health Assessments.Our data is collected through several statewide sources. The Health Management System (HMS) is used to record services delivered and client appointments. A RDHAS (Refugee Health Domestic Assessment System) billing system and FIRS (Financial Information Reporting System) accounting system are also used. Monthly visits and reimbursement statements are received from the state Refugee Health Program.
The cost/benefit analysis for fiscal year 2012/2013 is: Cost: $259,160.00 (salary expense)/443 clients = $585.00/client Benefit: $316,195.00 reimbursement (revenue)/443clients = $713.00/client FDOH-Seminole County continues to modify and improve practices in the Refugee Health program as further areas of opportunity are identified. The sustainability of Refugee Health services is dependent on the number of refugees resettling in our geographical location and the continued congressional funding of the Refugee Resettlement Act of 2008. Recently the federal government suspended operations due to federal budget issues. Our schedule was immediately affected by the freeze on new entrants to the United States. This fiscally solvent and self-sustainable clinic practice can be maintained indefinitely as staffing is minimal and easily duplicated in other clinical settings.