DuPage County Health Department is a local health department in DuPage County, Illinois. DuPage is the second largest county in Illinois, sitting directly west of Cook County; the state’s most populous county. Within its 336 square miles, the US Census Bureau in 2013 had estimated the population to be 932,126 residents, a 19.2 percent increase from 1990 (1, 2). Additionally, between 1990 and 2013, the Hispanic population increased by 275.4 percent and the Black population increased by 175 percent; there was a 124.3 percent increase in the 55 to 59 age group and a 162.4 percent increase in the 85 years and over age group; and, the DuPage portions of Aurora, Bartlett, Wayne, and West Chicago also experienced significant increases in population (1, 2). Between 2000 and 2009, the total number of births decreased by 25 percent, while the DuPage Hispanic birth rates were nearly double the overall birth rates in DuPage (1, 2). The DuPage County foreign born population increased by 24 percent between 2000 and 2013 (1, 2). Unemployment rates rose to a 10 year high of 8.4 percent in DuPage County in 2009, but have decreased since then and the unemployment rate in 2013 was 7.5 percent (1, 2)
DCHD is a certified local health department that obtained accreditation from the Public Health Accreditation Board (PHAB) in June 2014. The array of direct clinical services offered by the health department include behavioral health, maternal child health, adult health, and oral health services. Some of our successful preventive interventions include: Fighting Obesity and Reducing Weight Among Residents of DuPage (FORWARD) - a program to address childhood obesity through schools, RxBox – designated prescription drug drop off boxes to decrease prescription drug abuse, and the DuPage Narcan Program – a collaborative community effort to reduce the number of deaths attributable to Heroin overdose.
In addition to fulfilling the role as a healthcare safety net throughout the county, DCHD has also worked to assist its residents with completing benefit applications to ensure adequate access to health services and resources since 2005. Building off this foundation of assurance, and the growing need highlighted by the implementation of the Affordable Care Act, DuPage County had continued to work toward the goal of linking people to needed personal health services and the provision of health care when otherwise unavailable. The health department, along with other local health care systems and organizations, such as the DuPage Health Coalition (DHC), aims to address the growing need of this county-wide issue of inadequate access to quality health care; no longer looking for a solution in isolation, but as a collective for the benefit of the county’s residents.
By early 2013, through this joint effort, one of the area hospitals, Central DuPage Hospital (CDH), provided the data analysis conveying top ED diagnoses and costs of uncompensated care to begin to understand where and how this issue should first be addressed. Members hypothesized that through outreach and addressing social determinants within this patient population, three things could happen:
• the amount of uncompensated care could be reduced,• the number of ED visits by frequent users would decrease, and • the intervention would be sustained through cost savings.
This instantly appealed to the hospital as a partnership with community organizations would help them address their ED cost and usage.
The issue of ED over-utilization was not an isolated issue to DuPage County, Illinois. In fact, roughly 1 in 9 patients utilize the ED as a medical home and may be eligible for health care benefits (3). Utilization of ED services can result in inefficient use of health care resources and suboptimal health outcomes. Overuse of the ED results in approximately 38 billion dollars in wasteful health care spending annually, where more than half of these visits are potentially avoidable (4). Contributing to this issue is the patients’ lack of knowledge or health literacy. CDH found that only 20 patients accounted for more than 250 ER visits in 2012. Increasing access to primary care can be effective at reducing misuse, and adding more Case Managers and Community Health Workers to the workforce can help connect patients to insurance and a medical home.
The project goals set out at the inception of Engage DuPage were:• improve the health status of self-pay ED patients• increase the revenue appropriately owed to hospital for services rendered,• improve the financial assistance processes involving self-pay ED patients, and• reduce the number of avoidable ED visits among self-pay patients.
These top goals align with the Triple Aim approach of providing better care, better outcomes and maximizing resources. After a 12-month pilot, the program has expanded to include 2 additional hospital partners including 2 emergency departments and 1 inpatient department. Favorable outcomes continue to grow, enabling a number of success stories.
Setting the stage for this intervention is a history of local collaboration among health care entities. In 2001, DuPage County developed a program called Access DuPage that included a collaborative partnership of 14 organizations and other health/human service and governmental institutions including 6 local hospitals, the health department, the County, the DuPage Federation on Human Services Reform, the DuPage County Medical Society and other local providers. This started as an access to care program placing eligible consumers with a medical home. Funding for the program was provided by DuPage hospitals and grants.
The partnership with the Access DuPage (AD) Program has provided value in the demonstration project by connecting low-income, uninsured, and undocumented DuPage County residents to primary care. AD has a history of assisting underserved DuPage County residents with access to appropriate care settings. Prior to the implementation of Engage DuPage, not all appropriate self-pay Emergency Department patients were given an Access DuPage referral from ED staff. Although most all of these patients were given a financial assistance application, it was not standard practice to ensure an AD referral was made to those eligible patients.
Recently the Journal of Community Health published a study that evaluated AD health care utilization, satisfaction, and health status outcomes for recent enrollees compared to individuals who had been in the AD program for at least one year. The study showed that providing any access to care for uninsured, low income populations improves health status and health outcomes. According to Feinglass, “Access DuPage enrollment greatly improved access to health care and perceptions of health status. Established enrollees reported more clinical preventive services utilization, fewer cost and transportation barriers, greater ease interacting with health care providers, and higher ratings of health status and health care received” (5). This research demonstrates the value of the AD program to their membership population.
Participants in the Access DuPage program have additional access to prescription medications compared to uninsured patients. Since Access DuPage members, and the uninsured generally, have a disproportionately higher number of chronic diseases compared to the general population, greater access to prescription medications has a positive impact on their health, and a corresponding dampening effect upon their utilization of avoidable health care services.
It was determined that 72 percent of Access DuPage patients have been approved within 30 days of application submission. The average approval time, from the date of initial engagement in the ED to Access DuPage approval, was approximately 46 days. The average time from application submission to approval was approximately 24 days. The collective effort provided another opportunity to demonstrate the value and progress of public-private collaborations.
This focus on application assistance with programs such as Access DuPage highlighted a gap in linkage of patients to primary care providers and related services. The population served also required more intensive case management services. The Engage DuPage program aims to provide the client access to health care coverage while also assuring connections to providers and services. Identifying the target audience for the Engage DuPage initiative included research from each of the partnership organizations. The criteria had been narrowed down to four specific areas: • low-income, now eligible for expanded Medicaid under the ACA,• a diagnosis indicating automatic eligibility for specific benefits (i.e. medical necessity, pregnancy, oral health),• a diagnosis indicating mental health, substance abuse, and/or oral health needs (targeted as DCHD has capacity to provide direct clinical service), andfrequent ED users.
The innovative concept of placing DCHD engagement specialists directly within the hospital ED provided an ideal setting to initiate interventions with this target population. Engage DuPage staff work in three distinct phases: identification, engagement, and follow-up. Working with the ED staff, the Engagement Specialists identify their patients by utilizing information from the hospital EMR, learning of their uninsured status, and other factors to support the intervention. Once identified, the Engagement Specialist, gaining permission to speak with the patient, will initially interview the patient, complete an eligibility screening, and then schedule a follow-up meeting. Perhaps one of the most crucial phases occurs next with the follow-up appointment. This is where the Engagement Specialists will meet with patient at DCHD offices, at a public setting, or even in the patient’s home. The ultimate goal and point in which success can truly be measured is when a patient is able to transition to a primary care provider, become linked to needed health care services, and/or complete a benefiting application for needed health coverage.
During the planning phase, outreach to existing evidence-based programs in California provided insight that can be used for informal comparisons. For example, program administrators described a 25% patient uptake rate to the program as well as ED staff resistance to the partnership. However, in this project we have experienced closer to a 50% patient uptake with a positive reception by Central DuPage Hospital ED clinical and registration staff.
The initial planning phase lasted approximately eight weeks from the assignment of a project manager to day one of operations. During this phase, representatives from each partner provided input on developing project goals and identifying the target audience. The hospital reviewed the self-pay patient ER data to further plan program specifics like the days, times, and contacts. The initial staff needs for this pilot were discussed including the necessary onboarding and training steps. The representatives from each partner identified key staff contacts across hospital and health department. The approach for project evaluation included identification of specific program metrics to best track progress.
In addition to increasing access to care for members throughout the community, this partnership between the hospital and the health department lead to an increase in the workforce development. The staff requirements for this intervention included professional experience in case management and public benefits, and familiarity with community resources and local social service programs. The health department staff that qualified for this pilot included those staff previously designated as client benefiting specialists and intake specialists. A customized training was developed for these employees to fulfill more of a Case Manager or a Community Health Worker role. This approach allowed the partnership to utilize a cost-effective personnel resource for the care coordination. The training of the staff involved both State and Federal ACA modules, obtaining licensure as Certified Applications Counselors (CACs), EMR cross-training of both DCHD and the hospital, Public Benefits Training from DuPage Federation, crisis prevention and mental health first aid, and Emergency Room cultural awareness to better prepare staff for any circumstance they may encounter in the ED.
After planning and staff training, it was time to implement the pilot at the hospital location. Implementation of the 12-month pilot phase started in August 2013. The project was initially funded by Central DuPage Hospital and the DuPage Health Coalition. The pilot consisted of 2.4 full time employees from DuPage County Health Department, working 32 hours per week onsite in the ED. Once in the ED, staff were provided with general guidelines to assist putting the Engage DuPage process into practice.
For the pilot, data was compiled on a monthly basis to measure the following:• number of contacts made through the ED, • number of patients interested and eligible, • number of kept follow-up appointments • number of benefiting applications submitted and approved, • number of patients connected to benefits, primary care physicians, and/or DCHD programs.
The initial demonstration project was funded for a 12 month period with a total amount of $150,000 in seed funding to launch the program.
This initiative has promoted and refined a cooperative relationship between public-private healthcare providers with common goals of improved access to health services as well as improved health outcomes; an increasingly important competency for both partners. This experience demonstrates that a collective approach to caring for our shared patient population can deliver the greatest impact, resulting in patients accessing care in the most appropriate settings. Ongoing funding will allow for further examination of the cost-effectiveness of the partnership, a greater ability to track the health status of individual patients, the opportunity to capitalize on the completed ramp-up, and to build on the initial success demonstrated by this collaborative effort to date. The lessons learned thus far indicate a positive contribution to the health care system patient care approach and the promise of greater outcomes given the opportunity to further grow the program.
After an evaluation of the pilot program, the DuPage County Health Department, along with its valued partners from the DuPage Health Coalition and the DuPage Federation on Human Services Reform, recommended continuation of the Engage DuPage Demonstration Program and program expansion in the form of increased presence at CDH-ED and/or extension to other facilities within DuPage County. DCHD advocates for the program model to be adopted into county-wide service delivery strategy to support patient access to long-term coverage options and primary care.
Once the pilot was complete at Central DuPage Hospital, CDH agreed to another year to assure the continued success of the program. Another interested, area-hospital, Advocate Good Samaritan, began implementation of Engage DuPage beginning October 2014. Engage DuPage staff increased from 2.4 FTEs to 5 FTEs on rotating shifts at both hospital locations within the four days a week on-site. When not working on-site in the EDs, the Engagement Specialists continued to meet with patients for the crucial follow-up appointments at DCHD, a public setting, or within the patients’ homes. Then, beginning January 2015, the most recent expansion came in the form of staffing yet another specialist within the inpatient department of CDH. 6 FTEs are now being utilized to share the case management of patients from all three locations allowing DCHD to provide a service that previously did not exist within local health care settings.
Observations/ Significant Findings: • Individual patient case complexity and the associated level of engagement necessary to effectively case manage were both underestimated in project planning. The project approach and expectations were modified to reflect this new understanding. • Successful linkage of patients to appropriate care settings required more comprehensive patient follow-up than planned. For example, multiple contact attempts and appointments were often necessary to simply establish benefits/insurance coverage. • The level of effort necessary to assist patients to successfully obtain benefits and establish a connection with a primary care physician was greater than expected; it often took multiple contacts, ED visits, and a period spanning multiple months to reach the desired outcome.• While the greater patient case complexity led to lower case volume projections, the evaluation metrics for the project were not revised. The agreed upon evaluation metrics from the initial planning phase included the following:o Number of patients interviewed/engagedo Number of patients applying for benefitso Number of benefit appointments scheduledo Number of benefit appointments kepto Number of financial assistance applications completedo Number of patients successfully enrolled for Medicaido Number of patients accessing PCP post-program enrollmento Number of patients linked to supportive/ancillary benefit programs (e.g., Access DuPage and SNAP)o Number of patients linked to DCHD programs or services (e.g., Dental, Behavioral Health)
Pilot Outcomes from one hospital emergency department:
During year one, the specialists met with a total of 1,249 patients. Fifty percent met program eligibility requirements. Of the 738 benefitting appointments scheduled, 69 percent were kept. In total, 441 applications were completed, and 84 patients have ultimately connected with a doctor by attending or scheduling an appointment.
2014 program outcomes from two hospital emergency departments:
1,222 patient contacts, of which, 611 patients were interested. 50 percent of the patients initially approached by an Engagement Specialist felt that the service would be useful. From these 611 interested patients, 896 follow-up appointments were scheduled and 68 percent of those appointments were kept. Resulting from the kept appointments 679 benefit applications were submitted. 304 linkages were made to a primary care physician and/or a DCHD programs.
2015 year-to-date program outcomes from two emergency departments and one inpatient department:
From January to September of 2015, the Engagement Specialists have made 2,229 patient contacts, of which 1,618 clients met program eligibility. 73 percent of patients initially approached were interested in the services provided by Engage DuPage. 1,580 follow-up appointments were scheduled, and 81 percent of those appointments were kept. As a result of the increased percentage of kept appointments, 1,197 applications were completed, and approximately 269 linkages have been made to a primary care physician and/or a DCHD program.
A number of patients have been identified as “Success Stories”; patients that the health department and the hospital feel have fulfilled one or more of the project goals.
Patient number one: Initially engaged in September 2014, suffering from pneumonia, bronchitis, and cardiac condition. Received benefits and care through Access DuPage in October. Approved for SNAP benefit; obtained assistance with food access; applied for expanded Medicaid in December to address potential gap in coverage. Approved and eligible for coverage effective January 1st, and was able to schedule open heart surgery late-March.
Patient number two: Initially engaged in November 2014, suffering from chronic pain, had been recently incarcerated. Obtained coverage through Access DuPage to address gap, then Medicaid as of January 1st. Has since received surgical care and physical therapy for back pain. Approved for SNAP benefit; obtained assistance with food access. Linked with DCHD behavioral health services, now receiving counseling and psychiatric services. Connected to WorkNet DuPage Career Center to apply for vocational training and job searching assistance.
Patient number three: Initially engage in December 2014, over-income for expanded Medicaid, received assistance with Marketplace enrollment, and obtained affordable coverage with Blue Cross and Blue Shield effective January 1st. Was able to immediately begin treatment for skin cancer in January.
Patient number four: Initially engaged in December 2014, suffering from major depressive disorder. Uninsured and recently learned of pregnancy. Obtained immediate health coverage through State MPE program. Also successfully enrolled with AllKids program within 30 days for long-term coverage. Linked to DCHD behavioral health services for depression needs as well as WIC for maternal/infant nutrition support
Need is evident. Contributing factors to the growing demand include:• Health care industry is undergoing massive transformation. (ACA, financial incentives, quality standards, etc.)• Hospitals facing higher standards/expectations in adjusting to Medicaid managed care rules/development• Insufficient ratio of providers to patients creating a niche for community health workers
Collaboration is key. Organizational buy-in from all stakeholders will determine the level of success of the program.• Identify internal champions from each partner organization • Identify staff needs from onset• Collective participation to best position our workforce leading to improvements in health outcomes
Alternative financing must be explored. As the program continues to grow, the need for financial sustainability is evident.• Exploring billing opportunities• Investigating grant opportunities • Continuing to develop relationships with local partners to increase effectiveness of community linkages
Challenges from the pilot phase. Gaining access to patient health information is necessary, otherwise it is difficult to identify individuals who frequently overuse the ED. • Multiple EMR systems requires staff to learn multiple systems.• Need to ensure access to all views, connectivity, and ability to match datasets for meaningful evaluation. • Identifying training needs to cover a wide variety of skills necessary for effective intervention and care coordination over time. • Educating hospital staff by creating awareness, developing relationships, and collaborating effectively. • Trying to change behaviors in a complex patient population by increasing health literacy and going through the stages of change. • Data analysis and evaluation can be difficult to truly measure improvement in health status due to EMR limitations, staff data entry inconsistencies, valid mechanisms to track patients and their use of the health care system.
Future Direction. Potential next steps for the program include the following:• Focus on highest-risk groups including the homeless population, drug and alcohol abusers, and frequent ED users.• Emphasize health literacy needs among patients by developing toolkits to increase knowledge on how to use newly obtained coverage.• Refine IT functions to increase efficiency and improve data analysis.• Expand Engage DuPage program with interested partners.
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