You must accept the patient for who they are, where they are in the season of life, and respect their cultural beliefs. By acknowledging their cultural believes, and their season of life, you gain insight, and trust. This may be the first time any health care professional has communicated with them in their native language. As the bond of trust is being formed, the provider, and clinic staff must always respect the individual as a fellow human being, not as a low income, uninsured non-compliant freeloader.
Over the last 3 years we have seen a series of changes in our program. It has opened our eyes to see that we lack the ability to understand the world as our patients do. Example, at a patient visit the provider was discussing the patients eating habits, and was somewhat stern manner. The patient broke down and begin to cry, say I can only eat what I have”. I live in a house with 5 families, in one bedroom with my family of 7. We are not allowed to use the refrigerator, or cook. Most all of our food is canned. The provider and nurse begin to cry. This patient had be administered the Personal Needs Assessment, but was not honest due to being concerned about legal status. Food stamps where in progress from the assessment for the children, but not approved as yet. The social worker was called to the visit and begin assisting with housing, food stamps and Medicaid for the children and any other needs.
The number one lesson learned is you need to speak the language, due to the loss of emotion, and miscommunication during translation. Continue to ask questions and interview your patients more than once. Involve the family, for support, and to determine if the entire situation is being discussed. Meet them at their level, and always show compassion and concern. You never know in this economy when you could be in the same situation.
The Costs and Savings analysis indicated a loss/ benefit from the initiative being examined. Meaning that there was a loss experienced due DCPH have no additional revenue stream from Medicaid or MOC's. The target population at DCPU are 100% uninsured low income. All Medicaid patients are navigated out to a medical home in the community.
The cost analysis does not take in to consideration the cost reduction in diabetic complications or reduction in hospital cost. With the Point of Care Testing and reduction in the DSRIP patients HBA1c hundreds of thousands of dollars have been saved. With the use of the Siemens International Healthineers Diabetic Management tool it is estimated that the current cohort of diabetic patient at DCPH have saved approximently $778,231.82 in complication cost. Not only has a dollar valued reduction, but an increase in quality of life with a reduction in loss of eye sight, loss of Kidney function, and loss of limb.
As the safety net for the uninsured of Denton County the lack of Medicaid revenue has an impact on the cost analysis. Medicaid patients are navigated to a medical home in community to help sustain medical care and a relationship with the Medicaid provider. With the vast number of uninsured in Texas, DCPH will have a continuous flow of patients that will need assistance.
The relationship with any of the MCO's is non-excising. They have no desire to be involved with the DSRIP projects, or even discuss a relationship. For Public Health there is no reason the MCO would be interested as there is no way to make the patient paying members. Many would not qualify for Medicaid due to legal status or how to navigate the system. DCPH has for the last 3 years been try unsuccessfully to reach an agreement with Amerigroup. Offer a bundle measurement that would allow the member to remain with their current PCP and all Point of Care testing would be sent to their PCP reducing time and cost for Amerigroup. This would reduce the cost of office visits, missed work, and multiple visits by the patients. DCPH will continue to pursue the MCO agreement.
The patient has also lead to an impact on the cost analysis. Dealing with a population that has had little or no access to healthcare for most of the life span causes many problems. Low education and understanding of medical care and basic terminology can cause confusion. DCPH Diabetic Education and Case Management program (DECM) eliminated many problems. Each case manage is required to attend the appointment with the patient and do teach back after the provider leaves the room. This has eliminated confusion on how the patient interprets the provider's instructions. Even with this method of communication, the patient still has problems understanding the scope of diabetes and the complications. This problem can lead to medication errors, diet misconception on the part of the patient, even with hours of instruction. This lack of health literacy will take many years to overcome, and even with weekly group education will most likely remain a problem.