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Caring for the uninsured is everyone's responsibility. That's the adage behind a newly launched pilot program designed to unclog local emergency rooms with non-urgent health matters by helping the uninsured find a primary care provider.

The Medical Home Pilot, designed by the University of Tennessee (UT) in partnership with top hospital and clinic leaders, launched at the end of May and was the culmination of more than a year's worth of discussions on the problems facing the uninsured in Shelby County.

The goal is to help patients receive "the right care in the right place at the right time," said Teresa Waters, PhD, associate professor at UT Health Science Center, adding the ER is the wrong environment to receive primary care because it is designed to give acute, not continuous care. "Patients are not likely to see the same physician twice in the ER and ER physicians rarely have the time to address all of the healthcare needs of the patient."

Furthermore, if patients find a medical home, they can improve their health and avoid the crises that put them in the emergency room.

Leaders met regularly from UT, Church Health Center, Baptist Memorial Health Care, Methodist Le Bonheur Healthcare, St. Francis Hospital, and The Regional Medical Center hospitals, along with leaders of community clinics to develop the program.

Not surprisingly, initial surveys in each hospital revealed a large number of inappropriate uses of ERs. However, they were not all due to the uninsured.

"Non-urgent people using the ER cover all socioeconomic areas," explained Ann Langston, director of the Church Health Center.


How it works

When a patient arrives in the ER with a non-urgent health concern, the staff will treat him or her and then an ER nurse will schedule an appointment with one of the participating clinics, which include Church Health Center, Christ Community Clinics, Health Loop Clinics and Memphis Health Center. The fee is waived on the initial visit to eliminate any barrier to getting that first appointment made.

"Patients will be given a definite appointment at which clinic and what time," Langston said, adding the ER then informs the clinic, which will be ready to receive the patient at the appointment. "Patients are given a follow up appointment – we want them to know they can come here for their care."

Designed to be conducted in phases, the pilot began at Methodist University Hospital. Every 30 days, the project will be reviewed to track how well patients are complying and if any adjustments need to be made. The data will be monitored in three ways; 1) tracking referrals, 2) tracking follow up appointments, and 3) looking long-term to determine if those referred patients keep primary care as their medical home or end up back in the emergency room. After initial calculations on compliance, improvements will be made and other hospitals will be added. As issues with the program are ironed out at Methodist, the pilot will expand to the Baptist system and subsequently to the other systems.

"The Medical Home Pilot will be rolled out in phases in order to ensure constant feedback to the institutional providers and to assure emergency room physicians that the patients are getting the appropriate care outside the ER," explained Waters.

It's important to document the success of the program, Waters added, before deciding to make it permanent, which is why UT is assuming the role of research leader to ensure that information is available.


Community support

It was agreed the best way to solve the problem was to work within the hospital system, utilizing the resources already serving the uninsured in the local healthcare industry, rather than adding to it.

Typically the uninsured use the ER as their primary medical home, but the cost of inappropriate use is far more expensive than using primary care clinics. For a sore throat that can't wait but the doctor is booked up for weeks, people come to the ER.

"We know for a fact we have the highest volume of patients on Mondays," said Marianne Fournie, corporate director of emergency services at Methodist University Hospital, adding the common scenario is people get sick over the weekend and can't get an appointment scheduled for the week, so they end up in the emergency room.

Emergency departments utilize fast track and expedited triage areas to funnel the minor cases away from the major cases. Moreover, minor medical centers abound across the nation to deal with the overcrowding of ERs. But that's not enough, Langston said, and the overarching issue is people must recognize they need a primary care physician to be in charge of their overall healthcare. This group of community healthcare leaders, informally called the "uninsured working group," realizes they have to team up to reduce the drain on resources created by non-urgent use of emergency rooms.

"Everyone needs to get good continuity of care and the ER is not the place to do that," added Langston. "A primary care physician is the best physician to coordinate that continuity of care."

With patients going into the appropriate setting for their healthcare needs, everybody wins. Patients receive better care, the system delivers care at a more appropriate cost and hopefully some of the ER overcrowding is eliminated.

Langston commented that the founder of the Church Health Center, Dr. Scott Morris, has described the pilot program's goal for its patients as "loving them into the primary care system and out of the emergency department." Patients receive the appropriate care at the appropriate place.

"This program is so exciting because competing providers recognize that caring for the uninsured is everyone's responsibility," concluded Waters. "They are working together, as opposed to being at cross-purposes, to come up with a better solution."


June 2007

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