Providing Quality Care to Indigent Patients
by Jill Carroll, MSW, LISW
Managing the care of a population with multiple healthcare concerns and marginal resources was a challenge undertaken when the University of Iowa Hospitals and Clinics developed an innovative, hospital-based program to provide care coordination and case management services to the state’s qualified indigent care patients.
In 1999, a hospital focus group researched care provided to this group and concluded that it lacked cohesiveness and was cost inefficient and duplicative. Medically, the group served tended to have a higher incidence of chronic conditions, such as diabetes and hypertension, and a higher incidence of mental health and substance abuse issues. The patients were high utilizers of specialty services, and had higher pharmaceutical related costs, leading to greater institutional costs. This group of patients, numbering nearly 4,000, was required to use the hospital as their provider in order to receive state coverage.
Thus the Care Management Program of the University of Iowa was developed and provided an interdisciplinary team from the disciplines of nursing, social work and medicine to serve as the point of coordination for this population. This team functioned to authorize appointments, address hospital policy issues and assist patients in navigating their care throughout the hospital — a large tertiary care academic medical center.
The goals of the Care Management Program of the University of Iowa were to streamline hospital policies and patient care, improve healthcare outcomes for patients and improve patient satisfaction. Additional benefits included increased patient compliance and increased provider input and care collaboration.
Each discipline under the Care Management Program of the University of Iowa operated by providing their unique function, yet remained connected to their prospective departments. The nursing staff handled the phone center and provided symptom and medical triage as well as authorization of specialty care appointments. The social work staff assisted patients with mental health follow up and financial and transportation resources, and helped provide access to supplies and equipment needed to reduce their inpatient length of stay. The medical director provided evidence-based medical expertise related to policy formulation, case consultation and staff guidance. The program administrator helped staff deal with hospital systems issues by using contacts and knowledge of hospital departments to problem solve and develop creative solutions to programmatic and patient care issues.
Program initiatives that contributed to overall program success included the development of a primary care model with a shared gatekeeper function between the program and the physician. A toll-free telephone access was set up and nursing staff provided coordination and integrative functions. In collaboration with the pharmacy department, an extended prescription program including mailable refills was instituted. Hospital-based transportation and lodging were provided to improve access and as stipulated in the state program requirements.
The Care Management Program of the University of Iowa was highly successful in its impact. Program data demonstrated that specialty care visits and emergency room visits, as well as use of hospital-based psychiatric services dropped, while the use of community-based mental health services increased. The length of stay for program participants was lower than the general hospital population, too, and the cost of inpatient admissions declined. Approximately 90 percent of patients surveyed stated they were satisfied with the care they received. The program’s success was evidenced by its high-quality, cost-effective care that reduced inefficiencies and improved patient satisfaction.
