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Reducing barriers to care

A&M Rural and Community Health Institute created the Brazos Valley Post Discharge Care Coordination program
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Most of the time when you go to the Emergency Department (ED) of your local hospital, it’s for a genuinely urgent and serious reason: a suspected heart attack, symptoms of a stroke or perhaps a major injury. However, some people visit the ED because they have nowhere else to go for their health care. The trouble is, the ED was never meant to be used like a primary care practice. Caring for people that way is very expensive, and it diverts resources away from patients with true medical emergencies.

That’s why the Texas A&M Health Science Center Rural and Community Health Institute (RCHI), which provides solutions to small community or rural facilities that may otherwise have restricted access to certain programs and expertise, has stepped in to help by creating the Brazos Valley Post Discharge Care Coordination program (BVCCP).

Section 1115 of the Social Security Act allows states to submit a waiver to give them more flexibility in designing transformative, pilot or demonstration projects (called DSRIP, or Delivery System Reform Incentive Payment) that benefit Medicaid-eligible individuals. BVCCP is just one of about 1400 projects around the state managed under the Texas Healthcare Transformation and Quality Improvement Program. The state is divided into 20 Regional HealthCare Partnerships (RHPs), and the Brazos Valley is part of RHP-17, covering nine counties with 32 different projects and receiving approximately $93 million from the Medicaid 1115 Waiver.

The BVCCP receives a list from local hospitals of potentially eligible patients—those perhaps using the ED repeatedly or inappropriately, or those who came in with a serious condition that requires follow-up, but who do not have good insurance or a primary care physician.

Karla Blaine, B.S.N., RN, CPHQ, head of the program, explained that she and her team contact these patients referred from the hospitals—nearly all of whom are uninsured, underinsured or on Medicaid—to find out what is preventing them from having good access to health care. About 40 percent of referred patients are unreachable, either because they don’t respond or because their contact information is not correct. Another 40 percent are reached but decline services. Even though it is completely free of charge to them, only about 20 percent of those referred choose to enroll in the program, but the several hundred who do choose to become clients have cut their utilization of the ED by 30–35 percent.

The program aims to reduce barriers to health care by helping clients obtain basic health information, find affordable community medical services like a primary care physician or clinic and connect with resources that help them stay healthy. Blaine and her team also coordinate care for their clients by communicating with their health care team, ensure the person has needed medications and help them get to their medical appointments.

They also provide their clients with additional resources to support good health. “We reach out to different community organizations, such as food banks or affordable housing, to connect people with the services and other help that they need,” Blaine said. “We hope that if they’re socially stable, we can focus on their health care.”

When the Texas Healthcare Transformation and Quality Improvement Program began, the Texas A&M School of Public Health did population studies to determine community needs and provided the information to regional decision makers who were looking at how to best utilize the funds. The BVCCP program was designed in 2012 and began taking clients in October 2013. In that two-year period, Blaine, who was already working at RCHI and who has a background in case management, estimates that the program has already saved local hospitals approximately $1 million.

The current waiver expires at the end of September 2016, but the state is applying for an extension, which would allow the program to continue for an additional three years.

“We’re able to really help people with things they would not get help with otherwise,” Blaine said. “We try to advocate for our clients, connect them to a source of primary care as well as community resources, and our goal is to help improve their everyday lives. When a client has access to regular primary care, any chronic diseases are better managed, new problems are detected sooner and potential complications or hospitalizations are avoided. This is good for the client, improves the health of our community and better manages our limited health care dollars.”

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