Free Clinics: Local Responses to Health Care Needs

Chapter 9. Impact of Providing a Medical Home to the Uninsured: Evaluation of a Statewide Program

Chapter 9 Impact of Providing a Medical Home to the Uninsured: Evaluation of a Statewide Program James M. Gill Heather Bittner Fagan Bryan Townsend Arch G. Mainous, III Previous studies have shown that having a regular source of care (RSOC) is associated with higher quality of care, increased preventive care, and decreased emergency department (ED) visits.– While the majority of people in the United States have as RSOC, many do not. Barriers to having an RSOC include lack of insurance, low income, and unreliable transportation. Since low-income uninsured people represent a vulnerable population who are likely to be without an RSOC,– many programs aim to improve access and quality for the uninsured by providing an RSOC. The Community Health Access Program (CHAP) is a statewide program intended to improve access to care for low-income, uninsured persons in Delaware who do not qualify for Medicaid or other insurance programs. CHAP’s main mechanism of improving access is to provide an RSOC for eligible persons who do not already have one. The program operates in all hospitals in the state as well as all community health centers (CHCs), both federally qualified and nonqualified . In addition, it includes a volunteer network of private physicians (both primary care and specialists) who have agreed to take uninsured patients at a reduced fee, through a program run by the Medical Society of Delaware (the Voluntary Initiative Program, or VIP). Finally, CHAP is coordinated with the state Medicaid bureau. People are eligible for CHAP if they are Delaware residents who are uninsured (or have insurance that does not cover basic health care services), are not eligible James M. Gill, MD, MPH, is an associate professor at Jefferson Medical College, in Philadelphia, and president of Delaware Valley Outcomes Research, in Newark, Delaware. Heather Bittner Fagan, MD, MPH, is director of health services research at Christiana Care, in Wilmington, Delaware , and an associate professor at Thomas Jefferson University, in Philadelphia. Bryan Townsend, MA, JD, was a research assistant at Christiana Care and is currently an associate attorney with Morris James, in Wilmington. Arch G. Mainous, III, PhD, is director of research and fellowship director in the Department of Family Medicine at the Medical University of South Carolina. Impact of Providing a Medical Home to the Uninsured 87 for Medicaid or the State Children’s Health Insurance Program (SCHIP), and have incomes below 200% of the federal poverty level. Eligible people are identified by a variety of mechanisms: hospital staff identify people who seek care in their emergency departments (EDs) or inpatient services who are uninsured and need an RSOC; other clients are identified at community sites or through the Medicaid bureau (after being denied Medicaid); potential clients may also refer themselves to the program by calling a toll-free number. Once a client has been identified as eligible for CHAP, he/she is referred to one of the participating agencies (including the VIP network), which becomes his/her RSOC, based on geographic proximity. The CHAP care coordinator at this agency then helps the client get an appointment. The care coordinator also assists him or her with other health care needs, including transportation and referrals to specialists or ancillary services. The care coordinator also keeps track of CHAP enrollees who are assigned to his or her site and contacts those enrollees every six months to assess continuing eligibility. The objective of CHAP is to provide an RSOC to its target population. The goal is to improve access to care and thereby increase use of primary and preventive care, reduce hospital ED visits and hospital admissions, and improve patient satisfaction with care. The purpose of this study was to determine the extent to which CHAP was achieving these goals. Specifically, we examined the impact of CHAP on preventive services, ED visits, hospitalizations, and satisfaction with care. We compared these indicators from before to six months after enrollment in CHAP. Methods A retrospective cohort design was used to determine changes in preventive services, ED visits, hospitalizations, and satisfaction with care from enrollment in CHAP to six months after enrollment. Data were obtained from CHAP enrollees through interviewer-administered surveys at each point in time. The survey was modeled after the national Behavioral Risk Factor Surveillance System (BRFSS) survey and included questions on demographic characteristics, health insurance, access, utilization , preventive services, awareness of medical problems, satisfaction, and health status (see chapter appendix for full survey). The surveys were administered by trained interviewers at baseline and every six months thereafter. The interviews...