In December 2015, we published a blog about the launch of a pilot program for patient referrals from Rush University Medical Center. The article describes an innovative program in which low-income, uninsured patients discharged from Rush’s Emergency Room (ER) or inpatient care would be referred to CommunityHealth in order to establish a medical home.
That pilot program is now an official partnership “with the goal of ensuring high quality primary care for vulnerable individuals who were previously accessing care through the ER,” according to Judith Haasis, Executive Director of CommunityHealth. Rush has designated “navigators” who are charged with identifying uninsured patients who have recently been in their hospital and connecting these patients to care at CommunityHealth. With the patients’ permission, CommunityHealth is provided with contact information and reaches out to them for priority scheduling. Efforts are made to schedule with a Rush resident to provide continuity of care.
About 75% of patients referred so far through this program are eligible for Medicaid but have not yet enrolled, so CommunityHealth guides these patients through the application process, while providing transitional care during the interim. The other 25% of patients referred are not eligible for Medicaid; thus, CommunityHealth becomes their long-term medical home.
Since January of this year, 114 patients have been referred to CommunityHealth —45 of whom have already attended or scheduled an appointment with a primary care physician. The patients seen so far are in need of care management for a variety of chronic conditions, including diabetes, hypertension, mental health issues, and asthma/COPD. We are able to provide them with primary care, laboratory services, and medications. We also provide health education and specialty services like ophthalmology, urology, dental care, physical therapy, cardiology, psychiatry, and gynecology.
One Rush doctor who works with CommunityHealth said the fact we have a pharmacy is a game-changer from his perspective. Being able to provide medications for our patients completely free of charge makes us extraordinarily unique in the realm of safety net providers of health care. Many low-income, uninsured patients with chronic conditions would not otherwise be able to fill their prescriptions without our unique pharmacy model.
At a recent meeting, both partners agreed on the goal of having at least 400 individuals successfully transitioned from Rush to CommunityHealth by July 1, 2017. This amazing progress has not been achieved without overcoming a few hurdles. Emily Hendel, Director of Clinical Services at CommunityHealth, says contacting patients and scheduling their appointments has been the biggest challenge. Both partners are hoping to develop a more streamlined process in which Rush navigators can schedule patients directly through our EMR system.
This partnership has been very successful to date, both from an economic and moral perspective. When a patient chooses to make CommunityHealth his/her medical home, that patient’s health can be monitored with an eye toward prevention and chronic disease management. This reduces unnecessary costs that would have been incurred (by the patient and/or the hospital) if that patient had continued to access health care in a hospital vs. community-based setting. It is not all about the bottom line, though. Haasis says, “Beyond saving money, it is the right thing to do for the patients. This partnership aligns with the purpose and values of both mission-driven organizations.”
CommunityHealth has big plans to expand this partnership model. “We are really excited about the new phase of this program with Rush,” says Haasis. “Recognizing it is not a one-size-fits-all model, we are ready and willing to take the learnings from the pilot and apply them in new settings.” Currently, data from the pilot is being gathered and analyzed with the belief that the findings will make a compelling case for future partnerships with other hospitals and health systems.
“This partnership program is still in its infancy, but it has the potential to make a tremendous impact throughout the city,” says Haasis. Ultimately, by expanding our patient population, we can serve more individuals in need of essential health care and deliver a healthier Chicago.