Midway through a two-year study, two local health care facilities are seeing positive results from a pilot program aimed at reducing costs and shifting primarycare patients from hospital emergency rooms to community health centers.
The Emergency Department at Monmouth Medical Center in Long Branch is participating in a two-year study aimed at educating patients to use a health center for primary care rather than the ER. ERIC SUCAR staff Monmouth Medical Center, part of the St. Barnabas Health Care System, and its affiliate, Monmouth Family Health Center, both in Long Branch, are participating in the pilot program that is designed to encourage and support the transition of Medicaid and uninsured patients from the hospital Emergency Department to the health center for primary care.
According to Bill Vasquez, project director, the two Long Branch health care facilities were selected to be part of a $2 million grant program.
Above: The emergency room at Monmouth Medical Center in Long Branch. Left: Monmouth Family Health Center, an affiliate of the hospital, is located on Broadway. “The program was funded by CMS [Centers for Medicare and Medicaid Services],” Vasquez said. “New Jersey looked at high-volume counties that had more than the average of Medicaid visits in their emergency departments.”
The pilot program is designed to run for two years and began in December 2008.
The grant, which is administered through the New Jersey Hospital Association, was awarded to Monmouth Medical Center, SecondAvenue, and Monmouth Family Health Center, which is located at 370 Broadway and on-site at the hospital.
According to the St. Barnabas website, the health center “provides economically disadvantaged individuals in Long Branch and surrounding communities with highquality, comprehensive, affordable, culturally sensitive and linguistically appropriate primary and preventive health care.”
The center’s staff provides a wide range of services to more than 10,000 people each year, with more than 40,000 visits annually, the website states.
Most insurance plans are accepted, and deeply discounted services are provided to uninsured pediatric and adult patients. The center is staffed with personnel who speak fluent English, Spanish and Portuguese.
Health Center Executive Director Marta Silverberg explained the statistics and demographics for the health center.
“The population is 30 percent Hispanic, and 50 percent of our patients are below the poverty guidelines.
“Sixty percent are on Medicaid and 25 percent are uninsured,” she added. “We have 13,000 patients in our system and maybe 5,000 pediatric.”
Monmouth’s Emergency Department, which handles about 42,000 annual visits, provides comprehensive care to the acutely ill. The department also operates Express Care, a unit that is available for adults and children with minor emergencies.
Vasquez explained that the grant money provides for dedicated staffing in the Emergency Department and in the health center. The staffing includes advanced-practice nurses in the hospital, patient care assistants, a full-time physician, nursing staff, case management staff, a data analyst and outreach staff. He explained how the program works for the patient who currently comes to the emergency room for primary care.
“[When] a patient comes into the ED, they are seen in triage,” he said, “the same course any patient would take.
“It is then determined that the patient has a primary-care diagnosis, something that could otherwise be treated by a primary care physician. The advanced-practice nurse is called to see that patient and does the assessment, treatment, and medicates the patient accordingly.
“Then she educates the patient,” he continued. “She gets on the computer and pulls up the record of this patient, and accesses the appointment system and makes an appointment in real time.”
Dr. Catherine Hanlon, chairwoman of emergency medicine at Monmouth Medical Center, explained that the extra support provided to patients has helped them transition to the health center.
“We always referred patients to the health center, but what we did was typically give them a phone number and had them call to make their own appointment,” she said. “If you really want to beef up compliance, you need to walk them through the system a little better.
“We have a health center computer in our emergency department that we actually use to make patients’ appointments. It is not left open-ended for them to do.”
Vasquez confirmed that thus far the program has been successful in that patients are keeping appointments at the health center.
“What we found [is] that of the patients that were seen in the ED and appointments were made for them, that 70 percent show up and are seen in the health center as a result of the program,” he added. “The other 30 percent are individuals that say ‘I have my own doctor, I don’t need to go to your health center.’ ”
The program is succeeding in cutting down on the number of patients returning to the emergency department for primary care, he said.
“Of the 1,000 or so patients that have been referred [to the health center],” he said, “about one in nine have returned to the ED.”
Vasquez said those results are higher than anticipated.
“What we consider so successful is so many people are taking advantage of it,” he said. “I don’t know if we would have predicted a 70 percent success rate. We would have been real happy with 50 [percent].”
One of the most important aspects of the program is educating the patient, he noted.
“This is where we begin educating the patient,” Vasquez said. “It is not just moving people, it’s actually educating.
“Because this advanced-practice nurse is additional staff, she has more time to spend with these patients. She can really help educate them [on] why it is important, signs and symptoms to look for, why a follow-up visit is important,” he continued.
Vasquez explained that the true goal of the program is to use the facilities more cost-effectively.
“The goal of this demonstration was to more efficiently use the resources,” he said. “A primary-care visit costs that ER close to $400 a visit. The cost for that visit in the health center is about $125.
“To stretch those Medicaid dollars,” he explained, “they’d much rather have patients be seen in the appropriate setting.”
Vasquez explained the differences in the type of care the two facilities are designed to deliver.
“The ER is really episodic,” he said. “They go in there and take care of this, and this alone.
“[At the health center] they look at the well-being of the individual, their family history. We want the health center to become their medical home.”
Vasquez said that the inappropriate use of the emergency room by the community is what the pilot program aims to change.
“It is a model that people are looking to because it takes care of a portion of the population that uses resources poorly,” he said. “[In] the hospital, they want to take care of you if you’re really sick. When you’re a little sick, you should go to some place where that care is more appropriate.”
The idea is to educate people to use the health center for primary medical care.
“The ED doesn’t want to waste their time with the ‘walking well,’ and the HC wants to see that ‘walking well,’ ” Vasquez said. “It’s just people not being familiar with the resources.”
Vasquez explained that there is no guarantee for future funding once the grant program concludes.
“We don’t know whether there will be additional funding to continue it,” he said. “Given the kind of results we are seeing, we are hopeful that’s the case.”
There is also no guarantee that the program will work, because any patient who shows up at the ED must be seen.
“This is not an alternative to receiving care in the emergency room,” he said. “The federal requirement is that anyone who appears in an ER to request care must be seen.”
Vasquez explained the role of the health center.
“What the family health center cares for are individuals who would not otherwise have access to a primary care physician,” he said.
Vasquez explained that one misconception is that the ED is free health care.
“You’re always charged. You may not be able to pay it, but there is no such thing as free care,” he said. “The health center has a sliding scale; it is important [that] everybody contribute something.
“If they did lots and lots of free care, they’d go out of business,” he added. “We’ve seen a whole rash of hospitals close.”
When the grant was first being talked about, Vasquez explained, there was some initial trepidation in both organizations.
“There was certainly reticence, and there was some trust issues that needed to be breached,” he said. “The [family health center] and hospital work closely and collaboratively; they are two separate organizations.
“Fortunately, we worked things through in a positive manner,” he added. “Also, since the money was shared equally … there was no competition.
“The grant was developed between them, and both had to sign off on it before the grant was submitted,” he continued. “It took a little work, but everyone saw it as a plus for each side.”
Silverberg agreed that the existing relationship between the two facilities helped with the introduction of the program.
“We had a lot of the structure set up for it,” she said. “We are already connected electronically; we didn’t have to start from scratch,” she said. “It was easy to implement, because we had a very strong relationship.”
According to Hanlon, as of October there were about 800 referrals to the health center, but there also seem to be more and more patients using the emergency room.
“Of the patients that have been referred, there definitely was a decrease in the number of patients that have gone to the clinic and come back,” she said, adding, “We are still seeing an increase in the volume of emergency patients going up, and that is a national trend, not just a New Jersey trend,” she said.
“This is why we are running this grant, to try to get some of these people into more appropriate and cost-effective places to be seen.”
Hanlon said she is encouraged by the preliminary data that there will be cost savings realized.
“It will decrease but not eliminate the emergency room visits,” she said. “For the population that we are seeing, I think we definitely will see a decrease in visits.
“That’s what we are shooting for,” she added. “Our preliminary data are very encouraging.”