Program Details

Practice Type:	Promising
Program Name:	Reducing Barriers in Client Eligibility Determination for Primary Care Services
Organization:	Pinellas County Health Department
Web site:
Overview:	The main goal of the project was to create an eligibility process that would make it easier for the client to receive care. We focused on three main objectives related to this goal: 1. Streamline and simplify the eligibility process; 2. Reduce the rigid criteria for eligibility; and 3. Make treatment available on the same day as eligibility determination. Through a review of the current system and negotiation with Pinellas County Health and Human Services, along with collaboration from other community providers, we were able to reduce or eliminate several of the common barriers that existed for uninsured clients to access primary care services. Clients are now able to present for services and be immediately triaged at the point of eligibility determination—regardless of eligibility—and provided with more reasonably attainable eligibility documentation that will be required for subsequent visits.
Year Submitted:	2009
Responsiveness and Innovation:	The public health issue being addressed is access to health care for the uninsured population of Pinellas County. The Pinellas County Health Department used the following resources to determine the relevancy of the issue: NACCHO Self-Assessment, client report, and feedback from Board of County Commissioners/HHS. Currently, primary care clients are required to report to one location for eligibility where multiple documents must be provided and eligibility criteria is rigid. Once enrolled, the clients must then travel to another location for care that is not typically provided on the same day as the eligibility process. Furthermore, the existing eligibility period was only three months, requiring clients to repeat this process three or more times per year. The process proposed was developed and included a reduction in much of the mandatory documentation required, adopting less restrictive criteria related to income and assets, extending the eligibility period from three months to 12 months and eliminating the time and distance barrier between eligibility and service provision. The intended outcome streamlined the eligibility process, increased access to care and reduced the burden on emergency room utilization for local hospitals. Solutions identified were to eliminate multiple visits for eligibility and care; allow all clients to at least be seen for initial triage visit, regardless of eligibility ; reduce required documentation for eligibility; eliminate rigid eligibility requirements; make eligibility and service location the same; provide additional specialty care services (in house and by referral); provide disease management and case management; $5,000 cap on money available for services per client to reduce costs; change eligibility period from three months to one year. This project addresses a topic that is clearly not new to the public health arena although it is essentially new to the Pinellas County Health Department. More than a decade ago, the Pinellas County Health Department addressed some of the primary care needs of the community; however, this was the first time it was done as a collaborative partnership with County Health and Human Services, Community Health Centers, local hospitals, and providers. What was innovative about this is that the focus was shifted from defining rigid criteria for eligibility to focusing on the importance of relaxing the criteria to allow the client to access primary care and prevent them from seeking more expensive emergency room services. With estimates as high as 140,000 (15 percent) of residents in Pinellas county without medical insurance and a current system that was failing, improving access to care was a vital component to addressing the needs in our community. Another innovative component of this project, as compared to the existing system, is that services were made available immediately upon eligibility determination because that determination was made at the medical home. A review of the current system showed that many patients who visited emergency rooms were currently enrolled in the county medical program but unable to access services due to geographic barriers (distance and transportation) or waiting lists for appointments. Integrating eligibility at the service site completely eliminated this barrier for the first visit and patients were able to engage in triage, treatment, and case management when it was most needed. Although in our current economic climate, lack of insurance is not limited to the indigent and out-of-work population, these are the primary populations that are served by this program. That being the case, eligibility criteria requiring documentation, such as a birth certificate or proof of citizenship, often became a hardship for clients and was a primary barrier for obtaining eligibility. The new process, while still maintaining the necessary requirements and documentation to ensure proper expenditure of funds, was less cumbersome and allowed for at least initial care, giving the patient an opportunity to obtain the documentation prior to subsequent visits.
Agency and Community Roles:	The Pinellas County Health Department (PinCHD), proposed to work with key stakeholders from multiagencies in Pinellas County to provide primary care services to address the adult (18–64 years) primary care system for uninsured clients funded by the Pinellas County Health and Human Services Department (HHS). The system will move the current “sick care” model toward a “disease management” model that focuses on primary and secondary prevention. The desired outcome is to improve the health of the uninsured population as measured by agreed upon key health indicators. PinCHD designed a memorandum of agreement among all interested parties to work on the Pinellas County Uninsured Health Care Collaborative. The goals are to increase access to health care through the establishment of a medical home and to decrease costs by emergency room diversion. This was a collaborative project from the planning stages and continues throughout the implementation. The project’s success requires this collaboration because no single entity has the resources to address the issue on its own. Health and Human Services provides the funding and has an administrative role in the distribution of benefits to clients. The health department, in collaboration with Health and Human Services, determines eligibility. The health department, Community Health Centers, and some local providers provide the direct primary care services to patients. The Pinellas County Health Department has an extensive history of collaboration with community partners and maintains excellent relationships with these partners. The health department actively seeks collaboration in almost all areas of its operation. In fact, several of the health department programs have community partners as part of the management team for that program. Nearly all grants (where appropriate) applied for have collaborative partnerships and collaborative agreements as part of the application. The health department establishes agreements with its collaborative to ensure clarity in the understanding of roles and relationships to avoid potential problems and works diligently to address concerns with its partners to keep those relationships healthy.
Costs and Expenditures:	Implementation and start up costs totaled $126,436 for office supplies, medical supplies, furniture, electronic devices, and equipment.
Implementation:	The public health issue being addressed is access to health care for the uninsured population of Pinellas County. The Pinellas County Health Department used the following resources to determine the relevancy of the issue: NACCHO Self-Assessment, client report, and feedback from Board of County Commissioners/HHS. Currently, primary care clients are required to report to one location for eligibility where multiple documents must be provided and eligibility criteria is rigid. Once enrolled, the clients must then travel to another location for care that is not typically provided on the same day as the eligibility process. Furthermore, the existing eligibility period was only three months, requiring clients to repeat this process three or more times per year. The process proposed was developed and included a reduction in much of the mandatory documentation required, adopting less restrictive criteria related to income and assets, extending the eligibility period from three months to 12 months and eliminating the time and distance barrier between eligibility and service provision. The intended outcome streamlined the eligibility process, increased access to care and reduced the burden on emergency room utilization for local hospitals. Solutions identified were to eliminate multiple visits for eligibility and care; allow all clients to at least be seen for initial triage visit, regardless of eligibility ; reduce required documentation for eligibility; eliminate rigid eligibility requirements; make eligibility and service location the same; provide additional specialty care services (in house and by referral); provide disease management and case management; $5,000 cap on money available for services per client to reduce costs; change eligibility period from three months to one year. This project addresses a topic that is clearly not new to the public health arena although it is essentially new to the Pinellas County Health Department. More than a decade ago, the Pinellas County Health Department addressed some of the primary care needs of the community; however, this was the first time it was done as a collaborative partnership with County Health and Human Services, Community Health Centers, local hospitals, and providers. What was innovative about this is that the focus was shifted from defining rigid criteria for eligibility to focusing on the importance of relaxing the criteria to allow the client to access primary care and prevent them from seeking more expensive emergency room services. With estimates as high as 140,000 (15 percent) of residents in Pinellas county without medical insurance and a current system that was failing, improving access to care was a vital component to addressing the needs in our community. Another innovative component of this project, as compared to the existing system, is that services were made available immediately upon eligibility determination because that determination was made at the medical home. A review of the current system showed that many patients who visited emergency rooms were currently enrolled in the county medical program but unable to access services due to geographic barriers (distance and transportation) or waiting lists for appointments. Integrating eligibility at the service site completely eliminated this barrier for the first visit and patients were able to engage in triage, treatment, and case management when it was most needed. Although in our current economic climate, lack of insurance is not limited to the indigent and out-of-work population, these are the primary populations that are served by this program. That being the case, eligibility criteria requiring documentation, such as a birth certificate or proof of citizenship, often became a hardship for clients and was a primary barrier for obtaining eligibility. The new process, while still maintaining the necessary requirements and documentation to ensure proper expenditure of funds, was less cumbersome and allowed for at least initial care, giving the patient an opportunity to obtain the documentation prior to subsequent visits.
Sustainability:	Sufficient stakeholder commitment to perpetuate the practice is in place. The Board of County Commissioners and Health and Human Services are responsible for ensuring services. An annual contract is in place to provide services to 3,000 clients. After the initial one-year contract, an option to continue or expand will be based on available funds. Continuation of this project is completely dependent on available funding from Pinellas County Health and Human Services. Because Primary Care services are not a typical core public health function, at this time there is no plan to use health department funds to support this program. Although primary care is not a core function of public health, addressing community needs and filling gaps in services is, and as long as there remains a critical need for primary care services in Pinellas County, the health department will work diligently to address those needs. The health department has been actively seeking volunteers to assist with the primary care project in Pinellas. Although this does not directly affect the eligibility determination process, it does have a significant effect on the sustainability because it reduces the fiscal burden on some of the most costly expenses within the system. Pinellas has been able to secure the services of several volunteer specialists to treat primary care patients, which over time will result in considerable cost savings. The new “Cover Florida” insurance plan initiated by the governor presents some interesting possibilities in providing more comprehensive primary care services for Pinellas County residents and we will be exploring options to engage uninsured residents in this plan in the near future, thus reducing the burden on the primary care system as it exists now.
Lessons Learned:	Information was not provided in 2009

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