In 2011, a multidisciplinary health care team joined up with a variety of local agencies (governmental, non-profit, for-profit and faith-based organizations) in San Antonio, Texas to pilot a project designed to increase the utilization of primary care services for a vulnerable, uninsured subset of the city’s population, which consisted of 6,000 residents (many of whom resided there illegally). The integrated health care team included community health workers (CHWs) who were invaluable in providing information regarding obstacles to care that people within the selected community routinely faced. In addition to meeting requirements outlined in contracts signed with the financial lenders to the program, such as meeting a 10% reduction in hospital and emergency department (ED) visits to the widely utilized university-affiliated hospital, the team set two broad program goals to be achieved. The first goal was to improve health outcomes in the selected community. The second, and more innovative goal, was to attend not only to the patients’ physical well-being, but to address the social factors that determined the health of patients’ within the community.
Not surprisingly, the CHWs were essential to achieving the second program goal. CHWs “became the conduits for a bidirectional flow of knowledge and action.”[i] These members of the health care team were able to convey the vast needs of the community to the medically trained personnel. In turn, the CHWs (who resided in the community they were serving) established trusting relationships with the patients, who were intimidated by the prospect of accessing medical services due to language barriers and/or financial constraints, for example.
In addition to the impressive utilization of CHWs, it’s important to note the dynamic structure of the health care team, as well, which consisted of physicians, RNs, NPs, social workers, and pharmacists. Though they came from slightly different professional backgrounds under the health care umbrella, the team collectively subscribed to a philosophy of providing holistic health care, and they developed effective approaches to deliver this model of care to the community they served. In addition to addressing the psychosocial needs of the community, the team sought to improve access to health care in general, to reduce ED visits and/or hospital admissions, and to promote attainable self-management strategies on the part of patients.
While the team had obligations to uphold to their financial sponsors (such as the reduction in hospital admission rates as was mentioned earlier), it is interesting to note that they report there were “many partners willing to engage with us;”[ii] in other words, to provide financial backing. The group reports the greatest obstacles to achieving their goals arose when the clinicians and non-clinical staff disagreed over which methods to use to implement them. They state, “The marriage of clinical and community approaches, with their different world views and timelines, means that even the core implementation team is sometimes tested in its ability to reach consensus.”[iii] However, despite their differences, the team managed to yield some striking results. Out of the 6,000 patients they were caring for, 1,500 of them were deemed high-use patients, meaning they visited the ED and were often admitted to the local hospital frequently. By the end of the study, there were 1,034 participating patients left to evaluate out of the 1,500. Of those patients, the team saw a 24% decrease in hospitalizations and a 12% decrease in ED visits in one year (between 2010 and 2011). The team determined to have saved the local hospital system $250,215 in charges.[iv] Admittedly, the cohort of patients they evaluated was small and they lacked a control group, but the results are no less noteworthy.
The integrated health care team in Texas sets a precedent for those who are interested in crafting standards to deliver primary care, and/or for strengthening the union of public and private donors to assist in streamlining primary care for the nation’s vulnerable populations. The program, while serving a relatively small (though arguably a socially invisible) subset of people, was a tremendous success, especially because it was implemented in a state that is known for political conservatism and tactics to tighten immigration laws, which could have been major obstacles to the program’s progress.[v] The strategies used on the part of this team should be considered when devising ways to deliver primary care to our newly insured citizens under the Affordable Care Act. Once their coverage has been established, thousands of individuals will become consumers of medical care, though their vulnerability (due to being disabled or homebound, or because of their rural/remote locales, for example) will remain unchanged. Healthcare providers and public and private donors must be innovative in their endeavor to provide care to these populations, though endorsing the guiding principles of the health care delivery model in Texas seems to be a good place to start.
[i] Ferrer, R. L., Gonzalez-Schlenker, C., Lozano-Romero, R., Poursani, R., Bazaldua, O., Davidson, D., Gonzales, M. A.,, DeHoyos, J., Castilla, M., Corona, B.A., Tysinger, J., Alsip, B., Trejo, J., & Jaén, C.R. (2013). Advanced primary care in san antonio: linking practice and community strategies to improve health. Journal of the American Board of Family Medicine, 26(3), 288-298. doi:10.3122/jabfm.2013.03.120238, p. 290.
[ii] Ferrer et al., 2013, p. 296.
[iii] Ferrer et al., 2013, p. 296.
[iv] Ferrer et al., 2013, p. 294.
[v] Goodwyn, W. (2011). Texas republicans take harder line on immigration, as reported on National Public Radio (NPR). Retrieved on 11/21/2013 from: http://www.npr.org/2011/03/29/134956690/texas-republicans-take-harder-line-on-immigration.