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Nurses go on the road to bring primary care to uninsured patients.
Jim Parker (his name and identifying details have been changed), a 26-year-old uninsured U.S. citizen, broke his right forearm while doing some repair work at home. At a local ED, his arm was stabilized with an elastic bandage and he was given a referral to an orthopedic practice. He called for an appointment and was told that the physician did not accept uninsured patients. Jim offered to pay on an installment plan but was refused. He called other offices and received the same response. He had a broken arm and it needed to be set and put in a cast. If it healed improperly, he would be unable to keep his construction job. Then he would be not only uninsured but unemployed.
Why provide primary care services to the uninsured? Many communities have recognized that early detection and treatment of disease and ongoing health management reduce disability, increase productivity, and avoid costly health care services in the long term.
One such service is the University of Maryland School of Nursing (UMSON) Governor's Wellmobile program. Established in 1994, the program consists of four mobile health care units, each located in a separate area of Maryland. Each unit provides primary care services to uninsured residents, regardless of citizenship status. The services provided are acute and chronic disease management, screenings, preventive services, physical examinations, and immunizations.
Each mobile unit is staffed with a family NP; an RN care coordinator; an outreach worker, receptionist, and scheduler; and a driver with a commercial driver's license. The mobile units visit established sites on a weekly basis. There are no charges for the services provided by staff. The decision to not charge clients was based on the recognition that they would need to use their limited resources to pay for prescriptions, laboratory and radiologic tests, and specialty referrals. Since the clients are all uninsured, there's no need for a billing system, but visits are coded in order to quantify the services.
In fiscal year 2007 (July 2006 through June 2007), the Wellmobile program provided services at 7,262 visits. It's estimated that these visits avoided $2,704,500 in ED fees. In addition, the program is estimated to provide more than $1.5 million in unreimbursed services (ICD-9 codes were used to document the services provided, and cost savings were calculated using the applicable Medicare rates).
Clients are screened for eligibility in health care programs offered by the state, the county, local agencies, and medical systems. If the screening indicates that a client may be eligible for a service, contact information is provided and an appointment is set up, often before the client leaves the Wellmobile. Clients can continue receiving services on the Wellmobile while they are waiting for eligibility rulings. When a client is deemed eligible for a particular program (for example, Medicaid or a breast or cervical cancer program for low-income patients), all subsequent services are managed by that program and all Wellmobile records are forwarded to the new provider.
There are no additional staff members to assist with administrative tasks; each four-person team divides the work to coordinate services for all clients. Each interaction between a patient and a Wellmobile staff member is termed an encounter; an average of four encounters occurs per client per visit. These encounters may include setting up appointments with the Wellmobile's family NP (follow-up appointments may be necessary if laboratory tests indicate that further action is needed) and referrals to outside providers or other agencies. These may include a social services agency that provides help with food stamps or housing, the local health department that provides immunizations and breast and cervical cancer programs, or a charitable organization through which physicians work on a pro bono basis to provide care beyond that offered on the Wellmobile.
Jim Parker was lucky. He found his way to the Wellmobile in his community. While orthopedic services were beyond the scope of practice offered by the NP, the nurse care coordinator made some calls and found a local faith-based agency that worked with physicians who offered pro bono services. That agency was able to find an orthopedic practice that would provide Jim with the care he needed. Jim came back to thank the team and asked them to sign his cast.
The Wellmobile program's success depends on the network of partnerships and relationships with county health departments, local service agencies, hospitals, faith-based groups, schools, and private organizations in each region of the state.
The program's mission is to provide primary care services to the uninsured residents of the state; to explain that mission, I, as the director of the Wellmobile program, and members of the Wellmobile teams meet with representatives of local hospitals, health departments, and other agencies that provide services to the uninsured, such as the Salvation Army and other faith-based organizations that operate free health care clinics. Sometimes it's necessary to assure these interested parties that the Wellmobile is not entering the community to siphon off clients who have insurance, but rather to offer assistance to those who have problems accessing health care. The Wellmobile program has often been able to negotiate reduced fees with other providers, enabling its clients to obtain laboratory tests, X-rays, medications, and referrals for about the same fees that those who have insurance are charged. Some of these providers offer their services pro bono, with the understanding that only necessary referrals will be made so that the services aren't overused.
Other staff members and I serve on local committees and as partners on grant applications with health departments and agencies such as the American Cancer Society and the Area Health Education Centers. In addition, the staff members of the regional mobile units are residents in the communities they serve. Most of the staff have worked for some time in local health care agencies and have personal and professional relationships with various partner organizations. These relationships play an integral role in finding and securing resources for clients.
In addition to the primary care services it provides to uninsured residents of Maryland, the Wellmobile program serves as a learning opportunity for undergraduate and graduate nursing students in the areas of community health, health disparities, rural health, and primary care. The UMSON is beginning to explore the rich opportunities provided by the Wellmobile program for community-based participatory research throughout the state.
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