Expanding the Safety Net of Specialty Care for the Uninsured: A Case Study

Abstract

Objective. To describe core principles and processes in the implementation of a navigated care program to improve specialty care access for the uninsured. Study Setting. Academic researchers, safety-net providers, and specialty physicians, partnered with hospitals and advocates for the underserved to establish Project AccessNew Haven (PA-NH). PA-NH expands access to specialty care for the uninsured and coordinates care through patient navigation. Study Design. Case study to describe elements of implementation that may be relevant for other communities seeking to improve access for vulnerable populations. Principal Findings. Implementation relied on the application of core principles from community-based participatory research (CBPR). Effective partnerships were achieved by involving all stakeholders and by addressing barriers in each phase of development, including (1) assessment of the problem; (2) development of goals; (3) engagement of key stakeholders; (4) establishment of the research agenda; and (5) dissemination of research findings. Conclusions. Including safety-net providers, specialty physicians, hospitals, and community stakeholders in all steps of development allowed us to respond to potential barriers and implement a navigated care model for the uninsured. This process, whereby we integrated principles from CBPR, may be relevant for future capacity-building efforts to accommodate the specialty care needs of other vulnerable populations. Key Words. Uninsured/safety-net providers, integrated delivery system, communitybased participatory research, demonstration project, access to careCare for the uninsured and underinsured is largely provided by our nation's health care safety-net system comprised of providers who care for patients regardless of their ability to pay (Institute of Medicine 2000). Nevertheless, uninsured and underinsured adults have inadequate access to care, receiving fewer health screening, preventive, and specialty care services than privately insured patients (Ayanian et al.

How Should Clinicians Respond When Different Standards of Care Are Applied to Undocumented Patients?

“…In our community of New Haven, Connecticut, we established in 2009 a volunteer specialty-physician network that donates medical care in partnership with hospitals and local community organizations for uninsured patients with urgent medical needs. 5,6 Patients identified at our student-run free clinic with urgent specialty care needs are referred to a specialist who provides medical care at no charge to the patient in the specialist's own office. 7 Although not a panacea for lack of insurance, voluntary physician networks and free clinics are widespread in the United States and help to shore up the safety net in local communities.…”

Beyond Access

“…We expect social safety net activation should matter more for patients' use of specialty care than for primary care as cost is not the driving factor due to free clinics increasingly offering a range of services at low or no cost to the patients (Darnell 2011;Hall 2011;Johnson 2010;Spatz et al 2012;VanderWielen and Ozcan 2015). By identifying these two indicators of a social safety net, we gain a better understanding of not only if networks matter but also how broader activation of a social safety net may warrant further inquiry.…”

“…We further break down specialty care services by physical specialty care services (a physical ailment or issue is addressed) and behavioral specialty care services (a mental health issue is addressed or health education is sought out). Research indicates that for the uninsured, the combination of sporadic primary care with even more limited access to specialty care remains a central challenge (Hadley 2003;Shi 1995;Spatz et al 2012). In the case of specialty care, Katharine E. Zuckerman et al (2013) find in their study that the most frequent barriers for patients involved personal work obligations, childcare, and transportation constraints while barriers to the clinic included the process for making appointments and the availability of care.…”

Building a Bridge to Somewhere Better: Linking Health Care Research and Health Policy

“…For instance, Spatz et al. () have taken a proactive role in translating research that demonstrated barriers to access to specialty care into policy‐based solutions for those barriers. They describe the formation of a team in New Haven, which worked with Project Access to create a partnership of providers, advocates, and researchers, to identify and overcome challenges to obtaining specialty care.…”