September 23, 2008

1. Susan D. Yaggy, Chief Division of Community Health Department of Community and Family Medicine Duke University Medical Center Workshop IIIC: Helping the Un & Underinsured through the Public Health MazeLATCH Local Access To Coordinated Healthcare September 23, 2008

2. Duke Community Health • Created as a Division of the Medical School in 1998 with a staff of 2 • Collaborative community-based services • Programs created with extensive community input often a year in planning • Multi disciplinary; multi-agency

3. Preceding LATCH • 3 school-based clinics: 1 high school, 2 elementary • Minority health careers • Primary care with FQHC for homebound: diabetes, HTN, asthma • Dental van with Health Dept and schools • Large Medicaid care management programs: • 10,500 enrollees (now 20,000) in Durham • Non-clinical staff • Deliver education, advocacy, follow-up on clinic care, navigation in homes

4. LATCH History • Launched: January 2002; Healthy Communities Access Program (HCAP) funding from US Health Resources and Services Administration (HRSA.) • To improve access to health services • Improve health status for Durham County’s growing uninsured/ underinsured Latino immigrants. • Over 300 patients waiting on opening day.

5. Open to any: • Durham County residents who is un/underinsured – no means testing • Referred by local health and social service providers and self-referrals • Since 2002, over 14,000 referrals and nearly 11,000 enrolled patients

6. Enrollee Demographics • 41% Male, 59% Female • Race/Ethnicity: Hispanic/Latino (>96%) • Employed in low-wage industries (construction, landscaping, restaurants, housekeeping, childcare) • Average <7 years in US

7. Barriers • No knowledge of health system • Do not speak (any/much) English. • Some speak indigenous languages • Lack of available childcare • Lack of reliable/available transportation • Low/no literacy • No phone; 30 day phone • Cultural differences re: health and prevention • Documentation status; fear limits care-seeking and follow-up

8. What LATCH Brings: • Individual/Family Approach • Case management • Patient navigation – health and social services • Health education • Community outreach - delivered in neighborhoods and at home • Care managed (electronic information system) • Culturally and Linguistically competent staff • Primary outreach through El Centro Hispano, a trusted community resource

9. LATCH Services • Home Visits (program orientation, needs assessment and risk stratification) • Health Services Orientation/Coordination (PCP/medical home, urgent care, specialty, ER) • Referrals and Facilitation (appointments, directions, accompaniment) • Medication Access and Compliance/education • Bills Assistance (Self-Pay Payment Plan, Medicaid and Duke Charity Care applications) • Some Chronic Disease Management (asthma, hypertension, diabetes, depression, pregnancy, etc.) • Prevention Education • Advocacy • Interpretation/Translation • Limited Transportation

10. Enrollment • Medical and Social Service Providers • Walk-in enrollment --El Centro Hispano • Self-referrals • By fax, phone or in-person • Fax Referral/Consent Form with patient signature

11. A Working Consortium to Resolve Access Barriers • El Centro Hispano • Lincoln Community Health Center • Durham County Department of Social Services • Durham County Health Department • Planned Parenthood • Catholic Charities • Durham City Parks and Recreation • Center for Child and Family Health • Immaculate Conception Church • Duke University Medical Center and Health System • Duke Private Diagnostic Clinic • Duke University Hospital: Latino Health Project • Durham Regional Hospital

12. Some Recent Consortium Successes • HIPPA firewall blocking Emergency Medicaid enrollment • Billing and payment plan services not in Spanish • Health Dept. pregnancy confirmation requirement by MD • Literacy level on patient payment materials • Transportation system issues with DSS • Birth certificate—father’s ID

13. Program Support • Funding: HRSA funding ended in April ’06. LATCH now supported by DUHS • FY09 budget: $299K • LATCH staff: • Program Coordinator • SW (DSS contract) • .5 health educator • 3 CHW’s • .5 secretary • And administrative support from Division of Community Health

14. LATCH outcomes • Phone survey (n=225) in summer 2005 (225 of 485 completed phone survey – 46% response rate) • All participants born in Latin America and lived in US < 7 years • More intensive case management going to: • Clients who lived in Durham longer (7 vs. 6 years) • Clients who needed health care but could not get it • 80% reported having a “usual source of care” • ED use from 2004-2005 reported decrease: 32% (unweighted) to 21% (unweighted)* after controlling for health and demographic characteristics (*p<0.01)

15. LATCH outcomes, con’t.

16. 2008: Making LATCH a Base to Grow Systems of Care for Un/Underinsured • HealthNet: State grant through Medicaid Care Management: • Re-enroll 700/mo. who “fall off” Medicaid/sCHIP • Campaign for consistent surname $174K • Staff – health educator • Subcontract: El Centro Hispano: SEPA $80K • Latino Stroke prevention • Screen/Educate through El Centro Hispano • LATCH to provide education/care management for patients with stroke risk factors • Staff – health educator

17. 2008: Making LATCH a Base, con’t. • Project Access of Durham County: $299K • All-share system for specialty care • LATCH to provide navigation, support and disease management • New: RN, SW, CHW, p/t secretary and IT

18. In closing, we are learning • The strength of our coalition and capacity to eliminate barriers • The ability of our patients to adapt to a new (and difficult) environment • How to pull together all local resources to focus on a population • How to change patterns of care – seeking and create medical homes for un/underinsured patients

19. Thank you. Contact: Susan D. Yaggy Chief, Division of Community Health DUMC Box 2914 Durham, NC 27710 (919)681-3187 yaggy002@mc.duke.edu