Primary Care Homes: Access and Coordination with Public Sector Emergency Departments

This presentation will discuss the methodology used to: identify 1) Barriers to primary care experienced by an urban, largely low-income community of patients seeking care in the emergency department (ED) of a public/academic hospital; 2) Challenges in care coordination between ED providers and staff and outpatient primary care homes (PCHs); and 3) Alternative solutions to reduce these barriers.

Despite progress in the provision of local access to primary care, the EDs of large public hospitals continue to be the site of delivery for most health care services sought by low-income, uninsured patients. Furthermore, many patients who have a PCH are often redirected from the ED for follow-up in the hospital's outpatient clinic rather than at their established community PCHs. Lack of access to primary care coupled with a lack of coordination between the hospital EDs and community PCHs leads to poorer health outcomes, duplication of services, and higher health care costs.

Our main public/academic medical center is located in a service planning area with the following demographic profile: 55% Latino, 21% White, 18% Asian and 5% African-American. More than 50% of this population lives below 200% of the FPL, while 30% live below the FPL and 24% are medically uninsured. In 2009, the ED had approximately 110,000 visits of which approximately 90% were self-pay. Preliminary estimates demonstrate that only 30% of the adult population seeking care in the ED has a PCH and that almost ½ of patients in the ED waiting room identified the ED as their source of primary care. Reasons for high ED use include a lack of awareness of low-cost primary care options, perception of better care in large hospitals as compared to community clinics, and a lack of coordination within the system itself. Various efforts have been piloted to improve care coordination between the ED and primary care setting, including training of ED registration staff to inquire about PCHs, operationalizing a field in the hospital's computer system to include a patient's PCH information, and a volunteer program to help patients obtain information regarding their PCHs. A survey to assess patient knowledge and perceptions will be developed based on preliminary findings from these efforts.

Based on our pilot data and patient surveys, a PCH Committee composed of hospital and clinic leadership will be assembled to evaluate possible solutions. This evaluation will build upon best practices and will be based on proven effectiveness, population relevance, and cost-effectiveness.