What is Project Access?
Project Access is an organized system of charitable health care provided at no charge to low income uninsured people, on a voluntary basis, by physicians and other health care practitioners, hospitals, laboratories, pharmacies, and other health service providers. This system, implemented in many communities around the US, is based on the original Project Access model developed in Buncombe County, NC in 1995.
Though Project Access is only a partial solution to the inefficiencies and inequities of our current health care system, in many communities it is helping to improve health and reducing costs by coordinating timely care and follow-up, reducing inappropriate utilization of emergency departments, etc.
Why is this needed in Durham?
There are an estimated 20,000 low income (income at less than 200% of federal poverty level) uninsured (and not eligible for Medicaid, NC Health Choice, or Medicare) in Durham. Each year, a significant number of these people find it difficult or impossible to obtain appropriate medical services when needed.
I already donate "charity care" through accepting reduced fees, etc. Why should I do more?
Project Access of Durham County is NOT intended to discourage any individual or entity from continuing the charitable work they are already doing. PADChopes to build upon existing services; address unmet needs; enhance coordination, timeliness, continuity, efficiency, and comprehensiveness of care; and provide a system to track and to recognize donated care.
Are primary care physicians involved?
In order for a patient to receive services under Project Access of Durham County, he/she must have a "primary care home," with a primary care provider who refers them for services such as specialty consultations and coordinates care. Primary care providers assure that referrals are medically appropriate; and, to the best of their ability, determine that patients are motivated to keep their referral appointments and adhere to recommendations. Primary care providers must be available for follow-up/coordination of care after referrals.
Durham has a good primary care "safety net" in Lincoln Community Health Center (LCHC) and its affiliated sites (Lyon Park and Walltown clinics). These sites already provide primary care to many low-income patients, most of whom lack any insurance. However, accessing timely specialty consultations, surgery, hospitalization, and other services for these patients has been challenging. Thus, the initial focus of PADCis on providing access to specialty care for patients of LCHC. It is envisioned thatPADC will potentially be extended to include patients from other sites, including Durham's Homeless Clinic, TROSA, Durham Rescue Mission, and both private and Duke-affiliated primary care practices.
Who does Project Access of Durham County serve?
Durham city or county residents (residing in Durham for at least 6 months) who lack health insurance, and are not covered by Medicaid, NC Health Choice, or Medicare, whose household income is at or below 200% of federal poverty guidelines, and who attest that they lack sufficient assets (savings, stock, bonds, property, etc.) to pay for their health care expenses.
All participants must be current patients of Lincoln Community Health Center (or its satellite clinics). They must be established with a primary care provider at LCHC, must have visited with their LCHC primary care provider within 30 days of the referral request, and must follow up with their PCP for continuing, coordinated care.
How is eligibility for Project Access of Durham County determined?
If patients are identified by their primary care provider as needing specialty/diagnostic/ hospital services, that provider may refer them to PADC for eligibility screening. Patients are then screened for eligibility at the Lincoln Community Health Center or at the PADC Main Office by PADC staff. Eligibility is reviewed every 12 months.
As the program expands to serve patients in primary care "homes" other than Lincoln, other sites may be identified for eligibility screening.
How are patients enrolled in Project Access of Durham County?
Project Access staff is responsible for enrolling patients, educating them regarding their responsibilities under PADC (for instance, keeping appointments or canceling them with sufficient notice, following medical advice), and presenting them with membership cards which are good for 12 months.
There has historically been a very high rate of "no-shows" for patients keeping specialty consultation appointments; will this be any different?
In Buncombe County the "no-show" rate for specialty consultations for Project Access patients is less than 5%! In Durham, the initial "no-show" rate for PADC patients have also been less than 5%. PADC staff attribute this to thorough education/orientation of patients regarding their obligation to keep appointments and consequences for not doing so (3 missed appointments leads to dismissal from the program), reminder calls, and assistance with transportation as needed.
What about the Emergency Department?
PADC patients are educated about appropriate ED utilization and encouraged to contact their primary provider first when acute (but not obviously life-threatening) conditions arise. Project Access of Durham County does not cover Emergency Department care.
How much service am I being asked to commit?
It is the practitioner's choice how much care to donate. However, the PADC Board requests that participants make a minimum yearly pledge to provide 12 "episodes of care." (An "episode of care" may be one visit or procedure, or several, as needed to diagnose and treat a particular condition. Each "episode of care" may extend over no more than 3 months, though additional 3 month referrals for the same condition may be authorized as appropriate.) Given the nature of problems addressed by different specialties (e.g. acute, diagnostic, or preventive services) opposed to chronic disease management, it might make sense for some practitioners to commit to more, or to fewer "episodes of care."
How easily can I change my level of commitment or even drop out if I don't wish to participate?
Since this is a volunteer service, providers may change their level of commitment at any time. However, we of course request that providers work with PADC staff to assure that patients currently under care are not compromised.
How are service commitments and utilization tracked by Project Access of Durham County?
PADC uses custom-built database to track volunteer commitments and utilization.
Providers are asked to complete a standard HCFA 1500 claim form, indicating diagnoses and CPT code. While no actual charges are generated or paid, this form is processed by Physician WebLink (PrimaHealth) to track and report utilization and the "value" of all donated services.
Who is contributing services?
Physicians, physician assistants, and nurse practitioners from across the community are volunteering their time. Those donating time have been and will continue to be publicly recognized for their contributions.
Duke, Durham Regional, and North Carolina Specialty Hospitals are all donating hospital services including inpatient stays, diagnostic and ancillary services, and operating room charges. LabCorp and Spectrum Labdonateslab studies. Durham Diagnostic Imaging donates x-rays and scans. The success of this project hinges on a high level of participation. If everyone does their part, no one has to do too much. In Buncombe County, more than 90% of physicians participate in PADC.
Where are patients enrolled in Project Access of Durham County seen?
Initially, all patients must have as their primary care home one of the Lincoln sites. Specialists see patients in their own offices.
How much paperwork is involved in seeing these patients?
Every effort will be made to keep the paperwork from being burdensome. As always, accurate medical records will need to be maintained. A standard HCFA 1500 claim form will need to be completed to assist with utilization tracking. Consultation reports will be sent to referring providers, as usual.
How do program participants receive medications?
Outpatients receive most-commonly prescribed medications from the Lincoln Community Health Center pharmacy or from the Duke pharmacy (for patients seeing a Duke-affiliated specialist) for a small co-payment. Patient assistance programs will be utilized as appropriate.
Inpatient prescription medications will be filled by NC Specialty Hospital or Duke University Health System.
How do patients get referrals?
Patients are referred for specialist care from their primary care home. Specialty consultations are scheduled via the PADC central office, which selects consultants in rotation from the list of those participating. Each referral to a specialist consultant authorizes service for up to a 3-month period of time. Care beyond that period of time requires a new authorization. Patients will present their PADC cards at the time of presenting for service.
What about language barriers, transportation issues?
PADC employs bilingual staff to assist those with limited abilities in English. Transportation is also provided at no cost to patients when needed. A chronic disease/care management component is provided by Duke Department of Community Medicine's Local Access to Coordinated HealthcareProgram(LATCH).
How will labs or imaging studies be obtained?
Physicians and other participating providers order lab and radiology studies according to normal practice. Providers of lab and radiology services have agreed to donate their services to PADC patients.
How is this being organized, managed, and funded? Will it last?
Project Access Durham County is incorporated as a non-profit 501(c)(3) charitable organization, with full-time paid administrative staff, including a full-time Executive Director and 3 additional staff to handle patient eligibility certification, enrollment, orientation/education, and other projects; these staff also assist with provider recruitment and recognition and with tracking of provider commitments.
Many groups are playing leadership roles in provider recruitment and recognition, including the Durham-Orange County Medical Society, the Duke Health System/PDC, the Durham Regional Hospital medical staff, the North Carolina Specialty Hospital, and the Durham Academy of Medicine, Dentistry, and Pharmacy. PrimaHealth will assist in tracking commitments, referrals, and services provided. PADC will contract with LATCH, a program with demonstrated expertise in this area, for care coordination/disease management services and for supportive services like translation and transportation.
PADC is governed by a39-member board representing stakeholders from across the community (community and university-employed practitioners, hospitals, Lincoln Community Health Center, the Durham County Health Department, the Partnership for a Healthy Durham, the Durham Center (mental health), Durham-Orange Medical Society, local business community, the faith community, consumers, etc.). The Executive Director of PADC reports to the Board.
Major start-up and continuing funding is provided by Durham County government. Duke University Health System will maintain current levels of operating support to LCHC in addition to its contributions via PADC. The Duke Endowment and the Blue Cross-Blue Shield Foundation are providing substantial support. A significant Board function will be annual fundraising.
This program has thrived in Buncombe County since 1996, largely because of broad involvement, leadership, and support from health care providers and from representatives of all stakeholder groups across the community.
Are there liability concerns for providers?
Duke-employed practitioners participating in Project Access with the approval of their Department chair will be covered by their Duke liability insurance. Medical Mutual and probably other medical liability carriers will cover their subscribers for this charitable activity.
In addition, NC General Statute 90-21.16 protects from liability health care professionals who render services at no charge to patients referred by nonprofit community health centers or nonprofit free clinics.
If physicians have problems or concerns, who will address them?
The Executive Director of Project Access, the Project Access governing board, and a medical advisory group of health care practitioners will be available to address concerns.
Our community is already providing a great deal of care to the low-income uninsured. How does Project Access improve upon that? Aren't those who most need care getting it under the current system? Is this really needed?
PADC is not simply about providing care to the uninsured, or to the uninsured who are critically ill. The focus is on providing timely, coordinated, and appropriate care. This will reduce unnecessary Emergency Department utilization and other inefficiencies, allow earlier application of appropriate interventions, and lead to improved outcomes
This sounds like a good program, but the number of uninsured people Project Access has the capacity to serve will be only a minority of those in need – is it really worthwhile?
Project Access is only be a partial, and perhaps only a temporary solution. But we believe it provides important help to a significant number of those in greatest need. In addition, the detailed information gained from tracking of utilization and costs will be very helpful as we look to others beyond health care providers – to businesses, insurance companies, state government, etc. - to step up and help contribute to the resolution of this pervasive societal problem.