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Dome - Crossing Barriers of Income and Language to Deliver Care

Dome October 2012

Crossing Barriers of Income and Language to Deliver Care

Date: October 5, 2012

Berenice Nava examines 75-year-old Maria Portillo, who last saw a physician 15 years ago.  Thanks to TAP, Portillo was referred for surgery for removal of  her goiter.
Berenice Nava examines 75-year-old Maria Portillo, who last saw a physician 15 years ago. Thanks to TAP, Portillo was referred for surgery for removal of her goiter.

Unable to breathe clearly, the young man sought emergency care last fall at Johns Hopkins Bayview Medical Center and was quickly moved into the cardiac intensive care unit. The diagnosis: dilated cardiomyopathy, a weakened and enlarged heart.

 “He went from being healthy to needing four or five medications a day and being fully reliant on the health care system,” says Berenice Nava, the resident who admitted and continues to treat him.

With no family in the area and no health insurance, the Spanish-speaking patient would typically face an uncertain medical fate. Now, however, Nava coordinates his care through a Johns Hopkins Medicine program that helps uninsured and underinsured patients receive specialty care at Bayview Medical Center as well as at The Johns Hopkins Hospital.

Since The Access Partnership (TAP) began in May 2009, it has helped more than 1,700 patients receive treatment from Hopkins specialists who donate their services. Over the past three years, TAP has expanded to meet the needs of eligible residents in seven ZIP codes; areas of coverage now include Dundalk as well as many city neighborhoods. Participants have received more than 4,000 referrals, most often to radiology, ophthalmology and cardiology.

At Bayview, many TAP patients speak only Spanish and need additional assistance to navigate the system. Nava, a second-year resident in internal medicine, was born in Mexico and has requested to work with Spanish-speaking patients. “We not only share a language, but a culture,” she says. “And now these patients have a primary care physician who can communicate with them.”

Crafting an Avenue for Care

The TAP program grew out of a task force of physicians, administrators and medical students charged with finding ways that Hopkins could deliver health care to underserved residents of East Baltimore who demonstrate financial need. Cardiac surgeon William Baumgartner, president of Hopkins’ Clinical Practice Association, chaired the committee on specialty care that led to TAP’s development. A key reason for its success so far, says TAP program director Anne Langley, is the unstinting support and enthusiasm of CPA physicians.

The program requires that qualified patients pay a one-time fee of $20 for diagnostic tests and other special care. All referrals, usually made by residents, are reviewed by TAP medical director Barbara Cook, who checks to make sure that standard treatments are tried before specialists are consulted. Patient navigators assigned to TAP make appointments for patients and also remind them with follow-up phone calls.

Langley, who works as director of health policy planning at Johns Hopkins Medicine, says the program has not only improved access to care, but has also increased patients’ involvement in their own health through their small financial investment and the relationships they build with primary care providers and patient navigators. Similarly, she believes that TAP’s policy of reviewing and approving all specialty referrals has encouraged primary care providers to engage more deeply with their patients. “All of these things are important lessons as we move ahead in health care reform,” she notes.

By providing consistent care, the program should reduce visits to the emergency department. A study of TAP patients at Bayview’s general internal medicine clinic shows that nearly three-quarters of the 312 people seen from July 2011 through April 2012 were treated previously at Hopkins—a finding that suggests ED use, says Cook.

Additional data show that 23 percent of the patients had hypertension, 14 percent had diabetes, 8 percent had asthma or a chronic obstructive pulmonary disease, and 3 percent had kidney failure.

 “These patients need to be in primary care so that doctors can maximize their therapy for diabetes and hypertension, which are the leading cause of kidney failure,” Cook says.

She points out that through TAP, underinsured and uninsured patients also gain access to comprehensive primary care. The medical director denies about 10 percent of the specialty referrals she reviews from providers, usually hospital residents, to ensure that the initial treatment is thorough.

 “Before sending a diabetic patient to a podiatrist, for instance, I want to be sure the physician has done a thorough job of examining her feet,” Cook says.  “We don’t just push referrals as primary care doctors; we evaluate the whole body.”

Cook says some young doctors believe that TAP’s review process helps them think more systematically about the best way to manage patients. Sarah Polk, who directs the children’s medical practice at Bayview, says TAP also permits pediatrics residents to learn more about their patients’ home environment because they can now treat foreign-born siblings of U.S.-born children who already receive care in the clinic. When a pediatrician cares for all children in a family, she says, there are more opportunities to build rapport, understand family dynamics and propose feasible solutions to problems.

Sometimes TAP provides access to essential specialty care. Polk speaks of a 10-year-old East Baltimore girl, born in Mexico, who experienced as many as two grand mal seizures a day. Because she was not eligible for government medical insurance, her seizures were untreated.

“Through TAP, we were able to connect her with Neurology,” Polk says. “She just started this school year seizure-free.”

Without such care, she says, the developmentally normal child would be defined by her impairments. “It’s hard to imagine how a child could enjoy the academic and social benefits of school with daily seizures,” Polk points out. “Now she and her parents can focus on the routine challenges of childhood.”

—Linell Smith