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Johns Hopkins Medicine - Expanding the Boundaries of Care

November 2009

Expanding the Boundaries of Care

By: Linell Smith
Date: November 16, 2009

Through The Access Partnership, Hopkins reaches out to more uninsured and underinsured patients in East Baltimore.

Last December, Nellie Bell began an uncertain medical journey when a sonogram revealed that her fibroids had grown. She and Deborah Martin, her gynecologist at the East Baltimore Medical Center (EBMC), agreed that a hysterectomy would be the best course of action.

But how would the 56-year-old day care provider pay for it? Bell made just enough money looking after children in her row home to support herself and her 5-year-old grandchild. As a self-pay patient at EBMC, Bell faced the classic health insurance dilemma: too much income to qualify for Medicaid but not enough to buy reliable coverage on the open market.

She was rescued by a six-month-old program that helps uninsured and underinsured patients receive specialty health care at The Johns Hopkins Hospital. Thanks to The Access Partnership (TAP), Bell finally had a hysterectomy in August. When that surgery revealed leiomyosarcoma, a rare cancer that affects certain muscle cells, the partnership also arranged for her to see a cancer specialist. Bell is receiving chemotherapy at Sidney Kimmel Comprehensive Cancer Center.

Before Hopkins launched the program last May, EBMC patients like Bell could not get diagnostic tests and other special care recommended by their primary care physicians because they could not afford to pay in advance. Now qualified patients pay a one-time fee of up to $20 for a referral and receive no additional bills. “The people here at EBMC have all been like angels to me,” she says. “This program has been a blessing.”

Five ZIP Codes

All Hopkins specialty physicians donate their services to the program, which was created in response to a proposal by Hopkins’ East Baltimore Community Clinic Task Force. Formed after the closing of the Caroline Street Clinic for the Uninsured in 2006, the group of physicians, administrators and medical students set out to determine how Hopkins Medicine could best serve its uninsured neighbors who demonstrated financial need.

One recommendation was to place them in primary care clinics, such as EBMC, that already serve low-income residents. Another was to improve these patients’ access to Hopkins specialty care. Cardiac surgeon William Baumgartner, president of the Clinical Practice Association, chaired the committee that led to TAP’s creation.

Since it started, the fledgling program has proved so successful that it has expanded from covering EBMC patients living in two ZIP codes (21205 and 21213) to include clinic patients from 21202, 21231 and 21224. Roughly 1,130 patients who live near the East Baltimore and Bayview campuses are now eligible.

Barbara Cook, medical director of the partnership and former president of Johns Hopkins Community Physicians, screens referrals to specialists. She says one index of the program’s effectiveness is the high number of patients who keep their referral appointments. During the first five months, only two of 82 referrals scheduled for diagnostic tests and other specialty-care appointments were not kept. In contrast, the no-show rate in EBMC’s resident clinic can be as high as 50 percent, according to Hopkins internal medicine resident Lauren Block.

Cook says these statistics demonstrate the effect of thorough and compassionate treatment.

“If you take care of people in a respectful way, they’re going to do the right thing,” the physician says. “I’m also struck by the willingness of the specialists and their staff to work these people in.”

Now that the program is in place, administrators will also track participants to learn whether receiving such coordinated care reduces their emergency department visits, says program director Anne Langley, a strategic planner for Johns Hopkins Medicine.

Lessons in Primary Care

Not only does the program bridge a crucial medical gap, but it also teaches internal medicine residents primary care that is careful and cost-effective. Cook makes sure that referring physicians try standard treatments before calling specialists. So far she has turned down several dozen referrals. “Primary care doctors, for example, are supposed to treat all manner of foot ailments,” she points out. “So if a podiatry referral comes in for a diabetic patient with no evidence that the doctor looked at the patient’s feet, I send it back.”

She denies requests for MRIs for back pain unless records show that physical therapy, analgesics and other conservative measures did not work. She has also refused four sleep study requests.

“If a person weighs 300 pounds and is snoring at night, you can pretty safely say that they have sleep apnea,” Cook says. “But if they can’t afford the equipment they need to treat it, why pay the money to do a study? Instead, what the patient really needs to do is to lose weight and try other things to improve sleep hygiene.”

So far, most approved referrals have gone to radiology, cardiology and ophthalmology. Specialists in orthopedic surgery and physical therapy have also donated their time to treat patients.

Nellie Bell says the support she receives from program coordinators Antoinette Johnson and India Barnes is also vital therapy. The two women collect fees from patients, schedule their appointments at the specialty clinics, and remind them of the time and location of their visits. In addition, they keep in touch with patients like Bell to make sure they’re recovering well.

“Before TAP, I don’t know how we would have taken care of Nellie,” says Pam Mahoney, Bell’s primary care provider. “It would have been very difficult for her to get a hysterectomy. Months would go by where our patients would simply have to linger with abnormal studies and various conditions while a person with health insurance would be taken care of right away.”

The nurse practitioner says The Access Partnership implements Hopkins’ mission to deliver care to people in its neighboring communities.

“It makes you feel like you can finally do what you’re supposed to do,” she says.

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