Development and Implementation Grant
Requirements
                            Phase Two National Press Release

getCare HEALTH PLAN
Louisville, KY

  

 

        Objectives

The Vision:  There will e an effective permanent system for low-income, uninsured adults to receive appropriate timely and affordable healthcare.

The Mission:  The mission of the Communities in Charge Coalition is to create and implement an appropriate healthcare delivery system for uninsured adults who live in Jefferson County; are ages 19-64 and have a household income at or below 200% of the Federal Poverty Level (FPL).

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        Program Design

The Louisville Jefferson County Communities in Charge Coalition is a 115-member organization representing community healthcare stakeholders including hospitals, safety-net providers, University of Louisville, physicians, behavioral health/substance abuse experts, state and local governments, faith institutions, businesses, and healthcare consumers.  In August 2001, the Coalition formed a not-for-profit corporation to oversee development and operations of its programs for the uninsured in Jefferson County.

The Coalition has seven working committees to channel the skills of participants:  Finance, Information Systems (IS), Public Information and Outreach (PI & O), Research Care Coordination, Behavioral Health and Consumer Advisory.  The Coalition's diversity of volunteer expertise and interests are critical to successfully implementing and funding its programs.

It is estimated that there are approximately 46,000 uninsured adults in Jefferson County who meet the eligibility standards identified in the mission statement.  The Coalition is committed to developing a members benefit package available to all individuals eligible for services.  However, it is believe that like most communities there is a small percentage of this population who because of chronic illness, lack access to specialty care and poor disease management in utilizing a disproportionate amount of indigent healthcare resources.  This group of medically fragile individuals is thought to most benefit from coordination of care in medical/social case management model.  The community, therefore has chosen to enroll a small group of these patients in a demonstration project that is designed to test availability of services, eliminate duplication of efforts, and to develop system changes to improve health outcomes and diminish costs of care.

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        Financing & Outreach Strategies

Financing Strategy

After testing the medical, social and behavioral health/substance abuse treatment systems, with the pilot population, plans call for expansion of the services to more eligible members.  The coalition is negotiating with safety-net providers and government leaders to reinvest the achieved savings back into programs for expansion to the broader population.  In addition, a community-based effort to create a return-on-investment strategy is underway that would quantify cost benefits for the community at large, i.e., businesses, government, healthcare consumers and providers.  This information will be sues to help perpetuate the program in the coming years.

Care Coordinators

Care Coordinators perform a variety of functions to facilitate community-based care.  The program will employ a diverse team of professionals, including social service specialists.  The team will assist patients in accessing needed specialty care, behavioral health/substance abuse services, transportation, home health, and equipment and disease monitoring tools.  They will promote healthy behaviors, conduct patient education, conduct health risk assessments, client tracking and patient satisfaction evaluations.  Care Coordinators identify clients who likely qualify for SSI benefits and would with legal aid qualify them and secure coverage.  Care Coordination caseloads are expected to be 25-50 clients.  Referral into the Care Coordination Program will be by healthcare professionals, clients, or family members.  Client Participation in the program will be optional.

Delivery System

Health Care Services

Healthcare services are being provided by existing safety-net providers, including University Hospital and clinics, the FQHC's and private practice physicians.  All enrollees will have access to comprehensive healthcare services including a medical home for primary care, specialty care, diagnostic testing such as lab work and x-rays, pharmacy assistance, care coordination, inpatient/outpatient hospital services, 24/7 nurse help line for medical advice and behavioral health/substance abuse services.  Efforts are underway to expand services to include ambulance services, home health, medical equipment and dental care.

Inpatient/Outpatient Hospital Services

Inpatient and outpatient hospital services will be provided by University Hospital to the extent that space and financial resources allow.  Physicians who do not have privileges at University may refer patients to University of Louisville for care and then resume oversight for follow-up care.  Other hospitals will absorb inpatient care above University capacity or when a physician from another hospital opts to oversee care during inpatient/outpatient treatment.

Covered hospital services will include those services provided to Jefferson County residents through the Medicaid Program.

24/7 Nurse Help Line

Enrollees will be issued a telephone number to receive basic health information or advice on whether symptoms warrant emergency treatment.  The telephone line will be linked to registered nurses who will be available to receive calls 24 hours a day 7 days a week.  The service will be patterned after another successful program in the community which has proven effective in reducing inappropriate ER usage among Medicaid patients.  The telephone number will be listed on each enrollee's membership card.

Pharmaceutical Assistance

A proposal submitted in Health Kentucky Inc., would extend to comprehensive drug formulary to all Communities in Charge members in Jefferson County.  Using this formulary, prescriptions would be filled at clinic and hospital pharmacies as well as community-based private pharmacies.  Participating drug companies have agreed to replenish the pharmacy's stock of medications for eligible clients.  Participating pharmacies would wave their usual dispensing fees.  Under the proposed agreement, drug companies would continue to replenish the pharmacies stock for KPC-issued drugs, but pharmacies would receive normal dispensing fee for private patients between 100 and 200% of the federal poverty level.  The patient would pay this charge as a co-payment at the time the prescription is filled.

Diagnostic Testing

Diagnostic testing such as lab work and x-rays will be performed primarily by University Hospital, its clinics and the community health centers.  A member who chooses one of the clinics as his/her medical home, will continue to receive basic lab and x-ray services that extend beyond the capability to the community-based facilities.  The same services will be provided for patients being treated by the hospital and its clinics.  The University of Louisville Hospital leadership has pledged to provide these services, like other hospital services, up to maximum financial and facility resource capacity.

Other hospitals will perform diagnostic testing beyond University capacity or at the request of a participating physician.  Negotiations will be conducted with private labs in the community to provide services for the physicians who customarily refer patients to them.  Health Kentucky which sponsors the Kentucky Physician Care Program, has an informal agreement with Smith Kline laboratories and may be extended to serve Communities in Charge as well.

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        Accomplishments to Date

The Louisville Jefferson County Communities in Charge Coalition successfully completed Phase One of The Robert Wood Johnson Communities in Charge grant program during 2000.  This successful completion included the building of a highly effective coalition, researching the issue of access to healthcare for the low-income uninsured, raising community awareness, developing a plan for improving access to low-income uninsured, developing a financing strategy and successfully completing Phase Two grant to secure implementation funding for this plan.

At the time Jefferson County, Kentucky submitted the Phase One Robert Wood Johnson Foundation Communities in Charge grant application, the Louisville Jefferson County Communities in Charge Coalition was a concept.  The concept was to build on the foundation of collaboration within the medical community that had developed over an extended period of time.  An extensive communications and public awareness campaign was used to invite participation in the Coalition of the initiation of Phase Two.  Ninety-five individuals have joined the Coalition, representing a broad array of stakeholders with an interest in improving access to healthcare for the uninsured in Louisville, Jefferson County.

Most recently, the Public Information and Outreach Committee went through the arduous process of searching for a new name to market the program.  The committee chose getCare Health Plan.

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       Challenges

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        Contact Us

Wendy Ward
Executive Director
getCare Health Plan
552 E. Market Street, 2nd Floor
Louisville, KY 40202
Phone: (502) 583-4690
Fax: (502) 583-1978
E-mail: 
wward@getcarenetwork.org


       
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 Communities In Charge 2002 is a program of The Robert Wood Johnson Foundation.
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