RICHLAND CARE
Palmetto Health Alliance
Columbia, SC

April 2000

        §       Background

Health and Human Service Providers in Richland County have had a long and productive history of collaboration in addressing priority health and human service needs.  Although a number of collaborative initiatives have existed in the county for some time, the first formal structure designed for interagency/organizational cooperation and collaboration was formed in 1995.  The organization of Richland Community Health Partners (RCHP), was chartered as a non-profit corporation in the state of South Carolina for the purpose of planning, developing and implementing an integrated health and human service delivery system, which targeted the county's low-income residents.  Since 1995 RCHP, has provided a revenue of interagency collaboration address gaps to reduce duplication of services.  Current RCHP members include representatives from the following organizations:  Palmetto Health Alliance, Richland Community Health Care Association, Eau Claire Cooperative Health, Richland County Health Department, Cooperative Ministries, Richland County Government, Richland School District 1, Richland School District 2, Columbia Area Mental Health Center and the Central Carolina Community Foundation.

Priority concerns have included the organization and financing healthcare for older persons with chronic illnesses, the development of an integrated health and human service delivery system for low income persons and building systems of outreach and service delivery to reduce infant mortality among high-risk pregnant woman in Richland County.

In developing the Richland Care Community Coalition, we plan to utilize the Richland Health Start Model, in which RCHP members formed the nucleus of a much larger group whole sole purpose was to advise a specific initiative.  The initial meeting of the Richland Care Community Coalition was held on February 9th.  The attendees included RCHP members as well as representatives from the state's Medicaid Agency and Columbia Free Medical Clinic.  The University of South Carolina School of Medicine, and the Ryan White-funded Clinic for persons with HIV/AIDS.  We anticipate that the membership of the coalition will evolve over time as additional organizations and individuals are identified and asked to join the project.

The Palmetto Health Alliance (PHA) was one of the founding members of RCHP and has been an active participant and leader.  PHA provides inpatient and outpatient hospital care and services through two hospitals located in Richland County.  PHA was formed in 1998 through a merger of Richland Memorial Hospital and Baptist Medical Center of South Carolina.  As a condition of the merger, PHA received approval Certificate of Public Advantage from the South Carolina Department of Health and Environmental Control.  In order to obtain this approval, PHA agreed to make certain community health investments and provided medically necessary care to Richland County residents, regardless of their ability to pay.

Palmetto Richland Memorial Hospital, which is affiliated with the University of South Carolina School of Medicine, serves a tertiary referral hospital for the central portion of South Carolina and is the predominant provider of inpatient hospital care and services to the uninsured persons in the county.  In addition to Palmetto Richland Memorial Hospital, the county is fortunate to have two federally funded community health center organizations:  Richland Community Health Care Association and the Eau Claire Cooperative Health.  These organizations operate five health centers in the county.  The Richland County Department also provides preventive and personal health services to uninsured persons.

Richland County will be an organized healthcare delivery system, which will provide basic primary, subspecialty and acute care and access to pharmaceuticals, for selected target groups of low income uninsured persons in Richland County, South Carolina.  The healthcare delivery system will be a collaborative initiative of safety providers, i.e., community hospitals, graduate medical education programs, and community health centers, and elected officials social service organizations and healthcare consumers.  

The vision for Richland County Care would be to establish a coordinated healthcare delivery system for a select subgroup of uninsured persons.  This healthcare delivery system would emphasize establishment of a medical home and use of primary care and provide access to acute care, subspecialty care, prescription drugs and social services as needed.

Financing

Our financing strategy recognized the complexity of the financing problem in the absence of a specific federal and/or state program to provide access to health insurance for low-income persons.  Can we coordinate agreements and procedures to be used to facilitate access and care?

We have included the South Carolina Department of Health and Human Services as a member of our community coalition.  Together, we will be exploring ways in which to increase Medicaid eligibility to parents of CHIP children.  Another potential source of governmental support is local option sales tax, state law permits local option increases, but the majority of the funds raised through this method are required to be used to offset property taxes.  Even with this requirement, sizable amounts of new funds for healthcare for the uninsured could be raised.  Other new funding options which have proven to be successful in other communities will also be explored.

As a condition of approval of the Certificate of Public Advantage, PHA assumed responsibility for provision of medically necessary acute care for low-income persons.  This agreement formalized the previous practice of Richland Memorial Hospital.  However, there is not currently an organized program to institutionalize this commitment.  

Outreach Strategy

The plan for Richland County includes a targeted, marketing initiative based on the selected subgroups of the uninsured population.  We recognize that previous approaches, such as "if we build it they will come," will not achieve enrollment for many low-income persons.  Therefore the marketing plan will be culturally appropriate and will utilize multiple approaches to identify and enroll our target population.  Our health and human service providers will facilitate the marketing and enrollment process.  Existing enrollment and income verification processes such as the process and forms used in the South Carolina Medically Indigent Assistance Program, will be considered for this program.

Uninsured persons who are enrolled in Richland Care will receive an identification card that will be accepted by Richland Care Providers.  We will develop a system for tracking encounters and services to Richland Care enrollees.  Tracking service utilization is important to the success of the program.  Consideration will be given to existing computer systems and resources.  The System Administration subcommittee of the community coalition will assist project staff in the development of this portion of the project.

Delivery System

We recognize the lace of an organized healthcare delivery system for the uninsured persons is a major detriment to a community's ability to successfully address this problem.  Initially, we plan to thoroughly evaluate the community's current healthcare delivery system resources, which are to devote caring for the low income uninsured persons.  We are aware of the number of resources that could be better organized and coordinated.  These resources will be organized with Richland Care's delivery system to reduce duplication and attain maximum efficiency and effectiveness.  We also anticipate that this process will identify gaps in the basic service delivery system.  For this reason, we plan to "start small" with a subgroup of the uninsured population in order to maximize the potential for success.  Additional services and subgroups of uninsured persons will be added as resources are identified.

A Health Care Delivery System subcommittee of our community coalition has been formed to assist project staff in the planning effort.  Staff from the partnering organizations have been designated to participate in this activity.  The partnering organizations include all community hospitals, the two federally funded community health centers, the graduate medical education/residency training programs, the Columbia Free Medical Clinic, and the County Health Department.  Other individuals and organizations will be added to the subcommittee's membership as the planning process develops.

There are several potential barriers to the success of the project.  Project staff are aware of these issues and their complexities.  First the US Public Health Service has funded the two community health centers for one year and has indicated that only one organization will be funded in 2001.  These two organizations which are extremely important to the success of the Richland Care, had discussions in the past regarding consolidation/merger.  Richland County Council is presently working to bring the two organizations together.  The outcome of future organizations is unclear and could adversely or positively affect these organizations participation in the program.

Financing portions of the delivery system will be a challenge, especially those areas in which gaps in service are identified.  We believe that an incremental approach will be the most successful method of dealing with its issue of assuring continuing success of the program.

We are also concerned with the willingness of the target population to enroll in the delivery system.  Uninsured persons' values, priorities and healthcare service patterns must be recognized and accommodated in the planning process.

The target area for this project is Richland County, South Carolina.  The County's land mass is approximately 770 square miles, comprised of urban, suburban and rural areas.  The estimated 1996 population was 292,600.  The City of Columbia, the state's capital has 103,500 residents at the time of the 1990 census.  Twenty-one percent (21.2%) of these South Carolinians had income less than 100% of the federal poverty level.  The racial composition of the county is approximately 56% White and 43% African-American.  The numbers of other minorities (Hispanic, Asian, and Native American) are growing, but they currently represent a small portion of the total population.

A 1998 study by the South Carolina Health Alliance estimated that the average daily uninsured population in Richland County was 46,500 and 11,900 (25.6%) of this group were estimated to have incomes less than 100% of the federal poverty level.  During Year 1 of this project, we will conduct further studies of the uninsured market in order to segment this group based on parameters such as income, geography, age, health status, employment status, ability/willingness to pay premiums, and other characteristics which will facilitate development of the delivery system and financial/business plans.

Thomas E. Brown, Jr., Dr. PH, MBA  
Assoc. Professor of Medical Education & Research
Palmetto Richland Memorial Hospital
Five Richland Medical Park Drive
Columbia, SC 29203
Phone: (803) 434-4077  
Fax: (803) 434-4419
E-mail:  tom.brown@rmh.edu