1. Transylvania Regional Hospital Health Resources Navigation Program Navigate-To Steer; To Travel; To find one’s way and keep one’s course

2. Program Mission: To identify uninsured, low-income Transylvania county residents that frequently utilize the emergency department for non-emergent, or acute care as a result of complications from chronic medical conditions, and connect them with a medical home, medication assistance, financial assistance and any other community services that will contribute to their overall wellness and disease management.

3. Program Criteria: Uninsured residents of Transylvania County between the ages of 18 to 64 at or below 200% of the federal poverty level who come to the Emergency Department at least three times in a six month period.

4. Program Procedures and Policies: Potential clients for the Health Resources Navigation Program will be identified by:  Report abstracted from Medical Records  Daily ED reports from previous day’s patients  Referrals from the ED staff

5. Program Referral Process:  Contact potential clients from abstracted list by phone  Meet with potential clients in the ED when appropriate  Weekly meeting with ED staff to review list of potential clients  Weekly meeting with financial counselors

6. Program Enrollment:  Intake  Eligibility determined  Release and Agreement signed  ID card issued  Medical Provider assigned  Appointment scheduled if necessary  Community agencies contacted

7. Follow-up and Tracking System:  Ancillary Care for clients will be scheduled through Navigator  Follow-up with Community Resources  Client status, progress and ancillary care tracked on database

8. Program Policy:  Enrollment good for one year unless circumstances change prior to anniversary date  Adherence to Patient and Pain Management Agreement or client is disenrolled from program  If client is disenrolled medical provider’s point person contacted and client receives certified letter

9. Measurements of Success Health Improvements:  Decreased visits to ED  Patient compliance with primary care  Disease management Financial Improvements:  Decreased bad debt  Decreased overall cost of care for targeted patients  More efficient & appropriate usage of the ED

10. Patient profile: 6 Month Snapshot  Most common diagnoses: –Dental problems –Acute URI –Abdominal pain, headaches, bronchitis  296 patients = 1665 visits in 6 months  Average # of visits per patient: 5.6

11. Consistent Primary Care = one key  Primary care can lead to successful disease management AND  Overall wellness is achieved by identifying additional issues impacting healthcare and connecting the individual with resources to address those needs

12. Primary Care Keys:  TRH Physicians  Free Clinic  Etowah MAP (Medical Access Plan)  Francis Ward Health Service  Local Physicians

13. Many more hidden “keys” in the community  Alliance Counseling Services for Substance Abuse and Mental Health  Center for Women-Crisis pregnancy  Children’s Center-Victim Assistance Fund  American Red Cross-Community Education, CPR for Everyone and First Aid  WCCA’s Self-Sufficiency and SavingsPlus

14. Better Care Management = Healthcare Efficiencies  Annual targets have been set –100 patients in full “navigation” –100 patients receiving secondary navigation service –Reduce uninsured ED visits among targeted patients by 300  This is new – potential is very real. We will monitor closely and adjust efforts as needed.

15. Snapshot of potential efficiencies: 100 patients PatientAverage Charge Average # of Visits/Year & Total Charge/Patient Emergency Department (before enrollment) $450/visit (excludes ancillaries) 12 visits/year $540,000 Navigation patient in Primary Care $120/visit (excludes ancillaries) 4 visits/year $48,000

16. Transylvania Regional Hospital: Health Resources Navigation Program 2008-2009 Results

17. Annual Targets Set for First Year:  100 patients in full, Primary Navigation  100 patients receiving Secondary Navigation-those they don’t fit criteria, but receive resources  Reduce uninsured ED visits among targeted population by 300

18. October 1, 2008-September 30, 2009 Results:  98 patients in Primary Navigation  94 patients received Secondary Navigation  Uninsured ED visits among targeted population reduced by 311 visits

19. October 1, 2008-September 30, 2009  Total number of patients navigated in Primary Navigation- 98 (Target was 100)  Total number of ER visits of these 98 patients six months prior to Navigation-422  Average number of visits per patient: 4.3  Total number of visits after primary navigation-106 visits-average 1 per patient

20. Secondary Navigation Results:  94 people who had a total number of 155 ER visits prior to receiving resources  After receiving resources these people had a total of 85 visits  Total of 114 referrals made which included community agencies and other departments of the hospital needing resources for someone

21. Participant ED visits: Total # of visits Six months prior to enrollment Average # visits Per patient Total charge for visits in 6 months prior to enrollment* 4224.3$257,420 *Excludes ancillaries

22. Secondary Navigation ED Visits: Total # of visits to ED prior to receiving resources Total # of visits to ED after receiving resources: Total charge for visits before and after receiving resources: 155 85 Before: $94,550 After: $51,850

23. Participant PCP/ED Visits: Total # of PCP visits since enrollment Total # ED visits since Enrollment Average # of visits per enrolled patient since enrollment Total charges for visits since Enrollment (Does not include ancillary) 32497 ED: 1 PCP: 3.3 ED: $59,170 PCP: $41,200

24. Charge Comparison for Primary Navigation Patients Total ED charge for patients 6 mos. Prior to enrollment: Total charge for patients 10/1/08- 9/30/09: Variance (System-wide): $257,420 @$610 per visit (no ancillary) $152,121.31 (includes ancillaries) $105,298.69 plus secondary: Total Savings: $153,608.65

25. Additional Measures:  10 participants enrolled in Medicaid  1 participant got private insurance through her employer

26. Who do we thank?  Dr. Frederick Bahnson-donated consults,discounted procedures  Dr. Leland Berkwits-discounted rates  Dr. Carmello Hernandez-donated consults  Dr. Gerald Martin-seeing patient  Dr. Dale Nash-advisory role, seeing patient  Dr. Minerva Pinerio-seeing patient  Dr. Emily Sawyer-advisory role

27. And more…  Asheville Radiology-for discounts  Asheville Cardiology-for donated echocardiograms  Brevard Racquet Club-a 6 week scholarship  Children’s Center of Transylvania County-Victim Assistance Fund for counseling  Carolina Mountain Gasroenterology-for a consult  PML Lab for donating all pap smears to Navigation patients  Toxaway Charities-Medications, diagnostics, labs and specialty care for Dr. Buehler’s patients who are Toxaway residents All the scheduling people and office staff in the practices for fitting patients in that would have otherwise gone to the ED

28. What have we learned?  To be more aware and discerning when interviewing potential Navigation patients in relation to chronic pain issues  Educating potential clients more about the limitations of the program (Specialty care)  More reminders to clinical assistants about what resources are low cost or free to the uninsured such as pap smears at the health department, discounted medications,etc.

29. What’s Next?  Meeting with other area providers of the uninsured to brainstorm about a regional approach to specialty care  Transitioning Navigation clients after their first year of care into the Patient Assistance Program  Emphasis on preventative approach and secondary navigation in ED during first or second visit

30. Targets for Primary and Secondary Navigation 2010 Primary Navigation October-September 2009-2010:  25 new patients enrolled as of 6/22/10  Target for 2010: 50 new enrollees Secondary Navigation October-September 2009-2010:  332 patients seen and given resources in the ED during first or second visit as of 6/22/10  Target for 2010: 300 patients

31. Any Questions? Thank you again! Di Ucci, MA Ed., LPN Transylvania Regional Hospital 260 Hospital Drive Brevard, NC 28712 828-885-5732 ducci@trhospital.org 828-883-5111 Fax