Dale was homeless and uninsured when he moved to Santa Cruz last year to live with his sister. Shortly after that, he ended up in the hospital and underwent emergency surgery. On top of his surgical recovery, he suffers from mental health problems and diabetes.

Dale (not his real name) is the type of patient the Health Improvement Partnership of Santa Cruz County is aiming to assist with its second health navigator pilot project. Due to launch in August, the project will help people who have limited access to medical care travel the often complicated road from hospital bed to recovery, because those patients are often the most likely to land back in the hospital.

“We need to provide these services because we’re a compassionate community, but we also can’t afford not too,” said Eleanor Littman, Executive Director of the Health Improvement Partnership (HIP), a coalition of hospitals, a local low-income health plan, the Santa Cruz County Health Services Agency, private physicians, philanthropies and safety net clinics.

Based on the success of its 15-month 2010/2011 health navigator pilot that served 192 people and ended last August, HIP intends to expand the scope of this new pilot and build a business plan to sustain health navigators in the county.

The new pilot will target 250 patients annually for three years and is projected to cost $900,000. HIP has lined up funding, grants and in-kind services to pay for the first year. They recently secured a $200,000 grant from the California Wellness Foundation to continue the coordinator position for three years.

A program coordinator/nurse will lead the team, and HIP is currently recruiting for that position. A bilingual county-employed nurse navigator who will work predominantly at Dominican Hospital and Watsonville Community Hospital, and a bilingual county-employed mental health specialist are already on board. The search for a volunteer consulting MD is under way and contacts at four primary care clinics in the county will also join the team.

“Having somebody following us, making sure the hospital care plan is carried out, is very comforting to the hospital care team,” said Janice Sanning, Director of Case Management at Dominican Hospital Santa Cruz. “It’s like a safety net.”

While a patient is still in the hospital, the goal is to create a plan addressing all of their needs. The team will help patients fill prescriptions, make sure they understand the home care instructions, coordinate follow-up doctor’s visits and ensure access to primary care so they don’t end up in the hospital again. The team may also connect patients with community clinics for mental health or substance abuse problems and to social services for health insurance, housing, food and transportation, said Jordan Turetsky, Program Analyst for HIP.

 

“It’s just so obvious to me that for this population, folks who already have a lot of issues in their lives, it’s a really critical thing,” said Christine Sippl, Senior Health Services Manager for the Santa Cruz County Health Services Agency’s Homeless Persons’ Health Project.

Getting patients insured consumed most of the resources in the previous pilot. During the first half of this new pilot the team will focus largely on newly insured people under MediCruz Advantage, a low-cost county and federally-funded health plan. In January 2014, under the Affordable Care Act, members of MediCruz will roll over to Medi-Cal and the health navigator program will serve any low-income adults in the county at risk for avoidable hospital use.

In Dale’s case, the health navigator helped enroll him in MediCruz Advantage while he was in the hospital. She made sure he had access to the right medications upon discharge, not a simple task given that at one point he had 11 medications, said his sister, who asked not to be identified. And the navigator made sure he got connected with a mental health clinic.

Dale is doing much better now. He’s on social security and is living in subsidized housing in Watsonville. His sister is certain things would have gone much differently without Dianna, Guzman, the health navigator in the first pilot.

“Without Dianna, we wouldn’t have had a clue what to do,” said Dale’s sister. “She was a Godsend.”

In the 2010/2011 pilot overall re-hospitalizations, meaning patients re-admitted to the hospital 30 days after being discharged, decreased nearly 10 percent for MediCruz Advantage patients at the participating Santa Cruz County hospitals. At Dominican Hospital alone re-hospitalizations decreased almost 20 percent, HIP stated in its pilot evaluation.

And it’s not just uninsured homeless people with substance abuse problems who are using the hospital for health concerns that could have been headed off earlier in a primary care doctor’s office.

Patrick Shields, a full-time hospitalist and Medical Director for the Department of Hospital Medicine Palo Alto Medical Foundation, Santa Cruz Division, recalls one patient who was marginally gainfully employed but couldn’t afford insurance. Shields treated her several times in the hospital.

“She fell in that middle area. We see that all the time,” he said. “When someone doesn’t have a primary care doctor, they let things go.” Health navigators can improve a patient’s quality of life, he said. “So I don’t have to worry as much about patients when they leave.”

Sanning of Dominican Hospital believes that the emergence of new models for compensating healthcare providers will prompt them to make patient care more effective and cost efficient and that there will be incentives to make programs like health navigators sustainable.

“Now healthcare providers get paid more when people are sick,” Sanning said. Regardless of what happens with the Affordable Care Act, change is afoot, she said.

“Our Healthcare industry is going to move to better quality and more efficient care,” she said. She points to motivators like the Centers for Medicare & Medicaid Services proposal to cut compensation to hospitals with high readmission rates.

The Healthcare Cost and Utilization Project, which provides data used by the U.S. Department of Health and Human Services, reported last year that among 15 states selected for its report, 24.4 percent of Medicaid patients aged 45 to 64 who had been admitted to the hospital in 2008 were readmitted within 30 days of being discharged.

In 2011, the Central California Alliance for Health, a nonprofit health plan serving more than 200,000 low-income members in Santa Cruz, Monterey and Merced counties, had a 13 percent hospital readmission rate after 30 days, said Alan McKay, executive director of Alliance. And as of February 2012 32 percent of its medical budget paid for hospital admissions, McKay said. That includes long term care costs.

And a large percentage of the health plan’s budget goes to a small percentage of members. In 2010, the Alliance reported that only 8 percent of members accounted for 75 percent of costs.

“We were astonished to find such a high cost concentration,” McKay said. And of those 8 percent 70 percent of them had mental health issues or a chemical dependency as well, he added.

That jibes with data HIP gathered during its 2010/2011 pilot. Of the 192 uninsured, low-income adults who were assisted, 52 percent had mental health and substance abuse disorders, and needed help connecting with community-based behavioral health services, HIP reported.

The need for health navigators seems clear and the results of early projects are promising. But can these programs survive while they prove themselves cost effective? Sanning of Dominican Hospital is optimistic.

“If we’re going to move from paying for sick care to paying for services to keep people well, then somebody will decide to pay for this,” she said.