The Medical University of South Carolina (MUSC) in Charleston hasn’t solved the issue of care transitions for the indigent, “but we have thought about it a lot,” says Neal Axon, MD, MSCR, FHM, assistant professor in the Division of Hospital Medicine at MUSC. The hospital is experimenting with quality-improvement (QI) techniques learned through participation in SHM’s Project BOOST.
“The first principle I try to teach residents is that a good discharge for a patient without insurance is the same as a good discharge for a patient with insurance,” Dr. Axon says. “Many of the same principles apply.”
If the care plan fails to address basic needs of indigent patients, including access to housing, primary care, and affordable medications, that patient won’t be able to focus on their medical needs.
Affiliated primary-care clinics already see a high percentage of indigent patients, Dr. Axon says, so there might be some pushback when the hospital team attempts a new referral. “We have tried to distinguish between care that needs to be done in the first week or so after discharge versus ongoing follow-up,” he explains. “We have negotiated with the clinic so that patients can come back here for one or two visits for urgent follow-up care without being entered into the [outpatient] system permanently. We are also blessed to have federally qualified health centers in the Charleston area. We have cordial relationships with those clinics, even if it’s not as well-integrated as I might wish.”
Another service that can be helpful with care transitions for uninsured patients is a 14-bed transitional-care unit on the hospital campus. “It provides rehabilitation and long-term care for the small numbers of chronically ill patients with long-term disabilities who don’t qualify for Medicaid or Medicare and can’t be placed elsewhere,” he says. “We’re able to care for these patients in a less costly way on the unit, rather than leaving them in an acute-care bed.” The hospital, he adds, views the unit as a cost-avoidance measure.
Some have been on the unit for months; others do much better than expected and go home. “It’s always gratifying when patients come back to the hospital to visit and thank us for the care they received,” he says.
Larry Beresford is a freelance writer based in California.