Frequently Asked Questions Regarding Project Access for Clinicians
1. What is Project Access?
Project Access (PA) is an organized system of charitable health care covering the spectrum from prevention through acute and chronic treatment, provided at no charge to low income uninsured people, on a voluntary basis, by physicians and other health care practitioners, hospitals, laboratories, pharmacies, and other health service providers. This system, implemented in many communities around the US, is based on the original Project Access model developed in Buncombe County, NC in 1995.
Though PA is only a partial solution to the inefficiencies and inequities of our current health care system, in many communities it is helping to improve health and reducing costs by coordinating timely care and follow-up, reducing inappropriate utilization of emergency departments, etc.
2. Why is this needed here?
There are an estimated 20,000 low income (income at less than 200% of federal poverty level) uninsured (and not eligible for Medicaid, NC Health Choice, or Medicare) in Durham. Each year, a significant number of these people find it difficult or impossible to obtain appropriate medical services when needed.
3. I already donate “charity care” through accepting reduced fees, etc. Why should I do more?
Project Access is NOT intended to discourage any individual or entity from continuing the charitable work they are already doing. It is hoped that PA will build upon existing services; address unmet needs; enhance coordination, timeliness, continuity, efficiency, and comprehensiveness of care; and will provide a system to track and to recognize donated care.
4. Will primary care physicians be involved?
In order for a patient to receive services under Project Access, they must have a “primary care home,” with a primary care provider who refers them for services such as specialty consultations and coordinates care. Primary care providers will assure that referrals are medically appropriate; and, to the best of their ability, will determine that patients are motivated to keep their referral appointments and adhere to recommendations. Primary care providers must be available for follow-up/coordination of care after referrals.
Durham has a good primary care “safety net” in Lincoln Community Health Center (LCHC) and its affiliated sites (Lyon Park and Walltown clinics). These sites already provide primary care to many low-income patients, most of whom lack any insurance. However, accessing timely specialty consultations, surgery, hospitalization, and other services for these patients has been challenging. Thus, the initial focus of PA will be on providing access to specialty care for patients of LCHC. It is envisioned that, if all goes well, within the first year of operation, PA will potentially be extended to include patients from other sites, including Durham’s Homeless Clinic, TROSA, Durham Rescue Mission, and both private and Duke-affiliated primary care practices.
5. Who will the program serve?
Durham city or county residents (residing in Durham for at least 6 months) who lack health insurance, and are not eligible for Medicaid, NC Health Choice, or Medicare, whose household income is at or below 200% of federal poverty guidelines, and who attest that they lack sufficient assets (savings, stock, bonds, property, etc.) to pay for their health care expenses.
Initially, all participants must be current patients of Lincoln Community Health Center (or its satellite clinics). They must be established with a primary care provider at LCHC, must have visited with their LCHC primary care provider within 30 days of the referral request, and must follow up with their PCP for continuing, coordinated care.
6. How will eligibility be determined?
If patients are identified by their primary care provider as needing specialty/diagnostic/ hospital services, that provider may refer them to PA for eligibility screening. Patients will be screened for eligibility at Lincoln Health Center or affiliated LCHC sites by Project Access staff. Eligibility will be reviewed every 12 months.
As the program expands to serve patients in primary care “homes” other than Lincoln, other sites may be identified for eligibility screening.
7. Will this program “overwhelm” Lincoln’s already overburdened system?
It is not anticipated that the existence of PA will drive large numbers of new patients toward LCHC. Health care practitioners will be educated that the program is intended to serve the needs of already-established LCHC patients. It is also anticipated, based on Buncombe County’s experience, that primary care at LCHC will become more efficient as less time/fewer visits are taken up with trying to arrange specialty consultation for patients and as more definitive evaluation and management plans can be accomplished earlier in the course of an illness. It is anticipated that primary care providers will routinely receive feedback and education from participating specialist consultants about how to optimally manage common conditions and utilize consultative services most appropriately.
8. How will patients be enrolled?
Project Access staff will be responsible for enrolling patients, educating them regarding their responsibilities under PA (for instance, keeping appointments or canceling them with sufficient notice, following medical advice), and presenting them with membership cards which are good for 12 months.
9. There has historically been a very high rate of “no-shows” for Lincoln patients keeping specialty consultation appointments; will this be any different?
In Buncombe County the “no-show” rate for specialty consultations for Project Access patients is less than 5%! Staff there attribute this to thorough education/orientation of patients regarding their obligation to keep appointments and consequences for not doing so (3 missed appointments leads to dismissal from the program), reminder calls, and assistance with transportation as needed.
10. What about the Emergency Department?
PA patients will be educated about appropriate ED utilization and encouraged to contact their primary provider first when acute (but not obviously life-threatening) conditions arise. Project Access will not cover Emergency Department care.
11. How much service am I being asked to commit?
It will be the practitioner's choice how much care to donate. However, we are requesting that participants make a yearly pledge to provide 12 "episodes of care." (An "episode of care" may be one visit or procedure, or several, as needed to diagnose and treat a particular condition. Each “episode of care” may extend over no more than 3 months, though additional 3 month referrals for the same condition may be authorized as appropriate.) Given the nature of problems addressed by different specialties (e.g. acute, diagnostic, or preventive services) opposed to chronic disease management, it might make sense for some practitioners to commit to more, or to fewer "episodes of care."
Download/view a physician commitment form. (Word file)
12. How easily can I change my level of commitment or even drop out if I don’t wish to participate?
Since this is a volunteer service, providers may change their level of commitment at any time. However, we of course request that providers work with PA staff to assure that patients currently under care are not compromised.
13. How will service commitments and utilization be tracked?
Software developed for PA will be used to track volunteer commitments and utilization.
Providers will be asked to complete a standard HCFA 1500 claim form, indicating diagnoses and CPT code. While no actual charges will be generated or paid, this form will be processed by Physician WebLink (PrimaHealth) to track and report utilization and the “value” of all donated services.
14. Who is contributing services?
Physicians, physician assistants, and nurse practitioners from across the community are all being recruited to volunteer their time. Those donating time will be publicly recognized for their contributions.
Duke, Durham Regional, and North Carolina Specialty Hospitals are all donating hospital services; including inpatient stays, diagnostic and ancillary services, and operating room charges. LabCorp will donate lab studies. Durham Diagnostic Imaging and Atlantic Diagnostics have agreed to provide diagnostic imaging. The success of this project hinges on a high level of participation. If everyone does their part, no one has to do too much. In Buncombe County, more than 90% of physicians participate in PA.
Duke, Durham Regional, and North Carolina Specialty Hospitals will all be donating hospital services; including inpatient stays, diagnostic and ancillary services, and operating room charges. LabCorp will donate lab studies. Negotiations are in process with diagnostic imaging companies. The success of this project hinges on a high level of participation. If everyone does their part, no one has to do too much. In Buncombe County, more than 90% of physicians participate in PA.
15. Where will patients be seen?
Initially, all patients must have as their primary care home one of the Lincoln sites. Specialists may see patients in their own offices. If they prefer, it may be possible for them to do their PA consultations at another location, such as Lincoln Community Health Center.
16. How much paperwork will be involved in my seeing these patients?
Every effort will be made to keep the paperwork from being burdensome. As always, accurate medical records will need to be maintained. A standard HCFA 1500 claim form will need to be completed to assist with utilization tracking. Consultation reports will be sent to referring providers, as usual.
17. How will program participants receive medications?
Outpatients will receive most-commonly prescribed medications from the Lincoln Community Health Center pharmacy or from the Duke pharmacy (for patients seeing a Duke-affiliated specialist) for a modest co-pay (probably $5). Limited funding will be available to help pay for necessary medications not available on Lincoln’s formulary. Patient assistance programs will be utilized as appropriate.
Inpatient prescription medications will be filled by NC Specialty Hospital or Duke University Health System.
18. How will patients get referrals?
Patients will be referred for specialist care from their “primary care home” (see #15). Primary care practitioners or specialists may refer PA patients for hospitalization, for diagnostic and therapeutic procedures, or emergency department services. Specialty consultations will be scheduled via the PA central office, which will select consultants in rotation from the list of those participating. Each referral to a specialist consultant will authorize service for up to a 3-month period of time. Care beyond that period of time will require a new referral. Patients will present their PA cards at the time of presenting for service.
19. What about language barriers, transportation issues?
PA will employ bilingual staff to assist those with limited abilities in English. Transportation needs will also be addressed by the program. A chronic disease/care management component will also be in place through contracting with an entity with expertise in this area (LATCH). Essential patient education services will be included (for example: smoking cessation, healthy nutrition, weight management, physical fitness).
20. How will labs or imaging studies be obtained?
Physicians and other participating providers will order lab and radiology studies according to normal practice. Providers of lab and radiology services have agreed to donate their services to PA patients.
21. How is this being organized, managed, and funded? Will it last?
Project Access Durham County is being incorporated as a non-profit 501(c)(3) charitable organization, with full-time paid administrative staff, including a full-time Executive Director and 2 additional staff to handle patient eligibility certification, enrollment, and orientation/education; these staff will also assist with provider recruitment and recognition and with tracking of provider commitments.
Many groups are playing leadership roles in provider recruitment and recognition, including the Durham-Orange County Medical Society, the Duke Health System/PDC, the Durham Regional Hospital medical staff, the North Carolina Specialty Hospital, and the Durham Academy of Medicine, Dentistry, and Pharmacy. PrimaHealth will assist in tracking commitments, referrals, and services provided. PA will contract with LATCH, a program with demonstrated expertise in this area, for care coordination/disease management services and for supportive services like translation and transportation.
PA will be governed by a 21-member board representing stakeholders from across the community (community and university-employed practitioners, hospitals, Lincoln Community Health Center, the Durham County Health Department, the Partnership for a Healthy Durham, the Durham Center (mental health), Durham-Orange Medical Society, local business community, the faith community, consumers, etc.). The Executive Director of PA reports to the Board.
Major start-up and continuing funding will be provided by Durham County government. Duke University Health System will maintain current levels of operating support to LCHC in addition to its contributions via PA. The Duke Endowment and the Blue Cross-Blue Shield Foundation are providing substantial support. A significant Board function will be annual fundraising.
This program has thrived in Buncombe County since 1996, largely because of broad involvement, leadership, and support from health care providers and from representatives of all stakeholder groups across the community.
22. Are there liability concerns for providers?
Duke-employed practitioners participating in Project Access with the approval of their Department chair will be covered by their Duke liability insurance. Medical Mutual and probably other medical liability carriers will cover their subscribers for this charitable activity.
In addition, NC General Statute 90-21.16 protects from liability health care professionals who render services at no charge to patients referred by nonprofit community health centers or nonprofit free clinics.
23. If physicians have problems or concerns, who will address them?
The Executive Director of Project Access, the Project Access governing board, and a medical advisory group of health care practitioners will be available to address concerns.
24. Our community is already providing a great deal of care to the low-income uninsured. How will this improve upon that? Aren’t those who most need care getting it under the current system? Is this really needed?
PA is not simply about providing care to the uninsured, or to the uninsured who are critically ill. The focus is on providing timely, coordinated, and appropriate care. This will reduce unnecessary Emergency Department utilization and other inefficiencies, allow earlier application of appropriate interventions, and lead to improved outcomes.
25. This sounds like a good program, but the number of uninsured people Project Access will have the capacity to serve will be only a minority of those in need – is it really worthwhile?
Project Access will only be a partial, and perhaps only a temporary solution. But we believe it will provide important help to a significant number of those in greatest need. In addition, the detailed information gained from tracking of utilization and costs will be very helpful as we look to others beyond health care providers – to businesses, insurance companies, state government, etc. - to step up and help contribute to the resolution of this pervasive societal problem.
26. How do I contact Project Access?
Phone: 919-470-7262
Web: www.projectaccessdurham.org
Sally Wilson, Executive Director
swilson@projectaccessdurham.org
Krystal Holman
kholman@projectaccessdurham.org
