The local system for referring the uninsured did not seem to be working. The number of uninsured persons successfully appointed for specialty care was declining.

In 2007, the PHPDA retained MCPP Healthcare Consulting to evaluate the specialty referral processes for uninsured patients. They looked at specialty referrals from public health and community health centers in King County to Pacific Medical Centers and King County Project Access. The PHPDA funds the latter organizations to provide or arrange for specialty care for the uninsured.

A number of community partners participated in the work on this issue, including those who agreed to serve on the Oversight Committee. The participants included:

• Community Health Plan of Washington
• Country Doctor and Carolyn Downs Community Health Centers
• International Community Health Services
• Health Point (formerly Community Health Centers of King County)
• King County Project Access
• Neighborcare Health (formerly Puget Sound Neighborhood Health Centers)
• Pacific Medical Centers
• SeaMar Community Health Centers
• Seattle-King County Department of Public Health

The project goals were:

• Evaluate the current processes for eligibility determination and clinical referral
• Recommend changes to the referral system that would increase specialty care referrals (and visits) for uninsured patients.

Initial Status:

• Only 42% of uninsured patients referred for specialty care at PMC were submitted with eligibility application forms. Of the 42% of referrals with applications, approximately 70% were approved.
• 58% of uninsured patients referred for specialty care at PMC had NO PMC eligibility application form: hence, their referred was pended. Lack of an eligibility application form was the reason for 89% of pended referrals. This means that no eligibility application form or any supporting documentation was submitted.

Conclusions:

This is a classic systems study—which showed that well-meaning individuals were attempting to work in a system fraught with barriers and problems. The following changes were implemented:

• Uniform eligibility criteria were developed (for PMC and KCPA) using the same definitions of income and King County residency and the same acceptable documentation. A single application was developed that was then translated into multiple languages.
• Improved regular communication, standard reports and timely notification between PMC, KCPA and Public Health and Safety Net Referral Coordinators.
• Made improvements to the FAX system, which continues to be monitored for periodic problems.

As of March 31, 2008, implementation of these recommendations had led to an 83% increase in successful referrals.