Connecting Safety Net Patients to Specialty Care Providers in Denver

When Medicaid and uninsured patients needed specialty care, finding providers willing to see them in a timely manner was a major challenge. Colorado’s decision to expand Medicaid under the Affordable Care Act (ACA) had increased the number of residents with health care coverage. Over 380,000 more Coloradans had Medicaid at the end of 2014 than at the start of the year, representing a 49.2% increase in the Medicaid caseload.¹ In Denver, 60,000 more people had Medicaid at the end of 2014 than at the start of the year, contributing to an estimated increase in the rate of health insurance coverage in the city from 83% to 94%. This phenomenal growth in Medicaid coverage led to increased access for Denver’s low-income residents to many areas of care, but has exacerbated challenges in accessing specialty care.

Making sure that Medicaid enrollees and the remaining uninsured had access to specialty care strengthened the impact of health reform. Denver Health and the Mile High Health Alliance worked to build a streamlined, technologically advanced referral hub to connect patients of Denver’s primary care safety net clinics serving publicly insured, under-insured and uninsured residents to specialists throughout the city. This specialty care referral hub aimed to improve access in the following ways:

• Problem: Denver’s safety net primary care providers relied primarily on informal, ad-hoc relationships to find specialty care for their patients.
  • Solution: Provide a single, reliable mechanism for making specialty care referrals.
• Problem: Barriers such as transportation needs and language differences made it difficult for some publicly insured and uninsured patients to access specialty care.
  • Solution: Case management services ensured that patients had the resources they needed to keep appointments with specialists and communicate effectively during appointments.

• Problem: Specialist providers were concerned that accepting Medicaid or uninsured patients would be unsustainable to their practices.
  • Solution: Allow specialists providers to specify the number of patients they are willing to serve in a given time period.
• Problem: Appointment slots with specialists were limited, but were not always used for the patients who need them the most.
  • Solution: Connect primary care and specialty care electronically through an eConsult system, reserving in-person appointments for situations that require this type of interaction.

The Specialty Care Access Group of the Mile High Health Alliance learned from pioneering collaborative work to improve access to specialty care in other communities. eConsult or eReferral programs in San Francisco and Los Angeles had electronically connected safety net primary care and specialty care providers. Many communities had developed programs to connect uninsured patients to volunteer specialty care providers. The Denver specialty care referral hub uniquely combined both eConsults and a community-wide referral mechanism to make the most efficient use of specialty care capacity in Denver.

Resources and Support from the National Partnership

To support the Denver partners in this effort, the National Partnership for the Health Care Safety Net provided information about successful specialty care access programs in other areas of the country. Members of the National Partnership presented these findings to a meeting of stakeholders in Denver in December 2014. The National Partnership also explored how state-level policies, such as reimbursement for telehealth services, may have impacted the referral hub.

The Power of Collaboration to Expand Access

Denver Health worked in synergy with the Mile High Health Alliance to implement a collaborative strategy to improve access to specialty care in the city. As a neutral forum, the Alliance connected safety net primary care providers from safety net clinics across Denver to specialists in several large hospitals and health care systems and in private specialty care practices.

The Mile High Health Alliance was formed based on the Denver’s Community Health Improvement Plan recommendation to provide an enduring, collaborative entity to work on the systemic changes needed to improve access to care in the city. The planning group was supported by the Colorado Trust to conduct a six-month planning process to establish the Alliance and outline its initial priorities, one of which was determined to be access to specialty care for underserved populations. The other two priorities were “first access to care” (coverage, health and insurance literacy, and entry into care) and better managing high utilizers of the health care system.

The Specialty Care Access Group was formed in April 2014 to identify issues and formulate plans for activities the Alliance could undertake in this area. By July 2014, it had produced an initial plan for establishing a specialty care referral hub in Denver. In December 2014, the Specialty Care Access Group, with support from the National Partnership, convened a wider group of stakeholders from 33 organizations to discuss this draft plan. Presenters included representatives from Kaiser Permanente, the state Medicaid office, and the National Partnership. Discussions among attendees affirmed the need and urgency for both eConsults and an in-person referral hub, and suggested a number of refinements to the initial plan for the referral hub.

The Mile High Health Alliance was formally established in January 2015 and currently operates under a fiscal partnership with the Colorado Nonprofit Development Center. It includes hospitals and health care systems, safety net clinics, behavioral health care organizations, public health departments, other governmental entities, and social services and community-based organizations.

1. Estimates of insurance coverage calculated by the Mile High Health Alliance based on data from the Colorado Department of Health Care Financing, Connect for Health Colorado, The Kaiser Family Foundation, the American Community Survey.

Removing Barriers to Specialty Care

The Specialty Care Access Group of the Mile High Health Alliance developed a more detailed implementation plan to pilot the specialty care referral hub in Denver.

The strategy of using a community-wide referral hub for specialty care for the uninsured was pioneered by the Project Access program in Buncombe County, North Carolina, and has been emulated across the country. These programs reduce barriers to providing care for the uninsured and underinsured. In the Seattle region, care management services at Project Access Northwest support patients to keep their appointments with specialists, leading to a 95% show rate.

The eConsult model was pioneered by San Francisco General Hospital and provides a secure means for facilitating communication between primary care and specialty care physicians. eConsult/eReferral programs have been shown to reduce wait times for specialty care services in safety net settings. They support stronger collaboration between primary care and specialty care providers, eliminating the need for some in-person specialty care visits. eConsult programs can also ensure that preparatory steps such as lab work are complete before in-person visits, preventing unnecessary delays and maximizing the use of specialists’ limited time.

Based on a review of specialty care access programs across the country and consultations with local stakeholders, Denver Health and the Mile High Health Alliance determined that combining both eConsults and in-person referrals into a single model provides the best opportunity to address specialty care needs in Denver. While eConsults met some of the need for specialty care, particularly for more cognitive specialties, in-person referrals were needed in many cases. The referral hub distributed in-person visits in an equitable way across participating specialty care providers.

The Partnership for Denver’s Safety Net

Denver Health is an award-winning integrated safety net health care system serving over 150,000 patients each year. Established in 1860, Denver Health includes a level-one trauma hospital, one of Denver’s two local public health departments, specialty care services, and a network of community health centers and school-based clinics. Denver Health’s integration of all levels of care has been recognized as a model for other U.S. safety net providers.