Los Angeles County Department of Health Services (LAC DHS), proudly serves our most vulnerable neighbors—uninsured and undocumented. We are the second largest public healthcare system in the nation, with nine health centers, four hospitals, and three Emergency Departments (EDs). Around 300,000 patient visits per year occur in our public EDs, half occur at our largest ED in Los Angeles County + University of Southern California Medical Center (LAC + USC), home to 3 of our Clinical Scholars. We are the safety net for our 1.5 million residents who remain uninsured. About half of our uninsured patients are concurrently undocumented, a group of special significance to us.
Wicked Problem Description:
Uninsured leave our EDs without navigating to insurance programs and appropriate medical homes, resulting in suboptimal care for the most vulnerable patients. This financially burdens both our patients and medical centers. Our team refuses to see undocumented immigration status as an insurmountable and immutable barrier for insurance access. Nor as a barrier for health service access. Many of our uninsured patients, dually undocumented and uninsured, miss the opportunity to stabilize their health and families by connecting to legal partners. Our root cause analysis shows two subpopulations of uninsured patients, each with its own needs:
(A) Uninsured with Hospital Presumptive Eligibility (HPE) for Medi-Cal, requiring navigation and support to complete full insurance applications using a usual workflow. HPE is CA-state funded health service coverage for hospital and ED services for 30-60 days, based on patient’s self-declared low-income status. Generally, this coverage is available once per year per patient.
(B) Uninsured without HPE. These are residually uninsured patients who’ve “used up” their HPE and remain uninsured, using ED for health services. Often this population are socially complex experiencing homelessness or lacking identity documents to verify immigration status.
We transform our Public EDs to Centers of Excellence for Uninsured to optimize patient’s ability to obtain insurance, and resultant health services. Our team focuses our biggest new interventions on the residually uninsured population, notably legal interventions to provide immigration stabilization. By situating a legal team within an array of navigation services like community workers to trouble shoot insurance applications and any legal issues, we recontextualize undocumented status as a modifiable social health determinant.
For residually uninsured patients, we will build in accepted system to efficiently identify barrier to insurance access. We will appropriately refer them to resources — social services for patients experiencing homelessness, immigration legal services for patient’s whose barrier is immigration status & identity documents.
For patients with complex socially barriers to health insurance access, we will provide social service navigators via community health workers. This is an “augmented” service provided in conjunction with patient financial services staff, ideally real time and at bedside without disrupting patient flow.
The newest “culture shift” services will be our free/low cost immigration lawyers available to our residually uninsured patients who face barriers with identity documentations and/or immigration status.
We hope to see an increase rate of uninsured patients who successfully enroll in Medi-Cal after an ED visit, resulting in a shift in health access from ED/hospital to primary care medical home. As patients obtain insurance, DHS will diversify our payors, reserving uncompensated care for patients who really need it. Our community will benefit, our dually undocumented and uninsured patients will receive legal referrals, before a crisis occurs. Efficient use of legal services will result in successfully legalization of immigration status, as resultant pathway to insurance.
- Formalize Relationships with Partners
- Develop Immigration Specific Medical Legal Partnership, leveraging existing external State, County, and City legal services.
- Create IT clinical informatics system set up for “real time” evaluation of metrics – allowing for rapid PDSA cycles to identify, screen, refer, and track patient’s through insurance process.
- Train Navigators at LAC + USC for Engagement & Navigation – Start Providing Services
- Capacity development for lead navigator who can organize community leadership, including Allied Health Professional Volunteer Researchers & Develop Volunteer Base (Pre-professional Track) PDSA cycle for screening and targeted intervention
- Activate Clinicians & Social Work & Patient registration/financial services with Trainings for DHS Clinicians and staff – “on demand” online FAQ resources
- Pilot Site: Aim for 24/7 “live” intervention for Uninsured Patients
- Interval assess metrics for Pilot Site: Go/No-Go decision for expansion to other EDs?
- Preliminary financial feasibility “return on investment” for long term sustainability for public cost
- Optimize Pilot Site – what can be automated? Can navigation be done with “low touch” staffing?
- If expanded to other EDs – assess for successes & sustainability.
- If ROI not demonstrating success, can econometric analysis to demonstrate positive externalities for community on immigration stabilization bundling with uninsured navigation?
- Is Program valuable to non-DHS ED? In other Communities?
Health Agency Leadership; C-suite of DHS Hospitals. My Health LA; SEIU 721 labor representation
Clinical Implementation Dr Carl Chudnofsky & Dr Henry Kim and Chiefs/Chairs of Public ED; Dr Clemens Hong, Director Whole Person Care (WPC), Dr Heidi Behforouz, Community Health Worker training development; Community Clinics Association of LA & MHLA partners, Patient Advisory Counsel
Immigration Issues: Rigo Reyes Office of Immigration Affairs & immigration legal services sponsored by OIA including Al Otro Lado; For homeless patients: STAR Clinic, Housing for Health, Healthcare for Homeless, Homeless Outreach Teams
Pilot Site Implementation Advisory: Utilization Review; Patient Access Center; Patient Financial Services & Registration; USC Allied Health Professional Schools, LAC + USC clinical informatics team
Research support: Division of Research & Division of Global Medicine at Dept of Emergency Medicine. Gher Center for Health Systems Science USC, Immigrant Health Initiative at USC
Quantitiative data: Patient Financial Services & Financial Officers track total visits in ED, rate and number of uninsured patients, HPE new applications, started applications for Medi-Cal, completed/submitted applications for Medi-Cal, and deny/approval rate for applications. They also have general categorizations for why applications were not submitted or denied. To track success of immigration legal services Office of Immigrant Affairs & Whole Person Care intend on tracking cases referred to legal teams, rates completed intakes, cases who are provided services, and resulting outcome of legal case. We hope to request ability to track cases who resultantly are eligible for insurance after immigration services and status modification.
Qualitative data: Researchers in implementation science will be asked to provide research support, such as stakeholder interviews & focus groups. This helps us improve medical staff, legal consultants, and end-user/patient experiences.