Expanding the Safety Net of Specialty Care for the Uninsured: A Case Study

Care for the uninsured and underinsured is largely provided by our nation's health care safety-net system comprised of providers who care for patients regardless of their ability to pay (Institute of Medicine 2000). Nevertheless, uninsured and underinsured adults have inadequate access to care, receiving fewer health screening, preventive, and specialty care services than privately insured patients (Ayanian et al. 2000; DeVoe et al. 2003; Wilper et al. 2008; Ayanian 2009). The demonstrated need for improved access and care delivery in the safety-net system has prompted increased federal funding (Hoadley, Felland, and Staiti 2004; Shi and Stevens 2007; Sack 2008), including 11 billion dollars to expand the capacity of federally qualified community health centers (CHCs) through the Patient Protection and Affordable Care Act (PPACA) (HealthCare.gov 2010). Increased federal support to CHCs may help improve the quality of primary care in the safety-net system (Shi and Stevens 2007); however, access to specialty care remains a challenge. One quarter of patient visits to CHCs result in a referral to a specialist (Cook et al. 2007); yet fewer specialists are participating in the care of vulnerable populations, and there is no clear system for patients or primary care physicians to access those who do provide care (Dunham et al. 1991; Reed, Cunningham, and Stoddard 2001; Hartwig 2002; Cunningham and May 2006). Continued reliance on a limited pool of specialty physicians results in long wait-times for appointments, and, subsequently, fragmented care plans, disease advancement, and overutilization of emergency departments and hospitals (Ayanian et al. 2002). Models of engaging specialty physicians in the care of the uninsured and underinsured are emerging (Isaacs and Jellinek 2007; Blewett, Ziegenfuss, and Davern 2008; Darnell 2010). Prior studies suggest, however, that these models need to extend beyond improving reimbursement to address other reasons many providers have opted out of caring for the uninsured; these include feeling overwhelmed by administrative hassles; lack of provider autonomy within the program; and patient complexity, including psychosocial needs (Shortell and Hull 1996; Chaudry et al. 2003; Cunningham and O'Malley 2009). One program, Project Access, is responding to these concerns by creating a network of specialists and hospitals willing to provide donated care for uninsured and underinsured patients and integrating this care through patient navigation (Cofer 2008). The model has been replicated in communities throughout the United States (Ablah, Wetta-Hall, and Burdsal 2004; Baker, McKenzie, and Harrison 2005). Core principles and processes of implementing Project Access may be relevant for policy makers seeking to increase the capacity of the safety-net system to accommodate the specialty care needs of the uninsured (Lavis et al. 2002) and of the growing number of Medicaid beneficiaries expected to enter the safety-net system in 2014, when legislation from PPACA takes effect. Accordingly, we aimed to describe the 2-year process of developing and implementing Project Access in New Haven, Connecticut. Using a case-study approach, we report how the core principles of community-based participatory research (CBPR) were applied to address barriers to participating in an expanded safety net for the uninsured, and ultimately, to engage community stakeholders in all phases of implementation of Project Access-New Haven (PA-NH), including (1) assessing the scope of the problem of access to specialty care for the uninsured; (2) defining the goals of the project; (3) engaging new providers in the safety net, including specialists in private practice; (4) establishing the evaluation and research agenda, including the review of early findings from the first 46 patients enrolled; and (5) disseminating and translating research findings (Israel et al. 2010). Deliberate attention to these key stages of implementation may facilitate the expansion of the safety-net system for vulnerable populations in communities nationwide.