Edited by Patrick Courtney, MA Health Services Research Collaborative

1. Primary care related ED utilization and the assessment of the need for safety net primary care in Harris County Edited by Patrick Courtney, MA Health Services Research Collaborative University of Texas School of Public Health

2. Background • Houston/Harris County hospitals’ emergency departments have become major providers of primary care, particularly for low-income uninsured people unable or unwilling to access basic medical services at private or public clinics or doctor’s offices. Under the initial sponsorship of Gateway to Care, the University Of Texas School Of Public Health has been collecting and analyzing emergency department visit data in Harris County hospitals to monitor primary care-related use of the emergency department.

3. Data used in ED algorithm • Each participating hospital supplied the following data elements on all ED visits not requiring admission: data and time of admission to the ED, primary and secondary discharge diagnoses, discharge date and time, payment source, patient age, patient gender, patient race/ethnicity, patient zip code, employment status, and disposition at discharge (e.g. home or self care, nursing home, etc.).

4. Four levels of classification of ED visits • Non-emergent: Immediate treatment was not required within 12 hours. • Emergent-Primary Care Treatable: Treatment was required within 12 hours, but could have been provided effectively and safely in a primary care setting. Continuous observation was not required, no procedures were performed or resources used that are not typically available in a primary care setting. • Emergent-ED Care Needed-Preventable/Avoidable: ED care was required within 12 hours, but the emergent nature of the condition was potentially preventable/ avoidable if timely/continuous primary care had been received for the underlying illness. • Emergent-ED Care Needed-Not Preventable/Avoidable: ED care was required within 12 hours and primary care could not have prevented the condition. • First three are summed together and considered “primary care related.” Algorithms have not yet been developed to categorize injury or mental illness.

5. History of ED algorithm in Harris County • 2002 data – 11 hospitals • 2003 data – 13 hospitals • 2004 data – 16 hospitals • 2005 data – 25 hospitals • Specialized hospitals not included (e.g. MD Anderson, HCPC, VA, etc.)

7. Implications of 2004 ED Algorithm Report • 54.5% of ED visits primary care related • 37.8% of PCR ED visits by uninsured • Is it a lack of primary care resources? • Are people not aware of safety-net providers or do they need more help deciding when to seek care or how to manage illnesses? • Are the providers in the area performing suboptimally? • Community Clinics Committee – focus on primary care capacity (outpatient)

8. Method for assessing demand for safety net primary care • Latest estimates of the low-income uninsured at the ZIP code-level. Low income defined as being at or below 200% of the federal poverty level, since many may be too poor to afford private insurance but not poor enough to qualify for Medicaid or CHIP. • Multiplied by the latest annual number of primary care visits (patient seen by physician or mid level practitioner) to Harris County Hospital District outpatient clinics: 2.1 • Summed for each quadrant

9. Estimated Supply • Project Safety Net clinics • Provide free and/or discounted primary care and serve as a medical home • Services available at least 20 hours per week • Note: PSN is part of St. Luke’s Episcopal Health Charities • 2005 primary care visits • Seen by physician or mid-level practitioner • Does not include immunizations or medication refills • Provided to the uninsured • Does not include visits of patients with public or private coverage

11. Supply/Demand Gap

12. Limitations of primary care capacity estimation • Supply overestimates capacity since patients may use clinics outside their quadrant • Supply for the uninsured is based on unproven assumptions about payer mix • Unmet demand of the uninsured underestimates clinic visits needed since clinics cannot survive if only serving the uninsured • Supply underestimates capacity since it does not include charity care of private physicians

13. Current steps • 2005 ED algorithm – 25 participating hospitals. Present results to hospitals before aggregate report is made public. Compare four years of data in 11 originating hospitals to assess trends over time. • Safety net primary care capacity – Collaboration among northeast quadrant safety net providers. Explore existing and potential expansion plans. Refine Project Safety Net survey and data.