Reducing the Emergency Department Revolving Door Syndrome for the Poor, Uninsured, and Chronically Ⅲ Patient in Los Angeles: Process Improvement Recommendations from a County Health Program Evaluation

摘要

My Health LA (MHLA), a Los Angeles countywide health program, connects eligible uninsured poor residents with partner primary care clinics and a range of free health care services. Nevertheless, primary care nonengagement and inadequate emergency department (ED) visits remained significant in this population in fiscal year 2015–2016. This evaluation examined the structure, process and outcomes of MHLA at select participating agencies to delineate pilot improvement models. Five sites were selected for the program evaluation, including a large urban ED, its affiliated urgent care clinic, and 3 partner primary care clinics. Data inquiry, interagency observations, and patient and workforce interviews were conducted. The structure, process, and outcomes of the program were evaluated and compared with other evidence-based interventions with similar populations. Successes identified in the enrollment pathway included free primary care services, use of a navigator in the ED, and perceived improvement to chronic illness management. Challenges identified included flawed program perceptions, patient communication gaps, and current program limitations. A 5-fold pilot process improvement model was proposed: enhancement of communication surrounding the patient, enhancement of communication with the patient at enrollment, enhancement of patient care coordination, initiation of financial incentives for clinics with satisfactory enrollee engagement, and expansion of service coverage. The proposed model can be applied to promote primary care engagement and adequate ED use for similar underserved populations elsewhere.