Efforts in the Inland Empire to steer patients toward primary clinics and away from emergency departments appear to be alleviating some of the strain placed on county hospitals in recent years.
EDs in Riverside and San Bernardino counties -- which were hit particularly hard by the economic recession -- grappled with increasing demand by uninsured patients, limited capacity and ever-increasing wait times.
Preparations for the Affordable Care Act, including strengthening county networks of safety-net clinics, seem to have had a positive impact on hospitals, according to Inland Empire sources.
"We believe in the premise that when primary care fails, patients go into the hospital," said Laurie Bowers-Kane, executive director of Riverside County's community health centers. "We are the largest primary care system in the county. We truly serve the uninsured and underinsured."
The county-run community clinics worked with Riverside County Regional Medical Center to ensure that patients weren't using the ED for primary care services, Bowers-Kane said. The county clinics also used data from Inland Empire Health Plan, a not-for-profit health plan that primarily serves Medi-Cal patients, to identify emergency department "frequent fliers" and refer them to clinics. Medi-Cal is California's Medicaid program.
"We reach out to those patients and do some education and assessing," Bowers-Kane said.
Similarly, in San Bernardino County, there has been an impact.
Ron Boatman, assistant hospital administrator at Arrowhead Regional Medical Center, a public hospital run by San Bernardino County, said demand for services in the ED has lessened.
The hospital first implemented case management efforts in its ED to direct patients to primary care clinics in 2012.
"I think that strategy definitely paid off," he said.
Boatman anticipates that the trend may continue after Jan. 1, 2014, when health care reform takes effect.
"We could see a further reduction," he said, citing the fact that patients will have access to a wider health care delivery system under the Affordable Care Act.
Both Bowers-Kane and Boatman said that enrolling patients in county low-income health plans had helped to direct patients away from EDs while connecting them to primary care clinics.
Clinics 'Will Be Highly Sought After'
Officials in the Inland Empire had varied opinions as to whether clinic demand will continue to grow as health care reform takes effect.
Carmela Castellano-Garcia -- president and CEO of the California Primary Care Association, which represents more than 900 not-for-profit clinics and health centers in California -- expects primary care clinics to see a rise in patients.
"We anticipate community health centers will be highly sought after by the newly insured," she said. "They have the dual function of being a one-stop-shop where people can get coverage and get care."
She pointed out that state health insurance reform in Massachusetts in 2006 resulted in clinic demand increasing by 40%.
Federally Qualified Health Centers, a type of primary care clinic, already experience high demand across California. More than 1,000 health clinics delivered primary care services to approximately 5.2 million patients in 2011, according to the Public Policy Institute of California.
According to data from the California Primary Care Association, health centers in the Inland Empire serve 5.5% of the population in the region, or roughly 227,000 people. In San Bernardino County, health centers provided care for 95,882 patients in 2011. In Riverside County, that number was 131,257.
Bowers-Kane said it's a "guessing game" as to whether the county clinics will see an influx of patients after Jan. 1. But she added, "We do not have plans of downsizing. We have plans of growing."
Boatman said that while he expects primary care clinics in general will see an increase in volume because of health care reform, San Bernardino County clinics could see a decrease because patients will have more optionsfor care.
However, if primary care doctors outside the county clinic system become overwhelmed by patients, the county clinics could attract more patients if they have nowhere else to go, he said.
The county's geography could be a factor in whether county clinics experience a reduction in demand. Currently, patients with no other option must drive long distances to receive care at county clinics, but once health care reform takes effect, they may be eligible to receive care at nearby clinics that were previously unavailable, Boatman said.
Need for Coordination
One of the challenges in the Inland region is improving coordination and collaboration among primary care clinics, said Castellano-Garcia and Matthew Keane, Community Clinic Association of San Bernardino County CEO.
The two counties are geographically large and have a combined population of four million, resulting in a safety-net system that is vast and somewhat fragmented. There are FQHCs, FQHC look-alikes, private not-for-profit clinics and county-run clinics.
A California HealthCare Foundation report released in 2012 noted that while strides had been made in addressing this challenge -- such as the formation of the Community Clinic Association of San Bernardino County -- there are still hurdles. CHCF publishes California Healthline.
"Health centers reportedly are guarded about sharing their expansion plans and have collaborated little with each other, especially as federal budget shortfalls reduced funding initially available for expansions under national health reform," according to the report.
The report also noted that FQHCs in the region experienced 40% more patient visits between 2008 and 2010, with both the number of Medi-Cal and uninsured patients increasing.
In 2012, the Community Clinic Association of San Bernardino County began to bring together clinics to foster more communication and collaboration. There are now 18 clinic systems with more than 50 clinic sites in the association, Keane said. Riverside County does not have an association. However, some Riverside County clinics belong to the San Bernardino County association, Keane said.
Keane said homeless, uninsured and undocumented immigrant residents will continue to seek care at clinics after health care reform takes effect. There are about 150,000 to 160,000 undocumented immigrant workers in the county, he said.
"Our clinics are going to be called upon on a greater level to provide services for all these new people and the existing people that IEHP [Inland Empire Health Plan] and Molina [Healthcare] both have," he said. The two insurers administer benefits for Medi-Cal in the county.
Meanwhile, Arrowhead Regional Medical Center in Colton has been taking steps to improve coordination with clinics outside the county system. Boatman said Arrowhead has formed partnerships to share resources with two private clinics: Inland Behavioral Health and the Community Health System. Staff members from the two clinics will be placed in Arrowhead's ED to identify patients who have conditions that can be managed through primary care, he said.
Another area of focus for Arrowhead is building relationships between primary care providers and specialists so they are not operating in silos and are equally informed about the services their patients are receiving, Boatman said.
Collaboration between counties and not-for-profit systems is important not only because it keeps patients out of EDs, but because it provides a referral system and access to preventive services, Castellano-Garcia said. Ultimately, that translates to lower-cost care.
"In counties where there is better collaboration, patients are better served," Castellano-Garcia said. "It's imperative that collaboration become the priority."