Zoning In to Keep Patients Out

 Gaby Galvin

IN SMALL RURAL TOWNS, not having a car can mean it's extremely hard to get critical health care.

That was Evelyn Wilmer's experience, when getting to one of her three doctors meant illegally crossing a busy highway or walking to a public bus stop, which was sometimes difficult when her rheumatoid arthritis caused painful swelling in her hips and knees.

Now, the local hospital is taking care of that problem. Each time Wilmer has a medical appointment, a hospital-funded van takes her directly to her doctor and back home, which she says has made it easier for her to access care while she finds a reliable ride of her own.

"My job requires me to stand all day," says Wilmer, who works at a Pizza Hut in southern Maryland's Lexington Park. "From my house to my primary care doctor, it's about 30 minutes because the bus makes stops. Another one of my doctors is about 45 minutes away … so (the hospital transportation) was a lot easier on me."

The ride program is just one result of a state effort to improve access to health care and reduce health disparities in underserved communities in Lexington Park – one of the poorest and most racially diverse areas in Maryland's St. Mary's County and home to about 12,700 people – as well as in Caroline and Dorchester counties; West Baltimore; Capitol Heights; and Annapolis.

Under the Health Enterprise Zones Initiative, Maryland allocated about $15 million across the five "zones" between 2013 and 2016, with the money used by county health departments, hospitals and their partners to address primary care shortages and social barriers to health, such as transportation and access to healthy food. Some communities have shuttered or adjusted their programs since the funding expired, but advocates say new research on savings to the state's health care system makes the case for investing in such hyperlocal interventions.

"We know public health works and primary care access works," says Dr. Meenakshi Brewster, health officer of St. Mary's County and president of the Maryland Association of County Health Officers. "They save money; they save lives."

While initiatives in the five zones were developed independently, efforts in each focused on recruiting primary care doctors and community health workers, improving access to health care and social services, increasing care coordination, and offering health education and screenings. Programs targeted low-income and uninsured patients with behavioral health issues and chronic conditions such as diabetes, cardiovascular disease and obesity.

"The state didn't require a one-size-fits-all approach," says Darrell Gaskin, a professor at the Johns Hopkins Bloomberg School of Public Health. "They allowed the organizations … and their respective partners to decide how they were going to address the barriers to care in their particular areas."

In St. Mary's County, MedStar St. Mary's Hospital had been helping patients manage chronic conditions like diabetes and asthma before the pilot began in 2013. But "we didn't have as many boots-on-the-ground opportunities to work individually and learn from our community what the real barriers to long-term health care are, like transportation, paperwork and things like fax machines and a copier," says Lori Werrell, director of population and community health initiatives for the hospital, which led the programs in Lexington Park.

"You would be shocked by the number of folks who were held up in getting some of their needs met because of technology they didn't have access to," she says.

The needed boots-on-the-ground came in the form of four HEZ-funded community health workers, who work with patients to help them stay healthy outside of the doctor's office.

Using HEZ dollars and its own $2 million investment, MedStar also opened a new medical complex in a previously underserved area in Lexington Park, offering primary care, behavioral health and, soon, dental services. Meanwhile, the shuttle route used by Wilmer and other patients to get to doctors' appointments included additional stops at pharmacies, parks and grocery stores, Brewster says.

"The nice thing about the HEZ mechanism was it was a significant amount of funding and it was focused on health equity," Brewster says. "A lot of the times when funding comes in, it's very restrictive or very narrow in its scope, or not enough to have an impact."

That freedom allowed community partners to experiment and figure out which programs worked best in their areas. In St. Mary's County, for example, the shuttle didn't get the ridership expected by program administrators, so they replaced it with a one-on-one medical transportation system that deploys two minivans and a refurbished police car.

"I think having facilities and community partnerships that demonstrate that collaborative magic at the local level is really appealing to a lot of primary care providers," Brewster says. "When you have a community that works together, it makes a big difference for your patients, and for your happiness as a provider, too."

The HEZ pilot saw tangible results. The $15 million investment between 2013 and 2016 was associated with an estimated 18,562 fewer inpatient stays and $93.4 million in savings across the five zones, according to research led by Gaskin and published recently in Health Affairs. Those estimates account for hospitalizations for conditions that the initiative targeted: diabetes, obesity, illnesses related to heart disease, asthma and behavioral health problems.

And though the program was associated with an increase of 40,488 emergency department visits, Gaskin says public awareness of it, as well as more widespread health coverage through the Affordable Care Act and Medicaid expansion, likely increased demand for health care services in the five areas. Maryland in 2014 also implemented a global budget payment system for its acute care hospitals that may have played into the HEZ results. The model limits hospital charges and spending and seeks to shift services to the primary care setting.

Even so, researchers found a decrease in inpatient stays when comparing the five zones with other Maryland communities that were eligible for the pilot but not included. Hospitalizations across the zones fell between about 13.7 percent and 17.5 percent per year between 2013 and 2017, Gaskin’s estimates show.

"They were trying to identify populations in the state that were underserved medically," Gaskin says. "The key here is that you're allowing the health care providers and their community partners to identify the at-need population in their community, and get (those patients) services that helps them better use or avoid inappropriate use of inpatient hospital care."

Since the HEZ pilot ended – it was developed under former Gov. Martin O'Malley, a Democrat, but expired under Gov. Larry Hogan, a Republican – Gaskin says some communities have struggled to maintain their programs without the state funding, particularly those spearheaded by more resource-limited county health departments rather than hospitals.

Prince George's County, for example, recently helped establish a nonprofit to coordinate care for patients who frequently visit the hospital, based on the success of the HEZ program in Capitol Heights. The Prince George's Healthcare Alliance, Inc. is still in its early stages as program administrators seek long-term funding.

"These groups are still trying to get grant funding, so if they can't get it from the state, they'll reach out to foundations and see if they can fund the kind of programs they're working on," Gaskin says. "The community-based organizations just scale back their programs and try to continue. They're very passionate about their causes."

In St. Mary's County, Brewster and Werrell say the initial funding was key to getting programs off the ground and ensuring they were sustainable when the pilot ended.

"Obviously any additional funding is welcome," Werrell says. "However, we are the only hospital in this community, and we feel that if we start something – unless there's really extenuating circumstances – if there's a benefit, then it behooves us to try and figure out how to sustain it."

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