The Continuing Care Clinic at Harbor-UCLA Medical center serves the residually uninsured and undocumented population of Los Angeles County and acts as a bridge to establishing permanent care. The CCC serves patients who present to the emergency department with an ambulatory care sensitive condition (e.g., diabetes, hypertension, cardiovascular disease, etc.), and are seen at the CCC until they are able to establish routine primary care via mechanisms such as enrolling in Medi-Cal or MyHealth LA.
After their care at the CCC, patients can receive a higher quality of care at community clinics and will no longer have to use the ED as their standard site of care. Regrettably, the clinic has a high no-show rate for return appointments (approximately 50%) and little is known about patient demographics or social factors that may influence whether or not they come in for care.
We interviewed 70 English and Spanish speaking patients (≥ 18 years of age) who attended an appointment or were scheduled for an appointment between May and June 2018. With approval from the LAC Public Health & Health Services Institutional Review Board, the author administered surveys to patients who presented to the clinic and on the phone via the patient call center for all other past appointments. Patients were recruited when the author was present and available.
Patients completed a 5-10 minute oral interview (in either English or Spanish) using several validated screening questions for demographic items, social determinants of health, and health literacy. Questions were largely selected from the CMS Accountable Health Communities (AHC) Health-Related Social Needs (HRSN) Screening Tool), along with input and modifications by local experts. Responses and results were collected and generated using REDCap.
A total of 70 patients were screened; 49 via phone call (64% response rate) and 21 in clinic (100% response rate). The mean age of the subjects was 48.9; 51% were female, 87% Latino/Hispanic, 76% spoke Spanish as their primary language, and 57% had less than a high school education. Patients reported high levels of food insecurity, concern for immigration status, social isolation, unemployment status, and financial strain.
In the clinic “no show” population 46% (n=32), patients reported they missed the appointment due to being busy at the time 38% (n=12); 8 of these patients reported they could not miss work. While 31% of clinic “no shows” (n=10) reported they did not know about the appointment
Patients were offered resources if they requested assistance upon being asked or if they screened positive under one of the domains of the Social Determinants of Health Screening Tool. Food resources were offered to 54% (n=38) of the interviewed patient and 40% (n=28) requested information/resources on immigration.
Health care services for patients of low socioeconomic status who are uninsured, underinsured, or undocumented are episodic and more expensive in part due to less use of ambulatory and preventive care. In Los Angeles, urgent and emergent services are used more often in the uninsured and undocumented population than insured patients.
Our findings show patients who visit the CCC continue to struggle paying for a standard site of care because they do not qualify for Medi-Cal or a Covered California plan; this financial strain is compounded by social factors such as concern for their living situation and employment status.
It’s important to recognize these social factors as barriers to medical care. Patients in the CCC should be provided with information on financial resources at Harbor-UCLA by their CCC provider, which can help patients pay for their medical care when they do not qualify for Medi-Cal or a Covered California plan.