SKYCAP is not a single organization with a dedicated set of staff or resources. Key activities are governed and managed by staff from several community partners. The University of Kentucky Center for Rural Health administers the project and provides key staff including a Program Director and Educational Coordinator. In addition to leadership staff from the University of Kentucky, navigation activities and clinical programs are developed and managed by a consortium of health care providers, faith based organizations and health-focused foundations. FHNs represent the majority of SKYCAP’s labor. Other community institutions that are considered partners in SKYCAP include academic institutions, public hospitals, health departments, community-based services, faith-based services, pharmacies, and others.
SKYCAP Participants. The SKYCAP administration and its partners work to add as many providers as possible to the network in order to reach the greatest base of uninsured and underinsured clients and to manage the activities of FHNs. Fifty safety net medical providers currently participate in SKYCAP, meaning they refer clients to the program and have the ability to access and modify records recorded in SKYCAP’s client tracking system. These providers operate out of public hospitals, health departments, an HCH, primary care clinics, emergency shelters, housing developments, and other clinics in the four-county SKYCAP target area. In order to share and store client data gathered from the client tracking system in a central database, SKYCAP entered a data sharing agreement between hospitals, physicians and other partners.
Exhibit 2: SKYCAP Structure
Note: solid lines indicate data transfer; dotted lines indicate referral or other case management contact.
Funding. SKYCAP received initial funding from the three-year CAP grants. It also received funding from a local foundation to expand its services from two to four counties in 2002. Additional funding was received through a federal Healthcare for the Homeless grant provided to a key partner along with several in-kind contributions from local hospitals, clinics, and health departments. At the current time, SKYCAP’s main funding sources will run out in August of 2004.
Core Activities. As described above, SKYCAP consists of two basic activities (1) maintaining a client tracking system to follow key health and social status variables as well as utilization for clients using safety net health care and social services and (2) empowering a cadre of FHNs to follow the progress of individual clients and provide basic case management or disease management services as necessary. Residents of Harlan, Perry, Leslie and Knott counties who are uninsured and underinsured are eligible to participate in the program.
Person-level records are initiated in the tracking system when an individual is referred to SKYCAP from any source in the community, usually clinics or hospital physicians. Each client is provided with their individual identification number which is attached to their record. Once they are referred, the program uses the FHNs to assist these clients in receiving care in the most appropriate settings. FHNs are randomly assigned to new clients who are referred to the system. They conduct an initial interview either at the client’s home or another setting where they query the client about demographic information, access to housing and transportation, chronic disease status (e.g., diabetes, heart disease, hypertension, or asthma), emergency room utilization or hospitalizations within the last year and other basic health status issues. FHNs then enter this baseline information into the client tracking system, as close to real time as possible. After this initial interview, FHNs also enter and update client-level information as they see clients in the field. Individual clinical providers are also able to use the client tracking system to access client level data and update information relevant to a client’s medical history, diagnosis and treatment. Thus, when all parties who interact with the client enter client-level data into the tracking system, the record holds an integrated and complete patient history, including any medical treatments received across the span of providers as well as case management services provided.
Client records currently held in the system are divided into three levels, depending on their level of need determined from the initial interview. Clients who do not have any of the targeted illnesses, do not require follow-up and require only a minimal coordination and delivery of services are considered to fall under Level 3. Level 2 clients have one or more of the target illnesses and are less able to obtain medications. These clients require a clinical review and at least two contacts per month. Level 1 clients are the highest priority, in that they have the least access to medical and social services and their illness is out of control. These clients require at least four contacts a month along with regular intensive, long term case management.
Depending on their need for services (i.e., their “level”), FHNs will continue to interact with clients on a regular basis by providing disease management education and linking them to needed services such as free medical services and pharmaceuticals. In addition to telephone contact, these interactions can involve in-person visits to the client’s home. The goal for clients at all three levels is to establish a primary provider or a medical home, provide access to necessary medications, and educate clients about their illness. Determining a client’s eligibility for free or subsidized drugs is determined using built-in system features. In the first three years of the program, SKYCAP reports helping more than 9,000 clients and facilitating 87,000 interactions between those clients and health or social service providers. Because the largest health center (and Section 330 funded FQHC) in the region lies outside of SKYCAP’s service area, SKYCAP’s client intake seems small when compared to the entire Southeastern Kentucky region’s service base. In addition, SKYCAP does not include a comprehensive record of all FQHC encounters in its service area. However, SKYCAP has fairly extensive penetration in the region it directly serves and in its specific patient population of the uninsured and underinsured.