We begin by describing the environment from which SKYCAP emerged and key aspects of SKYCAP’s early history, including the impetus behind the development of the program, its organizational structure, and the core functions it now provides to the community.
Impetus for SKYCAP Development. The rationale for creating SKYCAP stemmed from two trends identified by public health stakeholders in Southeastern Kentucky. First observers noted extensive, inappropriate use of area emergency rooms as first line providers for low income individuals seeking routine primary care services. Secondly, the region lacked a social services support system to serve the low-income clients affected by mental illness or other ambulatory care-sensitive conditions. Community organizations observed that these clients experienced several serious barriers to adequate care including lack of access to needed medications, problems scheduling appointments with ambulatory care providers, poor access to transportation and a lack of awareness around self management of chronic illnesses. Particularly problematic were those elderly or disabled low income individuals without adequate care support through family or other social networks.
Early History. Citing these trends, in 2000, the Hazard-Perry County Community Ministries invited the University of Kentucky Center for Rural Health and a community organization called the Harlan Countians for a Healthier Community to lead a social services program targeting underserved populations in Harlan and Perry Counties. The vision of SKYCAP evolved into two main components. First, the program would include an electronic client tracking system that allows service providers to record and share data on clients to facilitate community-wide tracking, continuity of care and provision of basic chronic care case management services for the uninsured and underinsured populations. The second activity, to be facilitated largely by this tracking system, is a health navigation program where “lay” Family Health Navigators (FHNs) would be hired and trained to work with clients individually to help them navigate the safety net and access social services available in the community.
While several counties in Kentucky had been collecting data on uninsured clients since 2001, SKYCAP’s goal was to track those data elements specifically requested by community providers and then to share that data across providers by deploying the system in ambulatory health care and social service settings. In planning data needs, SKYCAP sought input from a wide range of service providers from lab technicians, nurses, physicians to social workers and mental health counselors. Upon classifying appropriate data elements, they began to seek out vendors to create a client tracking system based on the needs identified. Data Futures, Inc., a local vendor, was selected to develop the system.
Mission and Goals. The overarching goal of the SKYCAP program is to provide a multi-dimensional (or “holistic”) approach to improving and managing health status for underinsured and uninsured clients by encouraging well timed use of available social services including mental wellness services, health care, and housing and transportation services. A key feature of this goal is to ensure that all clients have a medical home. Through the use of case management and navigation, SKYCAP hopes to benefit the community by reducing unnecessary hospitalizations and inappropriate emergency room usage for underserved individuals, particularly those with ambulatory care sensitive conditions. The client tracking system is seen as an integral part of this goal, by giving providers in the community, including FHNs, nurses, physicians, pharmacists and social workers access to the demographic, administrative and clinical information to help coordinate care and services provided to individual clients. The tracking system also holds the potential for providing policy makers and other stakeholders with a community-level overview of care provided to underserved individuals in the targeted counties.