SKYCAP’s client tracking system supports a range of services that are available for use by different members of the community. Its main function is as a data collection tool and community resources databank. As discussed above, various levels of information are input by FHNs, providers and other SKYCAP staff in the community and are stored in a central server. The data in the system generally covers demographic information, where clients received care, whether they can pay for care and whether they have adequate housing, along with other relevant information for effective case management. FHNs are the most common user of the system, entering and accessing data to facilitate the coordinated case management process. In the paragraphs below, we describe potential uses of the SKYCAP database.
Master Client Index. Since every client who is eligible is automatically referred to SKYCAP and receives an individual identification number and corresponding record, the system database serves as a Master Client Index. Baseline information on every SKYCAP client is entered by FHNs and can be searched for under various parameters to identify prior encounters. The data stored in the Master Client Index can be used to track trends in care and disease incidence and utilization management in one segment of the target population or in the community as a whole. The system also allows for systematic tracking of program enrollment, eligibility for drug access programs, as well as referrals to specialists or inpatient providers.
Common Electronic Client Record. The SKYCAP tracking system may also be used as a shared electronic client record. From their base ambulatory care setting, community physicians may gain access to the system to gauge if any changes, for example, in the clients’ home environment, may affect their access to pharmaceuticals or compliance with other therapies. The system may also hold clinical information entered by a physician or clinical team leader on individual clients such as diagnoses, medications prescribed, as well as notes to other professionals who may provide services to the client. Client records may be accessed from a number of different sites where patients may receive care and social services in the community, making client information transportable across their continuum of care. For example, one respondent noted that emergency room staff often calls the SKYCAP office to get the latest medications or dosages that a client was prescribed by another physician as it is quicker to pull information off the database than for the staff to retrieve the patients’ paper charts.
Reporting. The client tracking system includes a report function for clinics and physicians who wish to analyze information about their client population or utilization of services. Data can be pulled from the general database to find out what services clinics provided to the SKYCAP population. The system’s data may also be extracted for use by consolidated health centers to complete UDS reports. The HCH, for example, pulled demographic data about their client base from the SKYCAP system, in combination with other systems, in order to complete a UDS report.
Case Management. FHNs use the data entered within the SKYCAP system to help with case management and some limited disease management with their clients. For example, the system prompts the FHN to enter such information as appointment status, type of appointment as well as the services and medications clients received at each appointment. By tracking this information FHNs can remind the client of any necessary follow-up as well as maintain a schedule of regular contact with clients. The tracking system also provides FHNs with disease management protocols which serve to educate the client on how they can receive care and self-manage their illness adequately in order to reduce long term complications. Links to social service providers including those in charge of state and community housing, meals and mental health services had been mostly informal but are now becoming more formally integrated. For example, the executive director of one of the founding SKYCAP organizations, Harlan Countians for a Healthier Community, now sits on the local housing board. Also, the baseline information collected within SKYCAP’s MIS system offers the housing programs a tailored client base, resulting in a more institutionalized and streamlined link from SKYCAP patients to needed services. The vignette presented below illustrates how SKYCAP can identify and help address a wide range of social service needs beyond health care.
In Harlan County, a male presented to the emergency room for diabetic services. He had no insurance, no medicines and was unable to read. The emergency room staff referred the patient to the SKYCAP Program. A FHN who was assigned to the case observed the client’s need for mental health services and diabetes case management. In conducting the preliminary home visit and interview, the FHN discovered that the client had no refrigeration or running water. The FHN coordinated an interdisciplinary team of Housing and Urban Development staff, mental health specialists and health care providers to provide the client with needed social services such as low-income housing, transportation and mental health counseling as well as a primary care home to control his diabetes. By entering the client’s data into the SKYCAP tracking system, and checking in on a regular basis, the FHN could follow future appointments to arrange for adequate transportation and could track progress to make sure the client was able to comply with the treatment. The man is now living independently and his illness is under control.
Pharmaceutical Discount Program. Many providers emphasize the importance of increased access to benefits afforded through use of SKYCAP. The program links specific clients with free or reduced-price prescription drugs negotiated with local pharmacies, pharmaceutical companies and other indigent drug programs. Using the tracking component, clinics may view client prescription information to gauge which clients are eligible for this program as well as what drugs they have received at a discounted rate.
Overall Provider use of SKYCAP. From our interviews, it is clear that providers have come to use the system in a variety of ways, reflecting their individual needs and priorities. For example, one clinic uses SKYCAP essentially as a complete client tracking system, entering clinical information (e.g., client diagnoses and prescribed medications) after each appointment. Physicians at another clinic that already has an electronic medical record system separate from SKYCAP use the SKYCAP terminal in their office, although inconsistently, to pull up information on their SKYCAP patients, identified by a code on the front sheet of their electronic record, to look up information about what social/environmental conditions may be affecting their patients’ adherence to treatment. They also use SKYCAP’s patient record to view any treatment the patient may have received in other settings so they can communicate with other providers if they have a question or consultation and are able to anticipate any potential drug-drug interactions. Other clinics use SKYCAP solely to assess eligibility for ancillary benefits (e.g., donated pharmaceuticals) for their clients. Still others use it to review information about the clients’ ability to pay or their access to adequate housing or other environmental resources. Most users take advantage of and contribute to the MIS system in pieces, only using the one or two functionalities that benefit them the most.