Information provided by SKYCAP suggest that the case management portion of the initiative has substantially helped low income or uninsured residents navigate health and social safety net services available in the four county service area. The findings from this case study suggest that the use of lay health workers accessing a community-wide tracking database is a useful model for consideration in other settings. The main challenge for SKYCAP has been creating a culture where all relevant providers including hospital emergency departments and safety net ambulatory care providers regularly access, update and use the software and data structure available through the system. Our conclusions focus on the specific aspects of this challenge and how they may be addressed moving forward and in other settings.
Comprehensive Approach. Unlike previous cases studied under this project, SKYCAP offers an opportunity to learn about how an electronic data repository can facilitate the provision of a wide range of social services to low income and underserved populations. In particular, interviews with the stakeholders in Kentucky has demonstrated the potential improvements for identifying and addressing social service needs through use of dedicated health navigators aided by a means for electronic client tracking. Because this model incorporates a range of providers, the potential impact on population health status are substantially greater than programs focused exclusively on improving access to health care. In particular, the SKYCAP program has helped underserved individuals in Southeastern Kentucky access the appropriate social service at the appropriate time, thereby fostering health improvement and maintenance in a multi-dimensional or “holistic” manner.
Organizational Presence. One of the remarkable aspects of SKYCAP has been the initiative’s ability to operate without a single organization dedicated to its success and without a significant administrative incentive for participation on the part of providers. SKYCAP is operated out of the University of Kentucky Center for Rural Health and is led by an Executive Director, an Educational Coordinator, and several clinical and educational team leaders. With no single entity responsible for assuring buy in, SKYCAP’s leadership worked to create initial buy-in and participation from a wide range of community providers each with different organizational structures and incentives. In particular, because of the lack of substantial consolidated health center presence in the target area, SKYCAP is unable to encourage participation by providing services that are key to consolidated health center operations such as competent billing systems and consistent ability to produce UDS reports.
It is clear from our interviews that each provider approaches their participation in SKYCAP differently, fulfilling their own internal data and care management needs as the system allows. This has produced some clear benefits for individual clinics, for example, allowing them to track various services they have provided patients, or to be aware of other medications their patients might be prescribed. However, this has also led to inconsistencies in the types of data being entered for each individual across the community. Because providers are not bound by specific reporting or administrative requirements, desired data formats and reports vary across providers. In sum, SKYCAP’s implementation faced greater resistance than other network implementations since there was no dedicated organization behind the initiative and that there was substantial heterogeneity in the needs and orientation of the providers it aimed to serve.
Structural Incentives. Although stakeholders believed in the potential community-wide value that widespread use of the SKYCAP electronic client tracking system could produce, users did not always feel they could contribute to this potential due to the system’s incompatibility with specific work processes. Incorporating use of the application into FHN, clinic and provider culture and workflow represents an important next step in the application’s development. The current SKYCAP infrastructure asks providers to perform data entry tasks unrelated to their prior workflow and, in many cases, using a separate terminal not used for any other purpose. This approach presents important challenges including requiring double entry of administrative data on clients, incurring costs related to a system that is not yet related to the health center’s core operation and, most importantly, requiring a change in the work processes used by busy clinical staff (e.g., emergency room staff). We note that, at the time of this case study, SKYCAP was working to address these problems, to some extent, by implementing virtual private network-based access to their database. Data entry can also be greatly facilitated by developing specialized interfaces or processes that allow the transfer of data from existing to new systems with limited (or no) additional effort on the part of the users.
Demonstrating Data Value. One of the important challenges facing SKYCAP is the lack of specific institutional requirements that can be met by data produced via the system. While data tracked using SKYCAP is very useful particularly for supporting community-based case management, maximizing benefits from these data requires more complete participation from ambulatory care providers and hospital emergency rooms. Initiatives like SKYCAP may facilitate their own success by developing specific functionalities around administrative or financial needs faced by health centers on an ongoing basis. For example, by developing modules or reports that automatically highlight a specific provider’s clients who are eligible for insurance but remain un-enrolled, SKYCAP may be able to assist providers in increasing revenue from client visits. Developing these types of reports will ultimately create a dependency between the provider and the initiative that will sustain and improve the initiative over time. Enriching the data held in SKYCAP could also attract resources from researchers or other granting bodies who are interested in the SKYCAP model as a mechanism to provide reliable, population-level data on their target population. For example, one respondent reported that the State of Kentucky was looking at the SKYCAP model to manage the Medicaid population but that initiative has been delayed. Other entities have shown an interest in the SKYCAP model but nothing concrete has surfaced as of yet.
Strategies for Rural Areas. Rural Southeastern Kentucky area health centers faced some of the same major challenges that were uncovered in previous site visits to CHCs located in urban areas: low budgets for IT resources (including technical and management staff), lack of IT expertise, difficulty purchasing off-the-shelf systems due to highly customized needs, and an increasing client load. But, they also face a set of challenges specific to their rural environment. First, in terms of technical challenges, it may be difficult to procure the high-speed Internet connectivity that is needed to use networked applications because of low availability in rural settings. This will become less of a problem as broadband connections such as DSL become more widespread. For example, the SKYCAP program is in the process of moving from a frame-relay connection to a high-speed Internet connection.
Another technical challenge faced by rural areas is the lack of a concentration of talented IT professionals. Networking and using browser-based applications (as with SKYCAP) should reduce the need for in-person technical support visits to remote sites. Finally, being in a rural center may substantially reduce access to vendors. This challenge could be mitigated by the rural CHCs joining more broad-based consortia, including those based in urban areas, where there is a greater likelihood of having a wider selection of vendors.