Health Care for Children in Low-Income Families I. TOPIC Project GoodHealth II. LOCATION Southeastern New Hampshire III. SUBJECT Health Care for Children in Low-Income Families IV. SUMMARY Rockingham Community Action, a Community Action Agency serving southeastern New Hampshire, received a grant from the Robert Wood Johnson Foundation in 1992 to establish Project GoodHealth, a health care program directed towards children of low-income families. These families usually cannot afford routine medical care, sometimes resulting in minor health problems developing into serious conditions. Furthermore, when children do not receive regular checkups, they do not establish a continuous medical record, which is essential to ensuring effective treatment for problems that might develop later in life. The doctors participating in Project GoodHealth agreed to follow a rate schedule that reduces their usual fees for office visits by approximately 50 percent. Eligible families pay $5-$15 per office visit, and Project GoodHealth pays the balance. Project GoodHealth also assists low-income families with prescription medicine costs and specialist care. In addition to health care for children, Project GoodHealth began providing free counseling services when a group of private therapists volunteered their services. Project GoodHealth also provides information and referrals on topics such as parenting, child development, immunizations, home lead levels, and nutrition. Since May 1992, more than 500 children have enrolled in the program. V. SUCCESSFUL PRACTICE Developed a program of service and education involving a national health care foundation, other national and local nonprofit foundations, doctors who reduced their rates, volunteer counselors, the Visiting Nurse Association, and Community Action Agency staff to help meet the health care needs of low-income families who otherwise would not be able to afford basic medical care. VI. CONTACT Stephen Geller, Executive Director Rockingham Community Action (A Community Action Agency) 7 Junkins Avenue Portsmouth, New Hampshire 03801 603-431-2911 603-431-2916 (FAX) VII. CASE STUDY The Problem: In 1992, a comprehensive assessment of the health care needs of low-income families in the greater Portsmouth, New Hampshire, area found that these families are often forced to go without medical care, or to postpone care until the situation warrants a trip to the emergency room. Easily treated problems often become more serious, and more costly to alleviate, by the time treatment is sought. Low-income families often face the difficult choice of paying a heating bill or buying food instead of taking a sick child to the doctor. These families are generally unable to establish sustained relationships with family physicians, which results in children growing up without having established a continuous medical record that helps ensure effective treatment for problems that might recur over the long term. The Approach Adopted: Rockingham Community Action (RCA) established a task force comprised of physicians, nonprofit health and social service providers, local welfare administrators, and consumers to examine several health care delivery options. The task force determined that a physician's office-based model that provides care to children through a network of primary care doctors would be the most effective and practical way to ensure that low-income families receive the health care services they require. How They Implemented The Approach: RCA received a two-year, $112,000 start-up grant from the Robert Wood Johnson Foundation in 1992 to establish Project GoodHealth. Additional funding came from the United Way, the Foundation for Seacoast Health (a local health care foundation), and other private foundations. RCA developed the program in partnership with the Visiting Nurse Association. To be eligible for the program, a family's income must be too high to qualify for Medicaid, but it must not exceed 225 percent of the federal poverty level. This income range includes families usually referred to as the "working poor," and it is these families that are most at risk of going without necessary medical care. Families with limited health insurance coverage can qualify for Project GoodHealth if the deductible exceeds $100 per child. RCA recruited all eight of the local medical practices that provide primary pediatric care in Portsmouth and the six surrounding communities to participate in the program. Through Project GoodHealth, families select a primary care physician from among the participating doctors. The doctors agreed to reduce the cost of office visits for children enrolled in the project. The fee structure is based on the physicians' fixed costs and is similar to Medicaid reimbursement rates. The fees are usually about half what the doctors normally charge. The family makes a small co-payment of $5-$15, and Project GoodHealth covers the balance. Project GoodHealth also helps families pay for prescriptions resulting from office visits. Specialist care is available on a case-by-case basis. Primary care physicians make referrals when they think it is necessary. The referring physician and Project GoodHealth work informally with the specialists to negotiate fee reductions. The patients pay what they can afford, and Project GoodHealth pays the balance. In 1994, Project GoodHealth began providing free counseling services to families after 26 private therapists volunteered their time. The therapists insisted that the only fee be a small co-payment worked out between the therapist and the patient. All members of the family are eligible for counseling, which includes a full range of family and individual counseling. The participating therapists are not psychiatrists. Therefore, they cannot prescribe medications, but they can work with Project GoodHealth physicians to arrange for medications when needed. In addition to the direct health care benefits, Project GoodHealth offers an array of support services. A Project Nurse, who comes from the Visiting Nurse Association, and a Health Educator make home visits and provide one-on-one counseling to provide participating families with information and advice on health-related issues that the families indicated were important to them when they enrolled in the program. Project GoodHealth also publishes a newsletter to provide in-depth information and referrals on issues important to families, e.g., parenting, child development, immunizations, lead levels, and nutrition. Project GoodHealth staff also serve as a resource on Medicaid eligibility. The staff works to enroll families in the Medicaid program if they are eligible. There are also special assistance programs for people not usually covered by Medicaid; Project GoodHealth helps families get access to these services. Results: Since May 1992, more than 500 children have enrolled in Project GoodHealth, and they have made approximately 1,200 pediatric office visits. These families have established a consistent relationship with a single doctor, who can become familiar with the child's particular medical history and needs. Project GoodHealth's dual approach direct health care combined with support services has significantly improved the quality of health care available to low-income families and has provided support and education to alleviate the symptoms that perpetuate the long-term cycle of poverty and poor health. The task force that helped develop Project GoodHealth has continued to serve an advisory role. It has taken the Project GoodHealth model and developed a new program to provide health care services to adults and children. Seacoast HealthNet will begin serving New Hampshire's low-income population in the fall of 1995. Seacoast HealthNet will include specialist care in most medical fields and counseling services from the beginning of the program. The Robert Wood Johnson Foundation awarded a one-year planning grant of $94,000 under the Foundation's Physician Reach-Out Initiative to develop Seacoast HealthNet. The Foundation has agreed to follow with a three-year implementation grant of $225,000 to get the new project underway. VIII. KEY WORDS Children Community Action Agency Co-Payments Counseling Families Health Care Insurance Low-Income Families Medicaid Pediatrics Prescription Costs Primary Care Physicians Specialist Care Therapy Volunteers Working Poor