Written by: Center for Care Innovations

It’s well documented that patients without access to health coverage tend to delay care and end up in the emergency room – something that can have devastating consequences for their health and put financial pressure on the local medical system. That fact weighed heavily on the minds of leadership at Northwest Colorado Health, which has community clinics in Steamboat Springs and Craig, Colorado. Until recently, one out of every two of the organization’s patients without health insurance had no financial source to cover their medical care.

This was puzzling, because since it first opened its community health center doors in Craig, Moffat County in 2008, Northwest Colorado Health has offered a Client Assistance Program, using federal government funding to provide services for a sliding fee scale based on family size and income. The current minimum contribution for a clinic visit is $10.

Northwest Colorado Health serves a largely rural, low-income population eligible for a Client Assistance Program (Credit: Twitter). 

But the program wasn’t on many patients’ radars, and staff needed training on how to help patients enroll and stay enrolled in the plan. Employees also needed to brainstorm ways to work together as a team across departments to ensure that patients signed up for the plan and remained enrolled each year.

As part of a project for CCI”s Colorado Health Innovation Community, the health center interviewed staff in every department across the organization to learn more about how employees used and talked about the program. One pain point mentioned by multiple people: The need for follow up with patients and offering patients assistance filling out forms. The internal review also uncovered that there was no mechanism in place for an eligibility team member to know when Client Assistance Program forms had been handed out by a patient care representative. Because of this gap, eligibility team members didn’t know which patients to follow up with and who might need help completing their application.

So from the beginning, the organization understood it needed to create a system that helps eligibility team members and patient care representatives better track patients through the application process. This approach incorporates everything from what’s known as scrubbing the schedule for eligible patients (a close scour of the day’s appointment list prior to visits) to adding a tracking notation in the electronic health record to document who has been given paperwork. It also ensures a follow-up process for communicating with patients who haven’t yet turned in their financial assistance forms.

“We knew this was an underutilized resource for patients who qualified. We wanted to determine why that was the case to find out what things we could do better to educate both the staff and our patients,” says Amanda Arnold, Northwest Colorado Health chief operating officer. Adds Suzi Mariano, senior director of marketing and development at Northwest Colorado Health: “The staff needed support for this process to understand the importance and impact of following up on these forms. This was something we wanted to be part of routine practice and integrated into our workflow.”

Small shifts can make a big difference

Northwest Colorado Health provides comprehensive services to those in need, from birth to end of life, regardless of ability to pay, serving roughly 15,000 people, or 30 percent of the region’s population each year at its four health center locations, mobile clinic, and via hospice care. Around 30 percent of its patient population is Latino. Northwest Colorado covers a large geographic area  (roughly the size of Delaware, Rhode Island, and New Jersey combined). In this rural, isolated region many areas are federally designated as a Health Professional Shortage Area and a Medically Underserved Area/Population. These realities make access to affordable healthcare a high priority for the community.

But that was easier said than done. The health organization quickly discovered that a lot of patients found the forms for the Client Assistance Program—available in English and Spanish— so cumbersome and confusing that they couldn’t fill them out and enroll in the program without help.

The health group also flagged client records of patients who were eligible for the program and in the process of enrolling. In addition, the center improved coordination and communication between front office staff and the eligibility team to ensure patients signed up.

During the pilot phase of this project, the health organization experienced significant staff turnover—including losing the outreach manager overseeing this effort—which made it difficult to shepherd this innovation through from beginning to end. The outreach manager position remains unfilled due to budgetary constraints, so the organization regrouped internally in order to get the project back on track. “The pandemic had a spiraling impact on recruitment and retention that we’re still dealing with,” says Mariano.

Following up with patients proved essential to the project’s success.  Without that, people who would otherwise qualify for the program would have fallen through the cracks. At the same time, staff would have missed out on crucial feedback to help understand what barriers patients are facing to completing the forms. As Arnold notes, it’s challenging to eliminate obstacles if it’s not clear what they are. Staff worked to simplify what could be a potentially overwhelming process and, if needed, sat with patients to assist them in completing the paperwork.

Simplifying the process helped patients qualify for the program. The largest issue surrounding the previous workflow for Client Assistance Program applications was the paperwork that patients needed to provide to allow eligibility technicians to complete the application process, according to Raeann Kohpay, integrated practice and eligibility services manager. The main documentation required—proof of income—is especially challenging for patients who receive Supplemental Security Income and who do not receive regular proof of their fixed income. It’s also an issue for patients who are paid in cash or patients who don’t receive regular pay stubs. “Requiring proof of income created extra steps for patients that often delayed or made application completion unachievable,” adds Kohpay.

Make the change sustainable

So the health center did away with the requirement. Instead, the organization now allows patients to provide their own income statement. While some eligibility team members expressed concerns about the potential for fraudulent applications, that was a risk that management was willing to take to ensure that people acting in good faith received the support they needed. In the 18 months the program has been running only one application flagged for potential fraud has proven to be correct, notes Arnold. At the same time, 132 patients and counting have been helped by the financial aid plan.

Prior to this project, about 12 percent of patients at the health center had no health insurance coverage. The goal of this project was to cut that number in half – and it did. Currently, the health center has increased program sign ups by 5.8 percent, and it doesn’t intend to stop there.

The organization also had a shift in mindset: It decided to place the onus of securing sign-ups on the health center versus putting the responsibility solely on the patients. Eligibility staff were able to work one on one with patients to eliminate any barriers to filling out the paperwork, which helped to increase the return rate of forms. “At my age it is difficult to keep up with all the different documents needed for my health appointments,” says Sandy, 65, who attends Northwest Colorado Health’s Craig Clinic. “When one of the providers recommended I fill out an application for the Client Assistance Program, I was hesitant because it is typically such a hassle. But this process was so simple, and I am so thankful for that.”

Northwest Colorado Health intends to keep chipping away at the number of patients who haven’t taken advantage of the program, whether because of choice, timing, noncompliance, or other issues. They have also integrated this application process into the center’s systems so that it can continue regardless of employee turnover. Sustainability was important to the organization: It didn’t want to just fix the problem for right now. “It may not be some big, bold innovation, in some ways it’s so fundamental and basic,” says Arnold. “It’s about paperwork, process, and workflows. But we know it makes a big difference to the patients it serves.” It’s a feel-good win (and financially savvy) for all parties. “Every patient deserves the right to access health care when needed,” adds Arnold. “And I’ve seen patients not getting the care they needed because they had to pay out-of-pocket.”

It does require patient education and consistent follow-up. Many patients who initially signed up were not aware that the program requires an annual application. In fact, they typically only realized that when they received a billing statement for full fee for services. Now the eligibility department is pro-active: It notifies patients a month in advance that their support is about to expire and encourages them to reapply with current information so they can continue to receive affordable healthcare. “Working as a team to make critical changes in the workflow for the Client Assistance Program made the process simple and smooth,” says Kohpay. “The patients that the program serves have been elated with how easy the process has become. It takes a lot of stress off of patients.”

Next steps are geared towards longevity. That means ensuring all hires are educated about the program, being responsive to staff and patient feedback, gathering and assessing data to strengthen the program, continuing to evaluate policy changes to increase participation, and fine-tuning workflows and electronic health record information collection, as needed.

Mariano says the project’s success is an example of how sometimes the human touch is best. While technology is often lauded as the quick fix to an issue, this innovation, she says, was all about people helping other people, putting the humans first in a human-centered design approach to problem solving.

Lessons Learned

Start small. Even though the organization knew starting small was the right approach, every time it tried to speed up the process or make the project bigger than its original scope, the team ran into trouble.

Listen to people’s pain points. Leadership thought it knew what the solutions should be, but it wasn’t until the organization did some deep listening to frontline staff and qualifying patients that it really got a good sense of the hurdles at hand.

Plan for pushback. Staff can be invested in the status quo and resistant to change. Set clear expectations, explain why a shift is needed, be open to feedback, and look for ways to engage reluctant employees in solving a problem.

Practice patience. Expect to encounter events out of a team’s control that will affect the project and its progress. Staff shortages, post-pandemic retention issues, and patient concerns could all present challenges. Keep the organization’s eyes on the long game while knowing short term obstacles will arise.

Keep it simple. Don’t feel the need to find complex, high-tech solutions when easy low-tech options work well and are widely adopted. There’s no need to make things harder than they have to be. Sometimes all it takes is sitting with a patient and an application form and guiding them through the process.



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