Placing Patients in a Network of Care

When Cathy Tolbert visits new clients in Greenwood, South Carolina, it doesn’t take long before they find something in common. Chances are good she goes to church with one of their siblings, or shops at the stores where their children have worked.

If I don’t know them directly,” she says, I probably know one of their relatives. Everyone here feels just like family.”

Ms. Cathy” was born and raised in this close-knit small town and has found a calling in serving its neighbors. She works at AccessHealth Lakelands, a community-based network of care for people who have no insurance and aren’t eligible for Medicaid or Medicare.

Funding from The Duke Endowment has helped Greenwood and other communities develop 30 of these collaborative networks, reaching 77 counties across the Carolinas. Designed to be a link between the uninsured and local medical professionals, the networks improve health by increasing access to comprehensive care and services.

As Lakelands’ community health worker, Cathy arranges transportation to clinics. She makes sure clients refill their prescriptions. She encourages them to keep appointments, or schedule a dreaded test.

Adults without health insurance are more likely to delay medical care, waiting until avoidable problems become an emergency. Cathy’s goal is to help them stay on track toward a healthier life. 

They say, Thank you, Ms. Cathy. This wouldn’t have happened without you and your program.’ We cheer each other on and give each other inspiration every day.

She knows it’s hard. After her own doctor diagnosed prediabetes, Cathy joined a gym, changed her diet, and worked to shed extra pounds. She felt she owed that to her patients, and she now shares stories about meeting her goals.

She loves it when people stop her on the street to report on their progress or celebrate how good they feel.

They say, Thank you, Ms. Cathy. This wouldn’t have happened without you and your program.’ We cheer each other on and give each other inspiration every day.”

Linking to Quality Care

Helping the Uninsured Get Care in the Carolinas

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Improving access to health care has long been a priority for The Duke Endowment.

Since 2008, the primary strategy has been developing and supporting collaborative networks for people who are low-income and uninsured. Health care safety-net providers work in these networks to connect patients with chronic illnesses to a primary care medical home as well as managed access to specialty care and hospital services.

Technical assistance centers in both states help communities develop and implement these programs.

The 30 networks collect a wealth of data to measure their impact, and have been shown to decrease emergency department use, lower hospitalizations and reduce hospital costs. Aggregate outcomes include:

  • More than 68,000 patients currently enrolled
  • Nearly 14,000 physicians currently participating
  • More than $416 million in medical care provided in 2018
  • $109 million in hospital costs avoided in 2018

In Greenwood, S.C., AccessHealth Lakelands has connected more than 1,500 low-income uninsured residents to a medical home since opening four years ago.

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