Providence Health & Services – Patient Support Program

Portland, OR
January 2018

Overview
Since 2015, the Providence Health & Services’ Community Health Division has coordinated support within Providence Oregon for an assistance program that serves individuals across all five service areas. Providence Oregon provided funding and technical assistance to a community-based organization, Project Access NOW, to support the development of the Patient Support Program. In 2016, the Community Health Division and Project Access NOW worked together to expand the program to include $1 million in funding to further support the safe and secure discharge of vulnerable patients transitioning out of acute care.

The Patient Support Program is focused on serving low-income uninsured, Medicaid, Medicare, and commercially underinsured patients, and assisting them with non-medical needs such as transportation, food support, temporary medications, and access to temporary housing. Project Access NOW’s mission is to improve the health of their community by creating access to care and services for those most in need. Using Project Access NOW’s secure web-portal, Providence Oregon hospital discharge planners, social workers, and clinical staff may request assistance online, receive an immediate determination of eligibility for services, and print vouchers to provide to their patients to get connected to services.

Impact
All eight Providence Oregon hospitals are using this program. More than 500 caregivers are trained and can use the program, and almost 12,000 patients have been assisted, with more than 20,000 total assistance items requested. The four types of assistance most often requested include transportation, medication, food support, and temporary housing. In 2016, Kaiser Hospitals and Coordinated Care Organizations in the Portland metro area began using this program.

In 2017, Providence Oregon expanded services to include Meals on Wheels to increase access to nutritious food for those discharging who are 50 and older. Patients who are discharging from the four Portland area facilities to an independent living situation, who have no family support or other resources to assist them in access to food or meals, will receive home-delivered meals for up to 30 days.

Also in 2017, assisting patients with guardianship needs was added to the Patient Support Program, with the goal of establishing a program to assist incapacitated patients who have no legal surrogate by paying the legal fees, if needed, and securing a private or public guardian.

Lessons Learned
Hospitals face limitations when helping Medicare and Medicaid beneficiaries with services like transportation, medication, and housing. Partnering with a community based organization like Project Access NOW, whose focus is on access to basic needs, allows those most in need of services to be connected immediately through a seamless approach, to ensure a safe discharge.

The Community Health Division has learned that as the demand for the program continues to grow, additional needs for resources will increase. In identifying new needs, the Division will seek to bring new community partners into the conversation so that Providence Oregon can continue to provide high-quality care to the community’s most vulnerable.

Future Goals
Services provided through the program are intended to be a short-term bridge for those discharging from the hospital, ensuring a safe discharge. Future plans for the PSP include additional outreach and longer-term support for patients with a mental health diagnosis and those that are experiencing homelessness.

Contact: Pamela Mariea-Nason
Executive, Community Health
Telephone: 503-893-6449
Email: jeri.stein@providence.org