VISTA: Tri-City referrals cause spike at Vista Community Clinic
New system aims to deliver cost-effective care for uninsured patients
By PAUL SISSON - Staff Writer | ∞
Maria Lopez of Vista is treated by Dr. Enrique Boquin at the Vista Community Clinic on Wednesday. (Photo by Waldo Nilo - staff photographer) 
A woman walks into the Vista Community Clinic on Wednesday. The clinic has seen a surge in patients, in part because of new electronic referral system that links it with Tri-City Medical Center. (Photo by Waldo Nilo - staff photographer) VISTA ---- Officials at the Vista Community Clinic said they are seeing an increasing numbers of patients coming through their doors, and they attributed much of it to better communication with the emergency department at Tri-City Medical Center.
Barbara Mannino, the clinic's chief executive officer, said the number of patients referred by Tri-City has increased sixfold since the two organizations established an electronic link between doctors and schedulers in February 2007.
The system allows the hospital to electronically notify the clinic about uninsured patients that come to Tri-City's emergency room, so that the clinic can contact those patients for follow-up care.
With the old paper-based system, it was up to patients to call the clinic and set up an appointment. Often, those patients would not seek the follow-up care and end up in the emergency room again, officials said.
"The minute we started (the new system), the referrals just went through the roof," Mannino said.
Patients appear to appreciate the change. Maria Lopez, who made a recent visit to the clinic for a checkup, said through an interpreter that she prefers to receive treatment in a doctor's office rather than the hospital.
Lopez said she doesn't have insurance and would have to use the emergency room if the clinic was not available.
"To tell you the truth, I don't know where else I could go," she said.
Before making the change, doctors at Vista Community Clinic saw about 600 patients per year who were referred directly from Tri-City's emergency department. Now the number is closer to 3,600, Mannino said.
All patients referred either have no medical insurance or no primary care doctor.
Mannino said the clinic has had to hire extra personnel and expand its hours to cope with the influx of patients. She said that has further strained the organization's $24 million operating budget, which relies on grants and donations to help cover the gap between what its frequently poor patients can pay and what it costs to treat them.
The clinic operates in five locations in Vista and Oceanside.
Still, Mannino said she does not lament the spike in demand.
"It's what we're here for. This is our mission," she said.
Tri-City officials said they could not provide specific information on how or whether the change has affected the number of emergency room patients the hospital sees, or whether Tri-City has seen a decline in the number of uninsured patients visiting the emergency room.
Hospital officials said members of Tri-City's finance department were too busy working on an audit to compile that information.
But Dr. Cary Mells, director of the Tri-City Emergency Medical Group, which runs the hospital's emergency room, said recently he believed that a better referral system has meant fewer runny noses and other nonemergency cases in the emergency room.
"The more patients you can get into primary care, the fewer you will have come into the emergency department with nonemergency problems," Mells said.
Research performed by the San Diego Business Healthcare Connection found that the average cost of a trip to the emergency room is $3,300. Mannino said it costs about $100 for a regular checkup at the clinic.
Mells also said patients who receive treatment for legitimate emergencies at the hospital often need follow-up care from a primary care doctor after they are discharged. When a patient does not have insurance, follow-up visits may never happen and patients can end up back in the emergency room with a more severe case of the problem that sent them there in the first place.
The electronic referral system that now links hospital and clinic replaces a paper-based system that has been in operation since 1995. The new system is built into Tri-City's computerized patient charting system.
When a doctor fills out a discharge order, the computer asks for a referral and defaults to the clinic if no other primary care doctor is specified. Data on patient referrals are then collected and sent to the clinic, where a crew of 12 schedulers calls each patient up to three times to set up an appointment.
There are plans in the works to help Vista Community Clinic lessen its workload, officials said.
Mannino said that a $60,000 grant from the Tri-City Healthcare Foundation will help North County Health Services clinics use the same electronic referral system and spread patients to its 10 facilities that are scattered between Encinitas and Ramona.
Contact staff writer Paul Sisson at (760) 901-4087 or psisson@nctimes.com.
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Free Care at a cost wrote on Jul 23, 2008 9:54 PM:24 million dollars for one year? That's a huge business, but of course everyone deserves health care. Some of us pay thousanda each month for insurance, deductibles, medications. Our employers don't cover us. We pay our way. Some don't work, have more kids than they can afford, so they get FREE health care and ER visits. What's wrong with this picture?
Lets Make A Deal wrote on Jul 23, 2008 10:20 PM:The value of the property on Horne Street that Tri City leased to Vista Community Clinc has been on the cheap for years.
Now is Tri City willing to sell off their District's assets to Mannino rather than hold onto the property for a couple of more years for an economic turnaround?
Will the District consider selling to the highest bidder or is the District - so desparte for cash the CEO lacks prudence? Perhaps, better communication for Gonzalez and Mannino means she will be able to come up with the money to buy on the cheap - just a little easier?
Wondering is this just another give away similar to the making of the Marina Towers decision by a 4 to 1 vote? I guess in this District, you gotta be an insider for Let's Make A Deal otherwise you may be gonged!
Randy wrote on Jul 24, 2008 6:37 AM:How can the average trip to the ER cost $3,300?
Vista Granny wrote on Jul 24, 2008 7:18 AM:Tri City Hospital can't tell if this arrangement has cut the number of emergency room visits because they're too busy working on an audit? In other words, they're not too efficient of bright, are they? And as for those who complain that poor people who can't pay get "free" health care, so what! Would they prefer that these people just die? What if someone has a communicable disease - just pass it on before they die? Good health care is ESSENTIAL - quite complaining and be glad you CAN pay for health insurance.
Sweet Pea wrote on Jul 24, 2008 7:26 AM:Why is there no diabetes educator on staff at Tri City MC? My mother was a patient there and they would not discharge her until she knew how to give her own shot and showed that she could test her own blood sugar. That sounds good, but they didn't have anyone there to teach her how to do these things. They didn't even know how to order a blood glucose meter for her-I had to go to the store and buy it myself. She spent an extra day and a half there only because she couldn't get the instruction. Medicare paid for it, but what a waste!
Louise wrote on Jul 24, 2008 7:54 AM:Most of the people at the TCMC ER are not there for emergencies but for general care. While REAL emergencies sit there for hours the non-emergencies clog up the system.
This hospital should be sold, to a private for profit corporation so that Mannino can have her patients back.
Why should my tax dollars pay for this bond. I agree with the comments above why should I pay for the free care of those who irresponsibly choose to have more kids than they can afford.
I am having trouble paying for my family , why should I be expected to pay for theirs?
who monitors wrote on Jul 24, 2008 11:02 AM:the comments for NCT ???
OCEANSIDER wrote on Jul 24, 2008 3:14 PM:Louise's comments are flat wrong. At Tri City ER a triage nurse immediately sees each incoming patient. If that patient is there for the sniffles or some non-emergency situation, the triage nurse sends them away, telling them to see their regular physician or go to a free clinic. They are not seen or treated in the ER. Actually, most of the patients seen in the ER are there because of a real emergency. All of the myths about the Tri-City ER are propaganda to defeat the upcoming bond vote. Notice how "Louise" links her propaganda about the ER to the bond.
No insurance wrote on Jul 24, 2008 5:09 PM:I go to the V.C.C. because I do not have insurance.(just in case anyone makes a race comment..I am a White middle aged female!) I pay out of pocket for ALL my appointments and prescriptions. Meanwhile MANY of the patients get to be seen for FREE! Doesn't seem fair that some that are not legally here get it for free!
to Sweet Pea wrote on Jul 25, 2008 6:44 AM:I agree. I will not go to TCMC because the staff has limited knowledge about diabetes and there is no diabetes educator to help them. I have diabetes and have attended the classes that are held at the hospital. This is an excellent course (and it's not even provided by the hospital!), but it's not enough. There was a man in my class who was taught by his physician's "nurse" how to give himself his shot. When the gentleman mentioned to the diabetes educator that he was instructed to inject into his vein the educator couldn't believe it! He could have killed himself. This would not have happened had he seen a real diabetes educator rather than a medical assistant.Every hospital in San Diego County has a Diabetes Education Program with a Certified Diabetes Educator on Staff. Why doesn't Tri City Medical Center care enough about their community to offer this?
to Sweet Pea wrote on Jul 25, 2008 8:11 AM:I agree with you. We need a Diabetes Education Program that includes a Certified Diabetes Nurse Educator at Tri City. Not just a once a month class (which is outsourced) that no one knows about. TCMC's website emphasizes that 90-95% of the population has Type 2 diabetes, but they don't go the extra step and provide a diabetes educator for their voting constituents. Prevention is the key. Wouldn't it be wise to prevent unnecessary admissions to the hospital by educating people how to take care of their diabetes?
Frustrated wrote on Jul 25, 2008 9:20 AM:Why does everybody blame the hospital for lack of diabetes education. That is the whole idea of a primary care system. They have obviously put forth the effort (with minimal gratitude by most of you) to establish a system to provide this care by other facilities. Those are the places where basic standard health education needs to be taught. Hospitals are to treat emergencies that can't be handled at home or in a clinic. Seems to be a diabetes class, or almost any other class, could just as easily be given by VCC, NCHS, SMP, etc... I would like to give the hospital a pat on the back for doing things to improve the system. And do you people realize that if the bond doesn't pass, the hospital WILL BE SOLD... You want it to be owned by a private entity?? Well, I wish KAISER and their STELLAR care on all of you... Good luck with that.... WAKE UP!!
to Frustrated wrote on Jul 25, 2008 2:19 PM:Unfortunately, the "primary care system" isn't working. The only medical group offering diabetes education classes taught by qualified diabetes educators is Sharp Mission Park. It is open to their patients only and a person cannot self-refer. Greater Tri Cities IPA and Primary Care Assoc. Med. Group send their patients to a "free" diabetes class which is provided by one of the meter companies. Everyone in that class must use that meter whether it is a preferred product on their health plan or not. This is pushing the 'Safe Harbor Act' & is not acceptable! People continue to be discharged from the hospital without knowing how to inject their insulin, how to test their blood sugars, and what to do if they have a low blood sugar. Like it was mentioned by Sweet Pea-every other hospital in the county has both an inpatient diabetes education program and an outpatient program. Both are taught by Certified Diabetes Educators (CDE)-at least one Registered Nurse, CDE and one Registered Dietitian, CDE.
North County Health Services & VCC offer diabetes classes which are taught by "Health Educators"-they are not licensed RNs or RDs. TCMC has a "diabetes cart". Handouts and outdated meters are sometimes given to the patients if the nurses can find the cart. Yes, we all need to WAKE UP! If you have diabetes and you have to go to the hospital you'd better go to Sharp, Scripps, UCSD or Palomar.
to frustrated wrote on Jul 25, 2008 2:45 PM:You obviously don't have diabetes yourself. To belittle what a person with diabetes needs to learn and know in order to live and prevent the possible diabetes-related complications is pitiful. Diabetes is a life altering disease and if left untreated will lead to complications. Diabetes affects not only the person who has it, but also their entire family. Diabetes is not a 'little cold' that needs some basic care-it's a lifelong disease. "Basic standard health education" is not what a person with diabetes needs. It is much more intense. It's not a cookie-cutter diet that is handed to a patient--those don't work and end up in the trash. Teach the patient how to inject an orange-then what do they do? Eat it? How does a patient learn to inject themself if they don't receive the proper instruction? Who is a patient supposed to call if they are having a problem at home? Their doctor? Anyone who has tried to call their doctor for anything is laughing right now. It's not that they don't care, but rather doctors are too busy to take those calls-that is how the "primary care system" is set up. So, if any other class could be taken at the clinic or SMP why not move the cardiac wellness classes there? Rehab for the stroke patients? Why not send that to the medical groups and clinics too? Do you realize what the common denominator for cardiac & stroke rehab are? Most of those patients have diabetes and could have prevented the heart attack or stroke had they learned how to manage their own diabetes. TCMC has not had a diabetes education program for over 10 years. The nurses keep asking the hospital to hire at least a part-time RN, CDE, but to no avail. Kaiser at least has a well run diabetes education program!
to Frustrated wrote on Jul 25, 2008 4:10 PM:You are way off base and do not know any of the facts about the the "primary care system", which doesn't work. The community needs a quality diabetes education program. In a previous email I listed a number of facts, but the NCT chose not to post it. But please know that this is a big issue. 'Frustrated' sounds like she/he is afraid of losing her/his job. A private hospital wouldn't be a bad thing either. In fact, our taxes may even be reduced because we would no longer have to pay for the community hospital:-)
to to Frustrated both of them wrote on Jul 25, 2008 8:49 PM:Bravo!
Vista Watchdog wrote on Jul 26, 2008 11:21 PM:Time to SELL TCMC and convert the Hospital District into an Emergency Management District. With all the concern about coordinating our regional firefighting and getting the proper firefighting and EMS equipment into place in NC, the funds from the sale of the Hospital to a Private non-profit would bring NC's Emergency Management Services up to a world class level! Not only could it be used to update TCMC' ER to a world class ER/truama center, but also to help ensure all local cities and communities have the best possible EMS (police, fire, paramentic, etc.) money can buy, and without having to rais taxes!
THINK OUTSIDE THE BOX! This is a WIN-WIN-WIN solution!!!!
To Randy wrote on Jul 28, 2008 1:52 PM:"How can the average trip to the ER cost $3,300?"
By padding the costs in order to hide the ballooned administrative costs. Similar to why our schools are in massive debt (even though the budget rises billions each year but enrollment actually DROPS).
Teachers, doctors, nurses - all should get their due. Its the other 90% of the hospitals and schools that turn them into bloated garbage. Oh, and the politicians help.
lord wrote on Aug 8, 2008 12:20 AM:stop bitching there are not many clinics like this in other states, if you have no health insurance, well then you have no health ins, and you have to eat the medical costs and ruin credit. You should know that with no ins, YOU ARE LUCKY TO SEE A DR. get over it!! AT least you got some expert advice???
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