Building relationships: Referrals for specialty care in Kansas

by Claire Hutkins Seda, Writer, Migrant Clinicians Network, Managing Editor, Streamline

In Kansas, migratory agricultural workers are not centralized in one region, and consequently, migrant health services are spread out across the state. “It didn’t make sense to have a brick-and-mortar clinic dedicated to farmworkers,” explained Kendra Baldridge, LMSW, Section Chief of Special Population Health for the Kansas Department of Health and Environment (KDHE). Instead, starting in 1994, KDHE has offered a voucher program, establishing relationships with Federally Qualified Health Centers (FQHCs), rural health clinics, and private clinics throughout the state to assure the migrant population of Kansas can access the care they need.

KDHE’s voucher program holds agreements with over 700 providers throughout the state, with roughly 120 of those providers offering specialty care. In the voucher model, patients sign up at access points, which are generally FQHCs or health departments. A patient may see a primary care provider who accepts vouchers. If that provider refers a patient to specialty care, the provider may know which specialty care provider accepts vouchers, or the patient may reach out to one of KDHE’s case managers to determine which specialists in his or her area will accept the patient under the voucher program -- “similar to finding someone ‘in-network’ with [private] health insurance,” noted Baldridge. But, as many federally funded programs offering specialty care encounter, KDHE must work diligently to maintain strong relationships with specialty care providers.

“In this world of technology, a lot of times it just comes back to... having a conversation and explaining why our program is a benefit to clients and why it’s helpful for them to partner with us to serve farmworkers,” Baldridge said. “When we sign up a new provider, we have hopefully a face-to-face conversation, but at least a phone conversation, to plead our case.”  Specialists may turn down participation in the program because of lower reimbursement rates and the stigma against the primarily Spanish-speaking migratory and agricultural worker patients, who are viewed as a “difficult population to serve,” but KDHE has been successful in convincing specialists to take referrals, by helping them “see the benefit of serving the community,” Baldridge explained.

Much of the relationship between the specialists and the voucher program is developed by the regional case manager. Most of the urban population -- and consequently the largest concentration of specialists -- are in the “Eastern third” of Kansas, said Baldridge, where agricultural workers are more often employed at nurseries, orchards, greenhouses and tree farms, which supply the landscaping companies in the cities. In the north and west of the state, the dairy and feedlot industries employ most of the agricultural workers, whereas in southern Kansas, cotton processing facilities provide much of the work. KDHE has four full-time regional case managers as well as five part-time health promoters spread throughout the state who are bilingual in Spanish and English, and one health promoter in the western part of the state who is bilingual in Low German to serve the Mennonite community. 

KDHE’s regional case managers keep a pulse on the specialists who have agreed to take referrals.  Case managers need to stay flexible to keep their region’s specialist relationships functioning, said Baldridge, who worked as a KDHE case manager herself for eight years before taking the Section Chief position in 2015. And each case manager’s caseload is unique. “Our central Kansas case manager...seems to get quite a few referrals for specialists, and she has the routine down of talking with providers and [figuring out] who to ask for in the office,” to make sure she connects with someone who will accept the program and can make the final decision on whether to become a provider. Baldridge noted that this process is more challenging with larger providers like hospitals, where decision making may be more complex. 

Case managers also need to exhibit a level of flexibility to get specialists on board, said Baldridge. “Each clinic or provider might potentially work a little differently,” she admitted. “The case managers have the most contact directly with providers in that area [so it’s their job to] understand how each one works,” complying with the specialist’s policies or procedures, which may be a requirement for the specialist to accept a voucher program patient. A common example of this is a specialist requesting that the case manager call the specialist to set up an appointment on behalf of a client, rather than allowing the client or the referring practitioner’s office to contact the specialist directly. “It seems that in our experience... we’re the ones that have the ability to be just a little bit more flexible… If it’s something as simple as, they want a call from a case manager rather than directly from a client... that’s one of the easier ones that we’re able to accommodate,” Baldridge said.

The voucher program may send clients to some specialists only once every few years. In such a situation, case managers may find themselves re-explaining the basics of the program to a provider that has been a partner with the program for several years. To avoid that, Baldridge says, case managers are tasked with keeping up the relationship over time.

For KDHE, that open line of communication is paramount to a functioning specialty care referral system. “I really think it’s all about that relationship with the entities and the individuals that you partner with,” Baldridge concluded. “It may be a different kind of relationship with email and social marketing,” which may open different avenues of connection beyond the face-to-face meeting, “but still, it’s about making a connection.”