Background to the programme
As part of the Regional Programme for Access to Care and Prevention aimed at the poorest members of the population (PRAPS), the Health Directorate of Saint-Denis has set up an experimental access point for healthcare (PASS) in January 2014, supported by the Regional Health Agency (ARS). This PASS consists of a route to access healthcare and rights for users in precarious situations without having to advance any money. “Blind spots" have been identified for people in great difficulty, particularly access to general medical consultations, nursing care, physiotherapy and medical prescriptions. These needs can be met by municipal health centres (CMS).
Objectives of the programme
To model a simple city PASS and coordinate with two municipal health centres to promote access to primary care in the city for people without health insurance (without rights or with potential rights) and for people with difficulties paying the expenses that remain or advancing medical fees.
- Formalisation of the City PASS pathway by a steering committee and a technical committee: definition of arrangements, the intervention framework and the liaison sheet
- Search for and formalise partnerships (pharmacies, medical analysis laboratory, CPAM)
- Write and disseminate of communication tools (professional and user brochures)
- Deploy the measure and the city PASS activities in both CMS:
* Establish an access point: support with accessing rights by filling out CMU (Couverture Maladie Universelle) CMUC and AME documents in each CMS
* Train and educate administrative, medical and paramedical personnel
* Set up monitoring and evaluation tools for the process (dashboard)
Quantitative and qualitative results from the implemented actions
In 2014, 360 city PASS processes carried out:
- 360 people received by the two centres who have accessed medicines, laboratory examinations, radiology and/or nursing care without advancing medical fees.
- Including 260 people who have accessed their rights.
- Including 40 people who wanted to be regularly monitored by the municipal health centres
The PASS is a tool to address the non-use of rights. It allows individuals to renew contact with institutions. This first step can be a springboard to building a more general pathway to social integration with them.
There are only five city PASS experiments throughout Ile-de-France. Of these five places, Saint-Denis is the city where the population is the most precarious.
Partnership(s) developed in the context of the programme
PASS comprises more than twenty stakeholders:
- Public Actors: CMS Moulins, CMS Plaine, Direction Santé, Hôpital Delafontaine, Hôpital Delafontaine, Ville Evrard Pass, Coordination des sans papiers /MRAP, CCAS de la ville de Saint-Denis, SMAS de la ville de Saint-Denis, PMI ville de Saint-Denis, Maison de la solidarité et CPAM
- Associative Actors: Médecins Du Monde CASO, Médecins Du Monde bidonville, PROSES, PU-AMI, La Maison de la Santé, La place Santé /femasif et Samu social
- Private Actors: Laboratoire Centre Cardiologique du Nord, Pharmacie de la Légion d'Honneur et Pharmacie Kayes
Difficulties and/or obstacles encountered during the programme’s implementation :
- Very long waiting times for meetings and consultations because of the complexity of the situations (loss of rights, ignorance of measures ...)
- Problems with receiving and identifying poor people returning to the CMS
- The problem of aligning the PASS with the Department of Health project and the Medical project (impact on changing practices, work on the image and recognition of others, receiving Roma families, first-time immigrants etc.)
- Strong municipal engagement: 67% of funding comes from the town of Saint-Denis while the state only contributes 23%
Solutions used to overcome the difficulties and/or obstacles :
- Allocation of a social worker specially dedicated to welcoming, monitoring and supporting access to rights with CMU, AME, and CMUc users, but also to directing them towards measures that are necessary to continue care and access to rights. It increasingly integrates access to complementary health insurance.
- Including a welcome for the entire CMS team (coordinate the role of the multidisciplinary team)
- Improve the training of the welcome teams on multi-faceted support (optimise the reception of patients in distress, crisis and/or difficulties)
- Respect the CPAM agreement (processing CMU, CMUc and AME documents and reduce the delays in accessing rights)
- Regulation and articulation of other aspects of the PASS (medicine, hospital, CCAS, pharmacy, lab, association)
- Participation in social and health monitoring in the area on access to rights and care (Atelier Santé Ville group)
Suggestions for future improvement :
Need to establish the PASS on the long term which could constitute a gateway to the social protection system
Summary of factors responsible for the programme’s success :
- The PASS is part of ambitious social policy and was thought up within a comprehensive vision of city policies.
- Consultation work between associative, municipal and medical actors
- The level of intervention (support in sector 1 and geographical proximity) and good knowledge of the populations are key elements in reaching people who are "medically dormant."
- A regular steering and evaluation committee (associations, hospital, PMI, Health Directorate, CMS, CPAM) who work on practical case studies (analysis of people’s pathways: those who succeed and those who fail)
- Give great importance to the reception of patients
- Training of reception staff, doctors and nurses on precariousness
- Strong involvement of the hospital
Ideas for basic or applied research topics, that could be useful to the programme :
- The impact and improvement of health or positive social consequences (access to social rights, unemployment, employment, with "reintegration with the health system")
- The factors involved in the process of drifting away from primary care
To know more
The city PASS has inclusion criteria:
- Express a health problem
- Be unable to access rights
- Be unable to advance medical expenses.
- Live in the Saint-Denis area or have a connection with social actors in the city, or a medical connec