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How AlignCare® aims to better align resources and activities from a community-based perspective to benefit both humans and animals.

In his work in both human health and animal health, Michael Blackwell, DVM, MPH has always appreciated the human-animal bond. Following the recession of 2008, he was acutely aware that it wasn’t just the human members of underserved families that were impacted – their pets were too.

“We had many families that were not in good shape financially to pay for veterinary care once that recession occurred,” said Blackwell, who had served as chief of staff, Office of the Surgeon General of the U.S., and chief veterinary officer of the U.S. Public Health Service, before becoming dean of the College of Veterinary Medicine, University of Tennessee.

A national population survey confirmed it. The study was conducted by the Access to Veterinary Care Coalition, a partnership of for-profit and nonprofit veterinary service providers, animal welfare and social service professionals, and educators, working in collaboration with the University of Tennessee, Center for Applied Research and Evaluation, and commissioned through a grant from Maddie’s Fund. The coalition’s report, Access to Veterinary Care: Barriers, Current Practices, and Public Policy, found:

  • Dogs and cats living in lower-income households and with younger pet owners are most at risk for not receiving recommended care.
  • The overwhelming barrier for all groups of pet owners and all types of care is financial, with 80% unable to obtain preventative care due to financial constraints, 74% for sick care, and 56% for emergency care.
  • Veterinary service providers recognize the severity of the problem and feel a commitment to explore ways to address it. The highest level of agreement expressed by veterinarians in the survey was in response to the statement: “All pets deserve some level of veterinary care.” Almost all respondents – 95% – either agreed or strongly agreed with the statement.
  • Nearly nine out of 10 respondents indicated they agreed or strongly agreed that owned pets are a member of the family. Similarly, 87% agreed that not being able to obtain needed veterinary care impacts the owner’s mental and emotional health.

“Most people already assumed that finances were a big part of the barriers to veterinary care, and that’s certainly what the study confirmed,” said Blackwell. What was a bit shocking was how widespread the issue was. Blackwell said 28% of the respondents reported a barrier within the past two years, whether financial, transportation, or otherwise. With the recession of 2008, and certainly now with COVID-19, “we have tens of millions of families that are in that situation.”

Addressing the need through alignment

The study results led to another grant from Maddie’s Fund to create AlignCare® – the main project of the Program for Pet Health Equity and a collaboration among the University of Tennessee, Maddie’s Fund, veterinary service providers (VSP), social service agencies, veterinary social work (VSW), and community partners who are committed to family welfare through improving access to veterinary care.

“The root word is align,” said Blackwell, who now serves as the director of the Program for Pet Health Equity. “The principle of AlignCare is that rather than building new veterinary practices, nonprofits, and other things, if we simply better align our current resources and activities from a community-based perspective, then we can do a better job reaching families.”

The veterinary industry is made up largely of for-profit practices – small businesses that do the best they can to serve people who show up with limited means to pay for care, Blackwell said. “We know that practices want to help, but there is a limit to what they can give away. In these same communities, there are nonprofit organizations and individuals who are trying to help families that struggle. I don’t think we have the best efficiency in getting those resources to the families.”

AlignCare intends to establish collaborations in a formal sense between these stakeholders to identify families that have a demonstrated need. “That’s very important because veterinarians will bend over backward to help, but they want to know that they are making sacrifices to help someone who really needs it.” Likewise for those who donate money to help others. There’s a need to ensure those dollars are going to the intended recipients.

AlignCare was conceived as a One Health project. The basic idea is that in order to improve health outcomes for humans, you must factor in the animals, as well as the environment or ecosystem. “These all intersect,” Blackwell said. “Likewise, if you want to do a better job of reaching animals, you have to factor in the reality of the humans, as well as the ecosystem.”

Using the One Health template, AlignCare has a direct focus on human reality through social work, veterinary social work specifically. The Program for Pet Health Equity builds partnerships with community organizations. Initially, they were made up mainly of social service agencies or programs, such as a Head Start program, senior assistance, etc. “We start with those who are already supporting families.”

One reason is that because more often than not, the families supported have pets. These traditional programs are not designed to help with pet-related issues. “We help those agencies by making available the option for veterinary care,” Blackwell said.

Once a family is identified, they get enrolled in AlignCare by a veterinary social work coordinator using an app to capture key information about the family makeup – human and non-human members. “We want to know about the human members because of the dynamics that go on with that family’s pets,” said Blackwell. “Sometimes what’s going on with the humans is impacting the pets. And it can be vice versa. We capture information through that app to a health record. Then that family is referred to a veterinary service provider who is also enrolled. By and large, these would be for-profit veterinary practices, but they can be nonprofits as well as long as they provide sick care because the crisis happens when someone needs sick care.”

The veterinary service providers operate under policies that have already been established. Blackwell said the policy has several requirements. The first is that the veterinary practice uses incremental veterinary care. “That is something we are characterizing through our work, but it’s something that is traditionally done in veterinary medicine. If a client has limited resources, what do you take out of the treatment plan? What is it that you don’t do? What diagnostic test do you delay because you’re trying to do the best you can with the resources that you have to work with? We’ve done that in veterinary medicine forever, but we have not standardized these decisions.”

The work is intended to standardize the decisions that veterinarians make every day to do something to avoid doing nothing, he said. “We also call it a tiered approach to the patient. Where do you start, and what do you bump up to as you need to? They agree to practice incremental veterinary care. If the person shows up without money and people are trying to help through donations, the last thing we need is a veterinarian throwing gold standard care at them and running CAT scans or another testing that may not be critical to developing a treatment plan.”

The second part of the policy is that the veterinarian is willing to take third-party payments. Under AlignCare, the family is generally expected to cover a 20% co-pay. AlignCare pays the 80% subsidy.

The third and final part of the policy is that the veterinary service provider is willing to work with a veterinary social work coordinator.

“We want to offload some of the work and place it with professionals who are trained to deal with those issues,” said Blackwell. That includes coaching and counseling families with regular care and even end-of-life decisions. It also involves coaching and counseling the veterinary care team around the AlignCare families. “Ultimately then veterinarians have the predictability of who is showing up, what the fee structure is going to be, and they know they’re going to get paid because it is pre-determined. As those non-medical issues are encountered there is someone else in the space around the pet who is working with that family to address those issues.”

Ramping up

As of press time, AlignCare had just entered the demonstration phase and was implementing the program in three cities – Asheville, North Carolina; Knoxville, Tennessee; and Phoenix, Arizona. A total of 8-10 cities were to be part of the first phase.

However, due to the COVID-19 pandemic, Blackwell said they are in the process of trying to scale up early, “and not just in the 8-10 communities, because this program is needed across the nation,” he said. “It channels contributions out of the community to veterinary service providers in a structured way, including cost control measures so those funds are used efficiently and effectively and they get to the people intended to help.”

Veterinarians have been supportive of the program. “They are seeing these clients every day, and depending on the community, multiple times throughout the day. Now with COVID-19 where people have lost their jobs, the problem has just been exacerbated. They want to help. They also have said to us we appreciate that this is a system intended to address those human factors that can interfere.”

The whole concept of AlignCare is aligning the various interests in order to get a better outcome for the country, Blackwell said. “When we look at the human side of health care, we see all sorts of systems and programs, national in scope, built around policies intended to do some of the same things I’ve been talking about – controlling costs, ensuring dollars get to those intended, etc. What we don’t have in the United States is a national health care system for non-human family members. We’re trying to build a companion health care system that operates in a similar fashion to programs on the human side, but it’s for the non-human members.”

Industry stakeholders, such as distributors, manufacturers, and service providers, can play a role. “We want to develop corporate partnerships that help the national system to exist and operate.”

Snowball effect

Many families that struggle to pay for veterinary care are among the working poor. Blackwell provided an illustration of how even a routine visit can have a detrimental impact financially on the family. “First, they have jobs that do not pay them leave,” he said. “So when they have to go to the veterinarian for something as simple as a suture check, it can have pretty heavy consequences for them financially. They may have to take unpaid time off for work, for instance. Then pay for their own transportation. And this may be just for a veterinary visit that may take as little as five minutes.”