Building a Community Health System from the Ground Up: Lessons from the Hurricane Katrina Recovery

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Building a Community Health System from the
Ground UpLessons from the Hurricane Katrina
Recovery

• Eric T. Baumgartner, MD, MPH
• Director, Policy and Program Planning
• Louisiana Public Health Institute
• National Association of CountiesHealth Care
  Leadership Institute
• New Orleans, LA
• June 19, 2007

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New Orleans HealthPre-Katrina

• Population 465,000
• Poverty
• Poor public education
• Disparities
• Pre-K, LA adult mortality 2nd highest in nation
• Pre-K, LA infant mortality 2nd highest in nation
• Health expenditures at national average
• New Orleans stats worse for many indicators
• Insufficient community health capacity
• Unhealthy lifestyle

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Defining New Orleans Public HealthPre-Katrina

• New Orleans Health Department core public
  health, limited service delivery
• Louisiana Department of Health and Hospitals
  (DHH) core public health, limited service
  delivery
• Medical Center of Louisiana in New Orleans
  Charity Hospital the major source of out-pt
  and in-patient care - declining out-pt services
• LSU and Tulane Schools of Medicine clinical
  staff for MCLNO, safety net and research
• Non-profits safety net clinics, mental health,
  social services, enabling services insufficient
  capacity for New Orleans needs
• Health care marketplace limited safety net care
  role
• Louisiana Public Health Institute not direct
  health service provider

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New Orleans Public HealthChallenges Pre-Katrina
cont.

• Jurisdictional issues
• City assumption of direct service delivery
• City vs metro regional issues
• Town-Gown issues for Academia
• Policy of twotiered system of care
• Private hospitals 3 UCC vs 6 nationally
• No system for safety net referrals/back-referrals
  for efficient, timely, quality, longitudinal care
  and risk reduction
• Excess in-patient beds
• Funding insufficient subsidy, patient revenue

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Louisiana Two-tiered Health Care Policy

• Official State policy since 1800s
• Statewide state-run hospital/clinic system
• Expressly for poor and uninsured
• High minority utilization
• GME for 70 LA MDs
• GME funded in part State s/ Medicare 3
• Underfunded/insufficiant infrastructure and
  capacity
• Closed panel take little/no referrals from
  community clinicians including CHCs
• Policy legacy of limited safety net tradition of
  privates
• Preemption of safety net system

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Louisiana Two-tiered Health Care Policy cont.

• Elements of quality care, but
• Care was often much delayed
• Often lack of coordination of services,
  diagnostics and records
• Missed opportunities for disease/risk management
• Perpetual sick, institutionally-dependent
  population
• Disparities from a detached second tier system
  policy

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Katrina

• Approx. One Million people had successfully
  evacuated central Gulf Coast
• At New Orleans landfall, Category 3
• At dusk, All Clear sounded
• And then, the levees
• Surrealistic transition into a doomsday
  scenariowhere an entire community is uprooted
  and service capacity gutted

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Post-Katrina Planning Framework for Greater New
Orleans

• Hurricane Katrina caused severe damage to the
  infrastructure for health care and public health
  services in the Greater New Orleans area And,
• Spawned an extraordinary commitment of new
  resources to invest in community health capacity
  redevelopment

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Post-Katrina Framework for a Healthier Greater
New Orleans

• BUT, if all of the components of the health
  system are rebuilt as they were, Greater New
  Orleans risks experiencing the same bad health
  outcomes
• Framework for a Healthier Greater New Orleans was
  developed in August - October of 2005 by the
  Greater New Orleans Health Planning Group

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Post-Katrina planning framework for Greater New
Orleans

• Framework was developed by a group of over100
  people, divided into workgroups, representing
• Federal, state, and local health agencies
• Private, government, and nonprofit health
  providers
• Community groups

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Purposes of the Framework

• NOT a detailed plan, and NOT a comprehensive plan
  
• Identify priority areas for improvements in the
  design of the health system
• Describe principles that health-related agencies
  should follow in rebuilding
• Identify performance standards for key components
  of the health system
• Serve as a guide for agencies to develop more
  detailed plans

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Framework for a Healthier New Orleans Guiding
Principles

• All actions must support a healthier Greater New
  Orleans as Goal
• Plan must be at leading edge for health systems
  planning
• Plan must be grounded in best evidence and
  modeling for population dynamics by time,
  location, SES and health needs
• People of the community must participate at every
  level

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Framework for a Healthier New OrleansPriority
Recommendations
1. Healthy Neighborhood Design- promotes
healthy living and ease of service
accessibility 2. Safe external and
housing/indoor environments 3. Sufficient
public health capacity for assessment, policy
development and assurance
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Framework for a Healthier New OrleansPriority
Recommendations cont.

• Neighborhood primary care for all - foundation
• co-located with other health, mental health,
  social
• and enabling services, including affordable
• pharmceuticals
• - culturally proficient for neighborhood
• - health information exchange with referral
  partners
• Acute hospital and specialty services
• - in direct support of neighborhood primary
• care

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Framework for a Healthier New OrleansPriority
Recommendations cont.

• Health Information System
• - interoperability, common registry, data
  standards, electronic records!
• Health care workforce
• - build upon tradition of LSU, Tulane, Xavier,
• Dillard, others to assure LA workforce
• - adapt to distributive, primary-care system

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Metro New OrleansHealth Care Recovery Experience

• Devastation of New Orleans and regional primary
  care, physician practice and acute hospitals
• Prospect for investment in recovery
• Early and chaotic focal interventions
• Early and persistent independent actions
• But also inclination towards and driver of
  consensus approach to health delivery and
  financing

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However, Persistent Pre-Katrina Challenges

• Jurisdictional issues
• City assumption of direct service delivery
• City vs metro regional issues
• Town-Gown issues for Academia
• Policy of twotiered system of care
• No system for safety net referrals/back-referrals
  for efficient, timely, quality, longitudinal care
  and risk reduction
• Funding insufficient subsidy and patient revenue

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And, New Post-Katrina Challenges

• Uncertainties around re-population
• Getting consumer involvement in the planning
  process
• Dissemination of / buy in for the Framework among
  decision-makers
• Coordination with other planning efforts FEMA,
  Bring Back New Orleans Commission, LA Recovery
  Authority, Secretary Leavitt, Social Services
  Block Grant
• Funding dizzying array of recovery, voluntary
  funds
• - difficult to understand, manage, coordinate
• - short term support vs sustainability

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Community Health FrameworkApplication

• Created as above as ad hoc process
• Parlance of local stakeholders
• Became DNA for subsequent planning
• A Cultural shift in view of health and region

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Metro New Orleans Quest for Transformational
Change - Momentum

• Consensus Approaches
• Bring New Orleans Back Commission - Mayor
• January 2006
• Louisiana Recovery Authority
• Spring , 2006
• Louisiana Health Care Redesign Collaborative
  Governor, Legislature, Secretary Cerise,
  Secretary Leavitt
• October 2006

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Consensus System Features

• Eliminate Two-tier Policy, System, s
• Medical Home Approach
• Based on continuous, distributed primary care
• Primary care invokes rest of system in timely and
  coordinated manner
• Focus on Quality
• Health Information and Exchange Infrastructure
• Insurance Connector/Affordable Coverage
• Shift safety net dollars to coverage expansion

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And Then..

• January, 2007 Federal Response
• Financial analysis of conversion of DSH and other
  traditional safety net subsidy to coverage got
  approx 320,000 people to coverage and left
  400,000 uncovered
• In so doing, lost safety net funding
• La. lawmakers Leavitt's push for health
  insurance is unrealistic KATC TV

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Metro New Orleans Quest for Transformational
Change State Acts

• With failure of private coverage expansion,
  marginal Medicaid/SCHIP expansion
• Legislation to support Louisiana Health Care
  Quality Forum Board established for NFP
• Legislation to support 1.2 B LSU new hospital
  violates consensus principles
• Push for HIT/RHIO deployment little funds

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But Metro NO Quest for Transal Change Goes
OnLocally

• PATH Network HCAP Legacy
• Partnership for Access to Healthcare - regional
• 6 years community health provider driven
• LPHI Supernode
• Social Services Block Grant adm
• Behavioral Health Action Network
• School Health Connection
• Steps Grant
• Executive Director for LA Health Care Recovery
  Council
• Regional Pharmacy
• HIT Rollout
• Shared Services Organization

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But Metro NO Quest for Transal Change Goes
OnLocally

• As of June 07, 100 M HHS Primary Care
  Stabilization Grant through State with LPHI
• 3 years
• Support primary care and linkages
• Work with State and City
• Apply super node alignment
• 3 years funding
• Bridging till policy changes to sustain Medical
  Home approach

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But Metro NO Quest for Transal Change Goes
OnLocally

• Broadest Transformational change
• NEXUS

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But Metro NO Quest for Transal Change Goes
OnNexus

• Unified plan for rebuilding New Orleans 80
  destroyed neighborhoods
• Build an environment and a mix-use approach to
  each neighborhood that addresses the broad
  determinants of health
• Safety, nutrition, physical activity,
  socialization, services, commerce, jobs,
  education/training, upward mobility, home
  ownership and MEDICAL HOMES
• Health care as neighborhood partner
• Major neighborhood rebuilding Fall 2007
• STAY TUNED

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In Summary

• - Crisis-level need with clean slate scenario
  -gt
• provides opportunity of a generation
• - Organizational rush to rebuild what was
• esp. institutions
• - Multiple independent planning/requesting
• nodes
• - Displaced/disenfranchised constituency
• - Need for federal/state/local alignment with
  government/private sector coordination
• - Need for clear and effective local public
  health agency role assurance vs direct service
  delivery

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In Summary

• Ultimate challenge is not resources, it is
  getting stakeholders to work together in earnest
  run on reciprocal accountability
• Need for collaborative leadership, ex Secretary
  Leavitt principles, charter, plan, resourcing,
  partnership
• A role for NGOs in brokering, pulling partners
  together, creating channels of communication
  among leaders at all levels to build consensus
  for long-range planning

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Keys to Transformational Health Policy Change

• Intractable rush to status quo players
  acclimated to rules corps, institutions and
  trade associations
• Delivery system features are easier consensus
• Only get what is funded
• Need simultaneous solution for both winners and
  losers in transformation

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Keys to Transformational Health Policy Change

• Changing provider or payor is transactional not
  transformational
• US counties and municipalities need
  transformation of delivery and payment for health
  care
• Deliver better health and disparities elimination
  
• According all inclusion in accessible,
  affordable, quality integrated delivery system
• Finance on basis of outcome, not volume

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Keys to Transformational Health Policy Change

• Convener of Stature
• Shared galvanizing purpose
• Charter approach as roadmap and social contract
• Purpose
• Values guiding solution
• Rules of engagement
• Framework for deliverables

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Outlook?

• Conversation has already been altered
• More transparency/inclusion in many cases
• Higher cross-sector involvement
• Significant impact of Secretary Leavitt role
• Unprecedented voice for primary care (enough?)
• Most earnest reconsideration ever of two-tier
  health care policy
• 100 M investment in primary care/medical home
• Community capacity to care for its own should be
  noticeably improved but enough?
• Imminent change in State and Federal adms

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Bibliography

• Framework for a Healthier New Orleans
• http//www.sph.tulane.edu/PRC/pages/framework.pdf
  
• Bring New Orleans Back Commission
• http//www.bringneworleansback.org/Portals/BringNe
  wOrleansBack/Resources/BNOB20Health2020Social2
  0Services20PowerPoint.pdf
• Louisiana Health Care Redesign Collaborative
• http//www.dhh.louisiana.gov/offices/publications/
  pubs-288/Concept20Paper20-20Final.pdf
• LA HC Redesign Charter
• http//www.dhh.louisiana.gov/offices/publications/
  pubs-288/Official20Collaborative20Charter.pdf
• Medical Home Principles - Joint Statement
• http//www.acponline.org/hpp/approve_jp.pdf?hp

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Contact Info

• Eric T. Baumgartner, MD, MPH
• Director, Policy and Program Planning
• Louisiana Public Health Institute
• [phone]
• ebaumgartner_at_lphi.org
• www.lphi.org