Redesigning the Health System After Katrina: A Community Perspective

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Redesigning the Health System After KatrinaA
Community Perspective

• David J. Ward, MHSA
• warddj1_at_aol.com
• President CEO, Daughters of Charity Services of
  New Orleans,
• an affiliate of Ascension Health
• Chair, Regional Ambulatory Care Planning
  Committee, PATH
• Co-Convenor, LA Health Services Recovery Council
• Workgroup Leader, LA Health Care Redesign
  Collaborative
• Steering Committee Member, LA Health Information
  Exchange
• Adjunct Faculty Member, LSU Tulane Univ. Health
  Science Centers
• January 25, 2007

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Overview

• New Orleans, Pre-Hurricane
• Hurricane Katrinas Impact People Health
  Services
• Restoring Clinical Services
• LA Health Care Redesign Collaborative
  Assumptions, Process, Proposal, Implementation
• Summary of Lessons Learned Advocacy Imperatives

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Pre-Storm HEALTH DISPARITIESThe Burden of
Disease on the Poor

• Deaths/100,000 Population
• 27 Higher
• Cancer Rate 22 Higher
• Hypertension Rate 80 Higher
• Homicide Deaths 8 X Higher
• Low Birthweight 64 Worse
• Teen Pregnancy Rate 1.5 X Higher
• Late Entry into Prenatal Care 1.5 X Higher
• Asthma Rate 71 Higher
• Diabetes Rate 44 Higher
• TB Rate 2.75 Times Higher
• Serious Mental Illness 1.5 Times Higher
• Dental Disease, 3rd Graders 44 Higher
• Hepatitis C Rate 30 X Higher
• HIV/AIDS Infection Rate 3.5 X Higher
• Syphilis Chlamydia Rates 4 X Higher
• Obesity Rate 1.8 X Higher
• Orleans Parish, LA Summary of OPH Other
  Sources, 2003

Adjacent to Residential Neighborhood
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Some Health Status Indicators
Death Rate per 100,000 Population Stroke Ca
ncer Heart Jefferson 49.7 227.0 225.1 Orleans
67.8 229.5 242.5 Plaquemines 57.0 181.8 178
.3 St Bernard 63.5 284.1 302.2 State 55.7 21
0.4 254.4 National 54.2 191.5 232.3
Source Office of Public Health, 2003
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Some Health Status Indicators
Rate Per 1000 Births Infant Low Births Mortal
ity Birthweight to Teens Jefferson 7.7
9.1 50.5 Orleans 9.3 13.0 63.3 Plaquemines 7
.0 8.5 50.6 St Bernard 6.9
8.5 51.0 State 9.3 10.3 56.7 National 6.9
7.6 48.5
Source Office of Public Health, 2001 - CDC
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Impact of Hurricane with Flood Waters
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Yesterday we were able to care for 120 patients!
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LA Medicaid CommunityCare Enrolled
Providers/Physicians
Pre-Katrina(Aug05) Pre-Katrina(Aug05) Pre-Katrina(Aug05) Post-Katrina(July06) Post-Katrina(July06)

Parish PCPs Physicians PCPs Physicians

E. Jeff 39 88 42 99
W. Jeff 28 58 28 54
Plaquemines 4 7 1 3
St. Bernard 10 27 0 0
Orleans 132 329 37 120
213 509 108 276
PCP the number of enrolled "providers" (group,
RHC, FQHC, individual physician office)
Physicians the number of individuals providing
care (warmbodies--a single "PCP" might consist of
5 physicians).
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Blue Cross/Blue Shield Participating Physicians
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Grass-Roots Response Collaboration . . and it
continues

• In 2000 HRSA Healthy Communities Access Program
  (H-CAP) Grant, resulted in Partnership for
  Access to Healthcare (PATH)
• Formation of Regional Ambulatory Care Planning
  Committee to restore services 3 days a week
  (Oct. 2005 Mar. 2006)
• With LA DHH Leadership, applied for Social
  Services Block Grant 13.5M
• Reaching across hurricane affected areas, elected
  representatives to LA Health Services Recovery
  Council 13 civil parishes (counties)
• Recently, 2M Grant for Recruitment Retention
  of Health Professionals

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PATH / LA DHH / USPHS Collaborative Planning for
the Restoration of Primary Care
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Collaborative Planning for the Restoration of
Hospital Services
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Critical Success Factors for Clinical Capacity
Restoration

• Leadership From All Sectors, Working Together
• Resources Development Fund balance, Insurance,
  FEMA, Operating Grants, Volunteers
• Facilities Buildings, Sites, Zoning
• Work Force Development Health Professionals,
  Clinical Business Support Staff
• Clinical Services Coordination Ancillary srvs.
  Specialists Inpatient Continuum of Care
• Management Systems Infrastructure Financial,
  Human Resources, Community Relations, Clinical
  Systems, QI, Legal, etc.
• Collaborative Regional Planning for Rebuild/
  Redesign Financial Sustainability Strategies

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Hurricane Relief in Neighborhoods, Trailer Sites
Schools
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Restoring Primary Care Adaptive Use of Public
Health Neighborhood Facilities
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Partnership for Access to Health
Care DISTINGUISHED SERVICE AWARD FOR HURRICANE
RELIEF RECOVERY, 2005-2006 Honored
Organizations Their Leadership Bureau of
Primary Care Rural Health, LA DHH Catholic
Charities of the Archdiocese of New
Orleans Coordinated School Health Program of
Metropolitan New Orleans Common Ground Community
Health Center Daughters of Charity Services of
New Orleans, Ascension Health Department of
Pediatrics, Tulane University Health Sciences
Center Department of Internal Medicine
Geriatrics, Tulane University Health Sciences
Center Emergency Operations Center, City of New
Orleans Excelth Primary Care Network Heart-to-Hear
t International Jefferson Community Health
Centers Jefferson Parish Human Services
Authority Latino Health Access Network Louisiana
Public Health Institute Lower Ninth Community
Health Center LSU Health Sciences Center Medical
Center of Louisiana at New Orleans, LSU Health
Care Services Division Metropolitan Hospital
Council of New Orleans Metropolitan Human
Services District New Orleans Health
Department New Orleans Mental Health Resiliency
Task Force Ochsner Health System Operation
Blessing International Medical Alliance Region
I Office of Public Health, LA DHH School of
Pharmacy, Xavier University St. Charles
Community Health Center St. Thomas Community
Health Center U.S. Public Health Service,
DHHS St. Vincent de Paul Society Community
Pharmacy _________________________________________
___________ PATH is dedicated to creating a
culturally sensitive and seamless health and
social services delivery system for residents of
the New Orleans area that is, patient centered,
timely, safe, effective, efficient, and equitable.
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There is no point in providing more coverage if
the only coverage available is based on models
that are not designed to get the best outcomes
Louisiana Health Care Redesign Collaborative Octob
er 2006
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Relationship between quality and Medicare
spending as expressed by overall quality ranking
in 2000-01.
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Louisiana Health Care Redesign CollaborativeHurr
icane Recovery as an Opportunity Maximize
Health for s

• Intensely Aware of Long-standing Health Burdens
  of Population even more complex unmanaged
  conditions of returning evacuees
• With LA DHH Secretary Dr. Fred Cerises
  Leadership
• With US DHHS Secretary Michael Leavitts
  Commitment of Time, Staff Expertise, New Views
• Reached a Broad Based Consensus Across Sectors
  First, redesign the Health Care Delivery System
  to be Patient-Centered, then structure finances
  to support a system that maximizes value for
  health dollars
• Corollary Improving Health Status Will Require
  Adding System-ness in order for the patient to
  experience a seamless delivery system and gain
  efficiencies
• Goal of the Redesigned Health Care System The
  right care for the right patientin the right
  place the first time. (Institute of
  Medicine)

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Louisiana Health Care Redesign CollaborativePati
ent-Centered Approach to Redesign

• Rational organization centered around a given
  individuals level of medical complexity and
  need.
• At each level of complexity, the fundamental goal
  of the system is to facilitate a continuous
  healing relationship.
• Levels of medical complexity
• Healthy
• Mild to moderately ill
• Complex disease
• End of life

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Medical Home Models in Professional Literature

• Am. College of Physicians, The Advanced Medical
  Home A Patient-Centered, Physician-Guided Model
  of Health Care, Policy Monograph, 2006.
• Am. Academy of Pediatricians, Policy Statement
  The Medical Home, Pediatrics, July 2002.
• Am. Academy of Family Physicians, The Future of
  Family Medicine, Annals of Family Medicine,
  March/April 2004.
• Society of General Internal Medicine,
  Redesigning the Practice Model for General
  Internal Medicine A Proposal for Coordinated
  Care, Policy Monograph, July 2006.

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Elements of A Medical Home System of Care

• Primary Care Clinician MD/APN, time for the
  full, lifecycle appropriate Standard of Care for
  prevention primary care
• Electronic Health Record Inter-operable with
  other providers Continuity of Care record of
  problems, medication, visits, etc.
• Ancillary Services Laboratory, Diagnostic
  Services, Pharmacy
• PCP Support Services Behavioral Health
  Services Interdisciplinary Assessment Teams
  Disease Management Programs Clinical Pharmacy
  Consultation Community Prevention Services

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Elements of A Medical HomeSystem of Care

• Patient Support Services Appointment Prompting
  24/7 RN Call Service Care Coordination/
  Navigation Eligibility Insurance Connector
  Enabling Services
• Medical Management Across Continuum of Care
  Emergency Dept. Liaison Oral Health Care
  Medical Specialist Referrals Inpatient Stays
• Network Management QI Finances Shared Services

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Extended / Specialized Medical Home Systems of
Care

• Goals Least restrictive setting, Cost-effective
  models, Adapted to individual pt.
• Persons with Developmental Disabilities
• Persons with Severe Mental Illness
• Persons with Substance Abuse / Addictive
  Disorders
• Frail Older Adults in Decline and Persons at
  End-of-Life

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Clinical Example Adult with Type II Diabetes

• Organized Approaches to Achieve ADA/NCQA Outcome
  Standards
• Convenient Preventive Health Screenings Eye
  Exams, Foot Exams, Nutritional Fitness
  Assessment, Smoking, Other Risks
• Medications Financial Access (PAPs affordable
  formulary) Compliance
• Health Education by Patients Cognitive Stage
  of Readiness Social Support Group Visits
• Community Prevention Services Healthy Behavior
  PSAs, Walking Club, Cooking Classes

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Financing of Medical Home System

• Payment Target in LHCRCs Concept Paper Assumed
  Financial Resources for a Moderately Managed
  Care Model
• Two Basic Options
• 1) Defined Contribution Paid to Insurer for an
  Individual Participant (risk adjusted on
  individual or group basis) or,
• 2) Defined Coverage (e.g., based on Standards of
  Care for a Medical Home System of Care)
• First option depends on competition and free
  market forces to produce health plans that do a
  better job than classical fee-for-service
  Medicare in producing health outcomes for the
  dollar.
• Second option would enable specification of
  standards of care that any health plan would have
  to meet in order to qualify for a participant
  subsidy, but would likely cost more per capita.
• Ultimately, Federal-State budgets will set
  framework for product design, alignment of
  incentives (perhaps around a Pay for Performance
  plan) including P4P), and rate of roll-out for
  vulnerable populations.
• It will likely take time to transition from a
  principally Supply-side (i.e., State Charity
  Hospital System) to a Demand-side (i.e.,
  Insurance Connector) Approach to sudsidizing care
  of low income, uninsured persons Hurricane
  recovery will likely complicate and lengthen this
  process.

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The Power of Dialogue Early Progress in
Implementing Redesign

• Medical Home Models Award of Center of
  Excellence Grant from UnitedHealth Foundation
  Excelth FQHC
• Electronic Health Record Expanded sites for
  CLIQ (shared clinical reports repository with
  Charity Hospital/ MCLNO) Shared Practice
  Mgt/Electronic Hlth Record System (EHS) Prep to
  add publishers to LA Health Information
  Exchange
• LA Quality Forum Learning community formed
  among PATH clinical leadership Group attendance
  at IHI conference Coordinating access to
  specialty services across virtual primary care
  network Broaden academic-research partnership at
  new community sites.

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Lessons Learned Towards Redesign Coverage
Expansion

• First, offer all stakeholders an opportunity to
  examine the current health services delivery
  system (esp., value for the dollars). This focus
  moves the dialogue away from the usual splitting
  up the pie, so typical around legislative budget
  appropriations.
• Second, once fully discussed, the Medical Home
  System of Care is a unifying concept, supported
  by MDs, hospitals, LTC providers, FQHCs,
  consumers, etc.
• Third, given the opportunity, there is likely a
  MD champion of health information technology in
  most organizations the value or inevitability of
  an EHR is widely accepted.

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Lessons Learned Towards Redesign Coverage
Expansion

• Fourth, there is clear recognition and support
  from the medical community for putting prevention
  into practice, but payment system tend to
  discourage MD/APN time investment.
• Fifth, a Quality Forum that serves in as a
  learning community will draw strong interest
  among providers. That keeps the enforcement of
  evidence-based standards of care with the payer.
  Such a Forum should facilitate objective
  assessment of care outcomes and encourage earlier
  adoption of improved clinical protocols. Payers
  can adopt progressively higher standards, as
  financial resources permit.

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Lessons Learned Towards Redesign Coverage
Expansion

• Sixth, there are likely access problems in every
  market. A collaborative approach to regional
  planning can be launched with relatively minimal
  funding. It can serve as a platform for
  fundamental finance reform.
• Seventh, when top government officials show up,
  time and again, where serious problems occur,
  they earn credibility and a personal right at the
  communitys table.
• Eighth, it will take generations to get this
  right States counties can benefit from a
  neutral, co-governed organization (i.e., LPHI,
  Access Health) to provide continuity in long-term
  initiatives.

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Improving Louisianas Health

• Through a system of care that
• provides a medical home at its heart
• is patient-centered
• linked together through electronic
• medical records
• is quality driven
• sustainable and,
• accessible to all citizens.
• The right care for the right patientin the
  right place
• the first time.