Redesigning Health Care post-Katrina: How the CNL Fits

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Redesigning Health Care post-Katrina
How the CNL Fits

• Ann H Cary PhD MPH RN A-CCC
  
  Robert
  Wood Johnson Executive Nurse Fellow
  
  Director,
  School of Nursing, Loyola University New
  Orleansahcary_at_loyno.edu

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Health Care in Greater New Orleans Prior to
Katrina

• Hospital-based (22) 9 hospitals were acute.
• Provider-centric (graduate medical education
  sites)
• Only one level I trauma for 300 miles Charity
  hospital
• Medical Center of Louisiana _at_ New Orleans
  (Charity and University hospitals)
• Care provided in emergency rooms and outpatient
  clinics in centralized downtown location
• A few FQHCs for primary care
• Nursing shortage
• Specialty residency slots prevailed

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• Nursing shortage worsened due to dislocation and
  withdrawal from the workforce.
• 4400 MDs were dislocated (of which 1575 were
  Primary Care). Many have never returned
• Demand for mental and behavioral health services
  ? for acute, brief, and chronic care MH
  management - while only 20 of providers are
  available. Suicides x 3
• While 11 of US pop is underserved, 34 of La pop
  are in PC HPSAs 48.1 in MH HPSAs 31.6 in
  Dental HPSAs.

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The Health Care System and Katrina Aftermath

• 3/9 acute hospitals open 13/24 of NH
• Inpt beds ? by 50 clinics reduced from 90 to 19
• Residency positions decreased by 1/3
• Hospitals/clinics increased uncompensated care
  (unemployment, immigrant workers, etc)
  financial instability
• Medical and pharmacy records destroyed and care
  disrupted

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• Marked increase in diagnosis and Rx for MH
  issues and, expected to continue to a chronic
  state.
• Hiring retention of staff and, referring
  patients outside of organizations to MH, dental
  and specialty care have grown more difficult
• 1464 died 215 deaths occurred in hospitals and
  NH for lack of evacuation 75 were age 75 and
  older (Bergal, 2007)
• 1.3 million displaced 200,000 homes, 40 schools
  and 10 hospitals destroyed

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• 179,000 jobs were lost, along with health
  insurance
• First responders PTSD-20 Depression-25 40
  sought counseling
• 54 of children met criteria for MH referrals
• Of those who evacuated to other cities, 33 had
  new depression anxiety symptoms. Some now
  returning to N.O.

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Health Care in Greater New Orleans Today The
Phoenix

• Primary care is the centerpiece with 90
  neighborhood clinics and mobile clinics.(100M
  CMS grant)
• Charity hospital remains closed hospital beds
  remain at 50
• Goal Every citizen has a medical home
• Models of primary care housed in communities,
  offering recreational services, internet access,
  group visits, interprofessional teams, EHR,
  resident training, integrated behavioral health

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• Telephone visits and consultation are increasing
• EHR is being championed along with
  Telepsychiatry as adjuvant to compliment
  face-face encounters.
• Plan to replace level 1 trauma facility through
  Federal arbitration

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Evaluation by Commonwealth Fund (2010)

• 27 reported cost-related access issues vs 41
  of US pop
• 34 had medical debt vs 40 of US pop
• 74 get high-quality and safe care when needed
  vs 39 of US pop
• 98 providers understand important info about
  medical record
• 88 easy/very easy access to phone advice or
  after-hrs consultation
• 79 reported excellent patient-clinician
  communication
• 52 reported provider helped coordinate other
  care
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Post Disaster Considerations Patients Changing
demographics and health needs of the population
at point of care

•  Transitional workers for rescue, recovery and
  rebuilding-each phase diversity/culture
• Comorbidity of mental health needs due to
  pre-existing conditions or new incidence of PTSD
• Chronic disease gaps in management for
  monitoring, prescriptions, trauma/acute overlays

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Patients Changing demographics and health needs
of the population at point of care

• Lack of medical record information and usual
  source of care provider communication/consultation
  
• Community and social support networks are
  destroyed, damaged, disconnected
• Underserved and elderly have higher care needs
  and more vulnerabilities (Kutner, 2007)

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Microsystems Changing nature of care,
transitions, financing, and communication

• Coordination of care resources radically change
• Coordination of staffing change
• Establish new capabilities for next level of care
  arrangements

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Microsystems Changing nature of care,
transitions, financing, and communication

• Financial projections for unit costs in era of
  stability differ radically from crisis
  operations ? LOS acuity, staffing ?
• Medical Error rates more labile
• EHR and portable communication for consultation
  and continuity of care in-house, transitions,
  and in community.

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Macro system Drift is there a Phoenix in the
future?

• Consider crisis is opportunity
  necessity is the mother of invention Ø
  sacred cows
• Patient-centric care in a shifting demographic,
  workforce, epidemiological, financing, and policy
  landscape
• Models of delivery to promote access,
  satisfaction, continuity of care, prevention,
  chronic disease management, lower administrative
  waste, interprofessional and integrated practices
  (i.e. IBH)

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Macro system Drift is there a Phoenix in the
future?

• Changing ratio of acute inpt beds to ambulatory
  centralized to decentralized neighborhood
  delivery
• Workforce competencies, regulation,
  transportability in a newly organized structure
  and delivery of services.
• What does the new microsystem look like?
• Transition and coordination of care between micro
  macro systems.

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Goodness of Fit in a Phoenix Environment(over
to YOU the audience)

• How can the CNL apply their competencies?
• What new competencies need to be developed?
• What would CNL curriculums look like to feed the
  new Phoenix?
• What are the Microsystem views of a reengineered
  community centric system? What specific
  assessments can be applied to this microsystem?
• How can you adapt current micro tools for
  leadership, culture, macro-org, patient focus,
  staff focus, interdependence of teams, info
  technology, process improvement and performance?
  (Mckeon ET AL, 2009)

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What skills can you bring to the decentralized
neighbor clinic network of delivery?
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