Creating a High Performance Healthcare:

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Creating a High Performance Healthcare
Rural Surgery Symposium - September 18, 2007
Mary Wakefield, Ph.D., R.N., FAAN
Associate Dean for Rural Health and Director
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Center for Rural Health (CRH)

• Est. 1980, one of first five in the nation
• The Centers mission
• Connecting resources and knowledge to
  strengthen the health of people in rural
  communities.

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Seven Core Areas of Focus

• 1. Rural Health Research
• 2. Rural Health Policy
• 3. Rural Health Workforce
• 4. Native American Health
• 5. Education, Training and Resource Awareness
• 6. Community Development and Technical Assistance
• 7. Program Evaluation

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CRH at a National Level

• National Resource Center on Native American Aging
  
• Upper Midwest Rural Health Research Center
• Rural People Rural Policy
• Rural Assistance Center (RAC)
• Rural Research Gateway

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A product of the Department of Health and
Human Services Rural Initiative.Established in
December 2002 as a rural health and human
services information portal.
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RAC Services

• Every State, DC, Puerto Rico 10 Foreign
  Countries
• Customized Assistance
• 4,200 requests
• Web-Based Services (visits)
• 2002 (1,350) 2005 (275,402)
• 2003 (56,027) 2006 (417,017)
• 2004 (124,133) 2007 (472,723)
• TOTAL VISITS MORE THAN 1,346,652
• RAC Health and Human Services Listserv
• reaches more than 5,600 individuals

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RAC Web Site
http//www.raconline.org

• Funding opportunities
• Information guides on key topics
• News and Events
• Experts and Organizations
• Publications and Maps
• Success Stories
• State Resources

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Office of Rural Health Policy

• HHS Rural Health Task Force
• Rural Health Research Centers
• State Office of Rural Health
• Rural Hospital Flexibility Grant
• Rural Assistance Center
• National Advisory Committee on Health and Human
  Services - 21 member panel 4 year terms

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National Advisory Committee on Rural Health and
Human Services

• Key Developments
• 2007 Report Out
• Substance Abuse, Head Start and Medicare
  Advantage
• 2008 Report Underway

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Concern is Crystallizing

• "The old models of medical care and public health
  delivery no longer work... the US health care
  system, both public and private,
  is in imminent danger
  of collapse...
• the public health system is faring even worse
  than private health care."

(AHA Health Research and Education Trust Sept.
2006)
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What Are the Most Important Health Care
Issuesfor Presidential and Congressional Action?
(Source C. Schoen, S.K. How, I. Weinbaum, J.E.
Craig, Jr., and K. Davis, Public Views on
Shaping the Future of the U.S. Health System,
The Commonwealth Fund, August 2006.)
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State Initiatives
Illinois All-Kids
MA Strategy for Health Care Everyone does
their part
Retaining/Expanding Employer Participation
Maines Dirigo Health
Vermont Health Care Affordability Act Enacted May
2006
Rhode IslandFive-Point Strategy
Utahs Primary Care Network Section 1115
Medicaid Waiver
California Governors Health Care Proposal
Minnesota Smart-Buy Alliance
New Jersey Raises Age of Dependent Status for
Health Insurance
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What do we need to Focus on to be the Best?

• A high performance health system is designed
  to achieve
  four core goals
• 1. efficient, high value
• 2. high quality, safe care
• 3. access to care for all people
• 4. system capacity to improve

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International Comparison of Spending on Health
1980 2004
EFFICIENCY
Average spending on healthper capita (US PPP)
Total expenditures on healthas percent of GDP
Data OECD Health Data 2005 and 2006.
(Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006)
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Medicare Expenditures (1970 - 2015)
Dollars (in billions)
Note Figures for 2010 and 2015 are projected
(Source 2007 Medicare Trustees
Report)
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QUALITY
States Vary In Quality of Care
20002001
Quartile Rank
First
Second
Third
Note State ranking based on 22 Medicare
performance measures.
Fourth
(Source S.F. Jencks, E.D. Huff, and T. Cuerdon,
Change in the Quality of Care Delivered to
Medicare Beneficiaries, 19981999 to 20002001,
Journal of the American Medical Association 289,
no. 3 (Jan. 15, 2003) 305312.)
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U.S. Adults Receive Half of Recommended Care
Quality Varies Significantly by Medical Condition
QUALITY
Percent of recommended care received
(Source E. McGlynn et al. 2003. "The Quality of
Health Care Delivered to Adults in the United
States, The New England Journal of Medicine
248(26) 26352645.)
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Primary Care Doctors Reports of Any Financial
Incentives Targeted on Quality of Care
Percent reporting any financial incentive
Receive or have potential to receive payment
for clinical care targets, high patient
ratings, managing chronic disease/complex needs,
preventive care, or QI activities
(Source 2006 Commonwealth Fund International
Health Policy Survey of Primary Care Physicians)
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National Quality Initiatives

• Multi-Sector Push
• The Private Sector
• U.S. Department of Health and Human Services
• The U.S. Congress

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Inpatient PPS

• FY08 continued 2.0 reduction for hospitals not
  reporting outpatient quality measures
• FY08 6 additional for total 27 quality measures
• 1 HCAHPS
• 3 measures relating to surgical care improvement
• 2 measures for 30-day mortality AMI and heart
  failure
• Proposed FY09 5 new measures for a total of 32
  quality measures
• 1 measure for 30-day mortality pneumonia
• 4 measures relating to surgical care improvement

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Outpatient PPS

• CY09 2.0 reduction for hospitals not reporting
  outpatient quality measures
• Proposed FY09 10 new outpatient measures
• 5 Emergency Department AMI Transfer Measures
• 2 Surgical Care Improvement Measures
• 1 measure each for Heart Failure,
  Community-Acquired Pneumonia, and Diabetes
• CMS seeking comment on 30 additional measures

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Important differences between rural and urban
areas.
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Important differences between rural and
urban areas that affect health care
delivery

• Healthcare availability
• Volume, case and service mix
• Demographics
• Income, education, insurance status
• Health behaviors
• Population density

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CMS Hospital Compare

• CAHs as a group are performing
• As well or better than urban hospitals on half of
  the pneumonia measures and surgical infection
  prevention measures
• Not as well as urban hospitals on all of the
  quality measures for AMI and CHF

(Source University of Minnesota analysis of
Hospital Compare Data for 2005)
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Medicare Hospital Value Based Purchasing Plan
(VBP)

• Rural hospitals want to participate in a single
  VBP program
• CAHs want to participate on a voluntary basis
• Rural relevant performance measures- ER
  Transfer
• Problem of small numbers in reporting
• Attention to rural in development of incentive
  structure
• Careful display of information in Hospital
  Compare

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QIO 8th Scope of Work

• 8th Scope of Work (SOW) required QIOs to do
  rural hospital work (Task 1c2)
• http//www.cms.hhs.gov/QualityImprovementOrgs/
• Greatly expands activities related to rural
  providers and incentives to work with CAHs
• QIOs Provide Key Support of Rural Quality
  Initiatives
• 80 have done joint activities with State Office
  of Rural Health
• 60 have done strategic planning for State rural
  support
• 90 cite active partnership and/or joint
  initiatives with State hospital association for
  rural hospitals

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QIO 9th Scope of Work

• 9th Scope of Work under development
• Anticipated focus on
• Prevention tied to IT
• Patient Safety
• Patient Pathways- care coordination

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Percent of Heart Failure Patients Given Discharge
Instructions - Why Not the Best?
Top Hospitals 91
Average All Reporting Hospitals
Average All Hospitals in North Dakota
One Rural North Dakota Hospital
Top Hospitals represents the top 10 of hospitals
nationwide. Top hospitals achieved a 91 rate or
better
(http//www.hospitalcompare.hhs.gov)
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Percent of Pneumonia Patients Given Initial
Antibiotic(s) within 4 Hours After Arrival -
Why Not the Best?
Top Hospitals 92
Average All Reporting Hospitals
Average All Hospitals in North Dakota
The same rural North Dakota Hospital
Top Hospitals represents the top 10 of hospitals
nationwide. Top hospitals achieved a 92 rate or
better.
(http//www.hospitalcompare.hhs.gov)
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ND Critical Access Hospital Quality Networkin
Development

• FOCUSING ON
• Develop infrastructure that supports rural
  hospital efforts to enhance quality of care
  provided to rural residents.
• Position rural hospitals to meet future
  challenges to the rural health care environment,
  including quality-based reimbursement.
• INVOLVES
• Critical Access Hospitals (CAHs)
• Center for Rural Health, ND Healthcare Review,
  Inc., ND Healthcare Association, ND Department of
  Health
• Plans for future involvement with tertiary
  liaisons, network representatives, rural non-CAHs
• SPONSORED BY
• ND Small Hospital Improvement Program (SHIP)
• ND Medicare Rural Hospital Flexibility Program
  (Flex)

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Electronic Medical Records and Information Systems

• Reduce duplicate tests
• Provide decision support for physicians and
  patients
• Facilitate referrals,
• Reduce medical errors
• Promote better management of chronic conditions
  and care coordination
• Registries
• Performance information

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Physicians Use of Electronic Medical
Records,U.S. Compared with Other Countries,
20002001
EFFICIENCY
Percent of physicians
2000 Data 2001 European Union
EuroBarometer and 2000 Commonwealth Fund
International Health Policy Survey of Physicians
(Harris Interactive 2002).
(Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006)
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Rural Health Information Technology

• New USDA Initiative on Electronic Medical Records
• Combines grant and loan funding (2080) _at_ 5
• Can apply up to one month before end of FY
• 50K up to 1 million
• Continuing annual grants and loans for distance
  learning and telemedicine

http//www.usda.gov/rus/telecom/dlt/dlt.htm
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North Dakota Health Information Technology (HIT)
Steering Committee

• Vision - implement a statewide health information
  technology and exchange infrastructure.
• Mission - facilitate adoption and use of health
  information technology and exchange to improve
  healthcare quality, patient safety, and overall
  efficiency of health care and public health
  services in North Dakota.

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Number of States with High Proportion of
Uninsured Adults Ages 1864 Is Growing
ACCESS UNIVERSAL PARTICIPATION
Data Two-year averages 19992000 and 20042005
from the Census Bureaus March 2000, 2001 and
2005, 2006 Current Population Surveys. Estimates
by the Employee Benefit Research Institute.
(Source The Commonwealth Fund National Scorecard
on U.S. Health System Performance, 2006)
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Receipt of All Three Recommended Services for
Diabetics,by Race/Ethnicity, Family Income,
Insurance, and Residence, 2002
Percent of diabetics (ages 18) who received
HbA1c test, retinal exam, and foot exam in past
year


Insurance for people ages 1864. Urban
refers to metropolitan area gt1 million
inhabitants Rural refers to noncore area lt10,000
inhabitants. Data Medical Expenditure
Panel Survey (AHRQ 2005a).
(Source Commonwealth Fund National
Scorecard on U.S. Health System Performance, 2006)
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Health Care Infrastructure Personnel
(BHPr, OWEQA, Division of Shortage Designation,
April, 2007)
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Using Telemedicine to Improve Access in Rural
Communities

• The use of electronic information and
  telecommunications technologies to support
  long-distance clinical care
• Improves communication with providers
• Provides better health monitoring
• Saves long distance travel
• Mental health has proven to be a good model
• High approval ratings from rural patients

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Barriers to Use of Telemedicine in Rural Areas

• Provider acceptance
• Health insurance coverage restrictions
• Licensing restrictions
• Lack of local infrastructure

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Current Efforts in Telemedicine

• Maine Telemedicine Services
• Links 300 provider sites with specialists at area
  hospitals
• Has reduced waiting and travel time significantly
• 87 percent of patients reported that
  videoconferencing consults are just as good or
  better than an in-person visit
• University of Tennessee Health Science Centers
  Telehealth Network
• West Tennessee Hospital Telehealth project
• Five rural hospitals provide specialty care and
  educational services using videoconferencing
  technology
• Local nurses serve as intermediaries
• Technology Exchange for Cancer Health Network
  (Tech-Net)
• Links seven remote cancer outreach clinics with
  specialists at UTHSC
• Results
• 4,500 patients have been seen through the
  telehealth network since 2003
• Time between telehealth patient referral and
  treatment is 39 percent shorter than in-person
  visits
• 96 percent rated telehealth visits as equal in
  quality to regular
• office visits, and 53 percent rated them as
  higher quality

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North Dakota Telepharmacy Project

• Licensed pharmacists provide traditional services
  to registered pharmacy technicians at remote
  sites via audio and video computer links
• 57 pharmacies involved in project 21 central
  pharmacy sites and 36 remote telepharmacy sites
• 33 counties (62) in North Dakota and two in
  Minnesota
• Served 40,000 rural citizens since its inception
  in 2002

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Alaska Community Health Aide/Practitioner Program
(CHAP)

• Backbone of most of Alaskas rural health
  communities
• 550 indigenous mid-level medical providers work
  in small community health clinics to provide
  emergency, clinical, and preventive services to
  remote population under supervision of physicians
  at regional hospitals
• Dental Health Aide Therapists (DHATs)
• Trained to perform fillings, cleanings,
  uncomplicated extractions, and other preventive
  services
• Certified after completion of two year program at
  the Otego University School of New Zealand

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Health Policy Forecast

• Predictions notoriously difficult
• Early signs of clear skies (initial
  deliberations/ position statements)
• Chance of late storms

2008 Climate Map
Level Funding
Cuts?
Increases?
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help everyone, to the extent possible, lead
long, healthy, and productive lives.
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• For more information contactCenter for Rural
  HealthUniversity of North DakotaSchool of
  Medicine and Health SciencesGrand Forks, ND
  58202-9037Tel [phone]
• Fax [phone]http//medicine.nodak.edu/crh
  
• Email mwake_at_medicine.nodak.edu