Strategies for a Healthy Future

1
Strategies for a Healthy Future

• Thurston County Community Health Task Force
• 1994 - 1998

2
Mission

• Identify health issues
• Assess current conditions and risk factors
• Prioritize action strategies

3
Principles Expressed

• Build on programs that work
• Start small and build success
• Maximize existing resources
• Strengthen existing relationships
• Expand local capacity

4
Priorities May 1994

• Access to Care
• Injury/Violence
• Drug Abuse
• Prenatal Care/Teen Pregnancy
• Mental Health

• Nutrition
• Environment
• Infectious Diseases
• Health Education
• Dental

5
Priorities July 1994

• Substance Abuse
• Chronic Disease
• Violence
• Access
• Infectious Disease
• Prenatal Care

• Education
• Environment
• Mental Health
• Nutrition
• Dental

6
Priorities September 1994

• Substance Dependence
• Infectious Disease
• Chronic Disease
• Violence
• Mental Health
• Teen Pregnancy
• Prenatal Care
• Lack of Family Strengths

• Dental
• Nutrition
• Water Contamination
• Health Education
• Unintentional Injury
• Food Safety
• Air Quality

7
Final Priorities June 1995

• Dental decay in children
• Immunization of preschool children
• Over nutrition, Obesity in school age children
• Air quality
• Water quality drinking and recreational
• Food safety
• Unintentional injury
• Child abuse and Domestic Violence
• Alcohol and Other Drug misuse and dependence

8
Implementation Strategies

• Action or objective to be met
• Convener community leader
• Collaborators others necessary to meet objective

9
Community Coalitions 1998

• Fitness Nutrition
• Drinking Water Education Monitoring
• Tobacco Free Thurston County
• Immunization Coalition
• Multi-Service Teen Center

10
Community Coalitions 1998 (cont.)

• Neighborhood Centers
• Home Food Safety
• Playground Safety
• Child Safety
• Dental Coalition

11
Thurston County Community Health Task Force
continues

• Access to Primary
• Medical and Dental Care
• 1999 - 2002

12
Four Subcommittees

• Childrens Dental Access
• Clinic Expansion
• Increase Insurance Access
• Advocacy

13
Recommendations

• Support establishment of Access to Baby and Child
  Dentistry (ABCD) program in Thurston County
• Actively pursue a Federally Qualified Health
  Clinic satellite (FQHC) with both medical and
  dental services
• Increase enrollment in publicly funded insurance
  products Medicaid, Childrens Health Insurance
  Program, Basic Health Plan

14
Advocacy Subcommittee

• Part of each recommendation
• Childrens Dental
• Insurance Access
• Expand Clinic Capacity

15
Where are we now?

• Clinic Expansion
• Sea Mar Community Health Centers took over
  operation of the Community Care Clinics (both
  medical dental) January 1, 2001
• The Clinic is currently at full capacity for
  medical and dental primary care
• Sea Mar is seeking to co-locate medical and
  dental services

16
Where are we now?

• Childrens Dental Access
• 30 dentists in Thurston Mason Counties are
  accepting Medicaid children for screening and
  treatment
• Over 3,100 children have been enrolled in ABCD
  since October 1, 2000 over half of all eligible
  for this program

17
Where are we now?

• Insurance Access
• Continuing to enroll in publicly funded
  insurance Medicaid, Basic Health Plan through
  CHOICE Regional Access Program
• Advocacy
• Some members of Task Force working to improve
  reimbursement, reform malpractice insurance,
  stable funding of public health, etc.

18
Next Steps

• Re-examine health priorities set in 1995
• Examine Menu of Critical Health Services from
  Public Health Standards
• Continue work to improve access to care, as
  defined by the Thurston County community

19
SeaMar Community Health Center

• Susan Amberson
• Clinic Director

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Who we are and what we do

• Federally-funded community health center
• Serve low-income, uninsured, Medicaid, Medicare,
  Healthy Options, Basic Health Plan, and privately
  insured patients
• Bilingual/bicultural care in English and Spanish
• Reduced barriers to accessing healthcare through
  a one-stop shopping modality of care
• Provided over 25,000 service encounters in two
  years
• One of the first community health centers
  nationally to be accredited through the Joint
  Commission

21
Community Health Centers- Benefits

• Federally Qualified Health Center status-
• Receives 330 funding from Bureau of Primary
  Health Care
• Simple majority (51) of the Board of Directors
  are users of services
• Required to provide care to all who seek it
  regardless of income or insurance status
• Benefits-
• Cost-based reimbursement similar to hospitals for
  Medicaid FFS
• Providers insured through Federal Tort Claims Act
• NHSC scholars and loan repayment
• charitable organization eligible for grants

22
Community Health Centers- Obligations

• Obligations-
• Must provide supplemental services (dental and
  mental health)
• Must meet productivity measures
• Must operate as non-profit
• Must provide at least as much uncompensated care
  as the amount of federal 330 funding

23
Thurston County Programs

• Medical
• Dental
• Mental Health
• Substance Abuse

24
Thurston County- Challenges

• Need among uninsured and publicly insured
  patients has grown beyond points of access
• Dependent upon increased funding for service
  expansion
• Multiple funding losses due to budgetary
  shortfalls
• No clear direction from consumers about
  healthcare needs
• Low-income populations have multiple needs beyond
  primary medical care
• Safety net providers referral circles

25
Thurston County Opportunities

• Commitment among many different practitioners to
  addressing problems
• Possibilities for collaborative efforts among
  private providers and safety net providers
  through volunteer clinics, disease specific
  collaborations
• Ask consumers what they need for better health
• Continue to advocate for increased reimbursement
  rates for publicly insured patients

26
Sea Mars Future Plans in Thurston County

• New clinic site
• Increase in supplemental programs
• Advanced access clinic redesign
• Implement chronic disease program

27
Capital Medical Center Primary Care Clinics

• Ann Neeld
• Chief Operating Officer

28
About Capital Medical Center

• Owned by HCA, the largest hospital company in the
  United States.
• Corporate mission of commitment to the care and
  improvement of human life by locally managed
  facilities in the communities served.
• Until late 1990s operated a group of primary
  care clinics in southwest Washington.
• History of successful integration of nurse
  practitioner role in clinics.

29
Background

• 2000 bankruptcy of physician-hospital
  organization.
• 2001 break-up of 52 year-old clinic composed of
  primary care and specialists.
• Loss of 30 plus primary care physicians from
  Thurston County.
• Increasing reliance on Thurston County for
  medical care by people in all southwest
  Washington counties.

30
Why a new clinic??

• Increased use of Emergency Department for
  non-urgent care.
• Loss of physicians in the community.
• New residents unable to find primary care
  physicians (or pediatricians).
• Physicians less accepting of covering patients
  from Emergency Rooms for follow-up care.

31
Why Nurse Practitioners?

• Educated and available supply of primary medical
  care providers.
• Well documented successes in providing medical
  care for population requiring primary and chronic
  care services.
• Washington State practice rules allow for wide
  scope of service.
• History of success with nurse practitioner role
  at Elma Clinic.

32
Nurse Practitioner Regulations in Washington
State

• Examine patients and establish medical diagnoses.
  
• Admit patients to health care facilities and
  refer to other practitioners or facilities.
• Order, collect, perform and interpret laboratory
  tests and initiate requests for radiographic and
  other testing measures.
• Prescribe medications according to WACs
• Identify, develop, implement and evaluate a plan
  of care and treatment for patients to promote,
  maintain and restore health.

Partnership for access to medical care
33
Clinic Demographics

• 25 of patients under 18 years of age
• 5 of patients are actually newborns
• 55-65 aged 21-55
• 5-15 aged 65 and older

34
West Olympia Payor Mix For 600 plus patients a
month

• Medicaid 30
• Healthy Options 30 (Medicaid HMO)
• Medicare 5
• HMO/PPO 25
• Self-pay-Charity-Other 10

35
Elma Clinic Payor Mix For 825 plus patients
per month

• Medicaid 15
• Healthy Options 30 (Medicaid HMO)
• Medicare 15
• HMO/PPO 30
• Self-pay-Charity-Other 10

36
Successful Outcomes

• More options for ER follow-up.
• Newborns have access to follow-up primary and
  preventative care.
• Medicaid/Healthy Options members have increased
  access to primary care in Olympia.
• Support from CMC medical staff.

Partnership for access to primary care
37
The 100 Access Project

• CHOICE Regional Health Network March 2003
• Kristen West
• Executive Director

38
100 Access Where we are today

• Our vision is 100 access to services for people
  below 250 of federal poverty in our region
• We identified Six Principles based on best
  practices in communities across the nation
• Were partnering with local, regional, and
  national leaders
• Were involving communities at all levels
• Weve launched an action campaign to make this
  real

39
Our Goal
Medical Home, Full Access
Medical Home, Not Full Access
No Medical Home
2007
100 Access
40
The Six Principles
Purchase services of greater value to the
community
The Power of Strategic Cross Leverage
41
Principles Mesh with State Board of Health
Strategic Policy Directions

• State BOH Strategy - Maintain and improve access
  to critical health services
• 100 Access will
• Fully fund primary care and prevention
• Stabilize the safety net
• Get small employers participating
• State BOH Strategy - Improve patient safety and
  increase value in government-purchased health
  services
• 100 Access will
• Include moving financing closer to the community
• Provide administrative simplification and
  redirect savings to direct care
• Include disease case management through health
  teams

42
Principles Mesh with State Board of Health
Strategic Policy Directions

• State BOH Strategy - Bolster the health system's
  capacity to respond to public health emergencies
• 100 Access will
• Include a community-owned information system
• Assist in the identification of illness
  clusters in the region
• State BOH Strategy - Reduce disproportionate
  disease burdens among racial and ethnic minority
  populations
• 100 Access will
• Increase language access and cultural competency
• Improve the health status of the low-income
  uninsured

43
Principles Mesh with Thurston County BOH
Priorities

• Dental Services
• 100 Access definition of primary care includes
  primary dental care
• Success of Thurston County dental program through
  Olympia Union Gospel Mission
• Immunization of preschool children
• 100 Access includes action campaigns to get kids
  enrolled in health care
• Every month were finding 200 people a medical
  home

44
Financing Approach

• Use whats already being spent
• State and federal visible assets and leverage
  with
• Hidden community assets
• Maximize Medicaid
• Community Health Centers and Rural Health Centers
• Get 6,000 uninsured kids enrolled
• Capture savings resulting from decreased
  fragmentation and delivering care better
• Solicit new revenue from employers and consumers
• This gets us pretty close to 100 Access

45
How it all comes together
Principle
Benchmark Leadership Community
Finance Approach

• Stabilize safety net
• CHC and RHC expansion
• Organize underpaid services
• Small employer coverage for low-income employees
• 3. Find and enroll low-income in medical home
• 4. Reduce costs and cover more
• Deliver relationship-based care through health
  teams
• 6. Purchase services of greater value to the
  community

Thurston County Access Task Force, WA
Increase in state and federal Medicaid
reimbursement.
Project Access Buncombe County, NC
Donated care.
Employers pay towards the cost of low-wager
workers coverage.
Medicaid reimbursement.
Project Access, 30 communities
Admin and direct care savings.
SkyCap, KY JesseTree, TX Clinical Redesign
CHCs, WA INPHO, WA
Contributes to 4 above.
Consumer and funder contributions. Plus,
contributes to 4 above.
Scituate, RI
46
Whats Happening in Thurston County

• Thurston County
• Dr. Albrecht is the champ for getting 70 of
  doctors participating in Project Access (1)
• Bill Perkins, small business owner, is organizing
  small employers (2,6)
• Susan Amberson, SeaMar, has organized a
  safety-net Council (1)
• Joe Wall, St. Peter Family Practice Residency and
  Holly Paul, Capital Medical Center clinic, in
  action on clinical redesign(5)
• Active consumer council
• Sherri Mc Donald, Public Health and Social
  Services, is hosting community roundtables

47
Whats Next

• Series of local and regional events to find and
  encourage champions
• Intensified community involvement
• Continued development of administration and
  financing options
• Encourage people who are interested to get
  involved
• Passage of legislation authorizing pilot projects

48

• Dr. Stephen Albrecht

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Project Access

• A system of health care for low income uninsured
  patients that better organizes physician
  volunteer services to leverage a closer alignment
  of existing healthcare and related resources in
  the community.

50
MANAGING COST OF CARE FOR THE UNINSURED THROUGH
COORDINATION
COST OF AD-HOC UNCOORDINATED HEALTH CARE
SERVICES FOR UNINSURED PATIENTS
COST OF COORDINATED HEALTH CARE SERVICES
FOR UNINSURED PATIENTS
51
??????

• Where do the uninsured go when they need
  healthcare?

52
Physician Charity Care
Nearly two-thirds of the uninsured report that a
physician is their usual source of care, and
approximately half receive care in a physician's
office.
http//www.hschange.org/CONTENT/356/ HSC's
Community Tracking Study Physician Survey Center
for Studying Health System Change Issue Brief No.
42 August 2001 Marie C. Reed, Peter J.
Cunningham, Jeffrey Stoddard).
53
Primary Care Visits For Patients with Medicaid or
No Insurance
77.9 Physicians offices 11.5 Hospital
outpatient departments 10.6 Community health
centers Note Locally funded health
departments included in physicians offices
Forrest CB. JAMA. 20002842079
54
Physicians Cant Do This Alone . . .
Hospitals (acute care and rehab) City/County
Elected Officials Neighborhood/County
clinics United Way organizations Faith
Community Local, State and National
Foundations Pharmacies Managed Care Organization
(Claim Forms) Area Health Education Center
(Evaluations) Department of Social Services
(Medicaid) Patients Health Partners (health
coalition)
55
Project Access Across the Nation

• Project Access has been successfully replicated
  in over 30 communities across the nation. These
  communities have established and are sustaining
  coordinated systems of charity care based on the
  Buncombe County Project Access (BCMS) model.

56
BCMS Project Access Outcomes

• Nearly doubled number of patients with regular
  source of care.
• Reduced per capita charity care costs by 45 from
  1996 to 2000
• ER utilization rate dropped from 28 in 1995 to
  8 in 1998
• 80 report improved health
• 20 million free care 1996-2000

57
Next Steps . . .

• Getting the word out . . .
• One-on-one meetings with specialty providers
• Presentations to community groups, hospitals, and
  ????
• Establishing a website email
• Seeking more champions
• Pursuing funding
• Developing a planning and implementation team

58
We Need Your Help!

• Heres how . . .
• Ask the tough questions
• Get involved
• Who else should we be talking to?

59
Contact information

• Dr. Stephen Albrecht
• Olympia Family Medicine
• Phone [phone]
• Email alberndts_at_attbi.com
• Dr. Kevin Haughton
• Providence St Peter Hospital Family Practice
• Phone [phone]
• Email khaugton_at_providence.org
• Holly Detzler
• CHOICE Regional Health Network
• Phone [phone]
• Email detzlerh_at_choicenet.org

60
Current Efforts to Increase

• Access to Dental Care

61
Community School Sealants

• History and Development
• Childrens Dental Health Coalition
• Grant award for portable dental equipment
• Smile Survey of 6-8 year olds

62
Partnership

• Thurston County Oral Health Coalition
• SeaMar Community Dental Clinic
• Thurston County Public Health
• Thurston County School Districts

63
Qualification for participation

• Public school with at least 30 children in Free
  and Reduced Lunch
• 2nd grade students with fully erupted 6-year
  molars

64
How the Program works in our community

• Contact with schools and families
• Education
• Screening with volunteer dentists (20)
• Coordination with SeaMar for sealant
• Placement of sealant by hygienist
• Follow up with schools, families and dentist
• Compiling and reporting statistics
• Planning and recruitment for next year

65
At the end of the 6th year

• 23 schools served in 7 school districts
• 7952 students educated
• 3128 students screened by dentists
• 2010 students received sealants
• 6829 sealants placed

66
Thurston County ABCD Program

67
ABCD is...

• Access to Baby and Child Dentistry
• Focused on Prevention and Education
• A Public/Private partnership between the Dental
  Society, Health Department, UW Pediatric
  Dentistry, Medicaid, and the Washington Dental
  Service Foundation

68
ABCD is...

• Collaborative approach to increasing access to
  dental services
• A Best Practice named by the American Academy of
  Pediatric Dentistry in 2000
• A Model Program for Washington State
• A community supported solution for a preventable
  disease

69
ABCD Provides...

• Care for children ages 0-5 years
• Prevention techniques starting early
• Family oral health education
• Training for dentists in caring for young
  children
• Enhanced reimbursements for dentists

70
Program participation...

• 30 Participating dental practices
• 3172 children enrolled, of 6026 eligible (March,
  2003)
• Outreach and enrollment continues
• Education and training continues

71
VISION

• HEALTHY MOUTHS FOR ALL OUR KIDS

72
Olympia Union Gospel Mission

• George Wehness
• Linda Barrett

73
Why dental care?

• Need is great
• Access, particularly for uninsured and unemployed
  adults, is overwhelming
• Our mission is to help
• We found willing partners

74
What have we done?

• Collaborated with
• Northwest Medical Teams
• CHOICE Regional Health Network
• Thurston County Health Department
• Thurston County Oral Health Coalition
• Recruited volunteer dentists
• Provided staff and space
• Provided restorative and preventive dental care
  to about 1,000 people without any other access to
  care

75
Principles Expressed by Community Health Task
Force in 1994

• Build on programs that work
• Start small and build success
• Maximize existing resources
• Strengthen existing relationships
• Expand local capacity

76
Menu of Critical Health Services

• General access to health services
• Health risk behaviors
• Communicable and infectious diseases
• Pregnancy maternal, infant, child health
  development

• Behavioral health mental health services
• Cancer services
• Chronic conditions disease management
• Oral health

77
Public Health Standards for Helping people get
the services they need

• Information is collected and made available at
  both the state and local level to describe the
  local health system, including existing resources
  for public health protection, health care
  providers, facilities and support services.
• Available information is used to analyze trends
  which, over time, affect access to critical
  health services.
• Plans to reduce specific gaps in access to
  critical health services are developed and
  implemented through collaborative efforts.
• Quality measures that address the capacity,
  process for delivery and outcomes of critical
  health care services are established, monitored
  and reported.