Overcoming Barriers in CCM Implementation:

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• Overcoming Barriers in CCM Implementation
• Lessons from an HCH Clinic
• Ed Farrell, MD
• Stout Street Clinic
• Colorado for the Homeless
• efarrell_at_coloradocoalition.org
• www.coloradocoalition.org

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Stout Street ClinicColorado Coaltiion for the
HomelessDenver, CO
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Overview of Content

• Briefest overview of homeless issues ever
• A clinical case to keep you awake
• Barriers, Barriers, Barriers
• How to overcome them (maybe)
• Clinical case 2 clinical priorities
• Lessons learned
• Resources/etc.

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• Realities of homelessness in the United States
• HOUSING
• Average wait 16 22 months
• HUNGER
• Requests for emergency food assistance increased
  23.
• HOMELESSNESS
• 37 of requests for shelter are unmet, 52 for
  families
• 2001 report, U.S. Conference of Mayors 27-city
  survey

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Consequences

• More than 2 million people experience
  homelessness every year
• More than 12 million adults in the U.S. have
  experienced homelessness during their lifetime.
• Every part of the nation affected.

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• Homelessness is caused by the interaction
  between

Economic Structure
Personal Vulnerabilities
Unemployment
Addictions
Domestic violence
Lack of housing
Poverty
Health problems
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Applying CCM model to homeless clients why we
picked diabetes.
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Clinical Case Mr. A

• 56 YOM presents 3/17/03 with severe anasarca,
  hearing voices, refuses ER eval ? MHH ? admit for
  severe CHF and CPS. DM 2 diagnosed during
  admission.
• Subsequent visits emphasize severe foot calluses
  and engagement/gaining trust/psych treatment/HCBS
  access
• Stout Street Bridges case manager Annie gets on
  the case.
• Atypical antipsychotic risperdal helps immensely

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Case of Mr. A, continued

• Worsening glucose control in 6/04
• gt 300 - 400s on metformin glyburide
• A1C 11.9
• 8/04 A miracle
• Comprehensive dental services accessed!
• Oral meds increased ? recent glucoses are
  62-168, last A1C was 10.2 on 9/16/04 (and
  dropping)
• No need for insulin ? no need for NH admission

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Barriers in sustaining/spreading the CCM

• There are so many different layers of barriers
• Client barriers it all starts here.
• Barriers to accessing care
• no access ? no BP control
• 3. Organizational and systems barriers

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Client Barriers

• Lack of financial resources
• Unawareness that services even exist
• Fear or distrust of large (or small) institutions
• Finding shelter/food/xxx are higher priorities
• Lack of transportation

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Barriers that keep our clients from accessing
care -- to name a few

• Provider attitudes
• Language and culture
• Scheduling difficulties
• Demand gtgt supply
• Inflexibility
• 4. Lack of comprehensive services
• Requiring documentation
• Long waits
• Complex systems
• The money we charge

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SYSTEMS/ORGANIZATIONAL BARRIERS DAY TO DAY

• Competing Priorities do we have enough to do?!
• Staff Turnover
• More clients, less time, fewer resources (MONEY!)
• Ineffective staff orientation
• No buy-in from staff
• Too much double work
• Endless data entry

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Overcoming client barriers

• Engage successfully Failure to engage ? end of
  relationship
• Your one encounter on a frenetic clinic day may
  be that clients most important 30 minutes of the
  year.
• Cultural competency, etc.
• Know your population and tailor services to their
  needs
• Break down the walls, reengineer, open access,
  etc

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Overcoming Barriers Holistic approach needed
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Overcoming barriers to access

• Outreach to your community
• Address transportation needs
• Collaborate, collaborate give them data a
  face behind the statistics
• Provide services regardless of ability to pay
• Ask your clients and listen to their needs

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Overcoming barriers -- organizational

• Prioritize your area for improvements maybe
  its not 2 A1Cs 91 days apart
• Seamless data entry straight into the computer
• Off-line time for staff who do data entry, etc.
• Orientation handbook
• Team rotation as a positive?
• Accept small victories

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Clinical issues survival kitsImplemented for
clients with diabetes-- easier to implement than
sustain!
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Clinical Case 2 Mr. H

• 58 YOM, medical problems include CAD, DM, HTN,
  MDD, others
• Disability process started waiting, waiting,
  waiting
• Received 249/month and became housed ? referred
  to CHC
• Visit and medication co-pay costs led to relapse
  of homelessness.

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Clinical Case 2 Mr. H, cont.

• He returns to the HCH clinic, and
• Co-pay was waived ?
• A1C 9.8
• Chol 232, HDL 29
• BP 152/98
• What are your clinical priorities?

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Clinical priorities for Mr. H

• Treating his DM 2 A1C, glucose, or BP control?
• UKPDS results? Model for Dx progression
  and Tx costs
• Cost per QALY, intensified treatment
• A1C 41 K (9.6K 2.1 m)
• Chol 52K/QALY
• BP - 1959/QALY
• Conclusion all are effective, prioritize BP
• JAMA. 2002 May 15287(19)2542-51

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Clinical lessons in Health Care for the Homeless

• Accept sporadic, intermittent care
• Consider starting that ACEI, ASA, Insulin, etc.
  earlier
• A 24 hour urine test ? no way.
• Think outside the box for follow-up care

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Lessons learned

• Work with clients in their space and time
• Work within the clients priorities and needs
• Consider the Motivational Interviewing approach
  (see reference)
• Recognize effective, easily embraceable treatment
  interventions
• - Administer a pneumovax ? success
• - Weight stabilization rather than gain ?can be a
  victory

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Lessons learned, continued

• Real-time seamless entry can be a reality.
• Until we get lab dumps directly into PECS, we
  will struggle mightily.
• Standardize employee orientation to cope with
  staff turnover, use buddy system, etc.
• Remember that MARN staff have better memories
  than providers
• pneumovax soared from 4 to 80-90 mostly
  due to standing orders and MARN staff were fired
  up

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Lessons Learned, hopefully not to be soon
forgotten

• Harness outside resources and volunteers
• Our full-service eye clinic has 28 volunteers
• Spin the statistics and the success story to
  inspire others.
• For some clients, their personal A1C goal is 9,
  not 7 Rejoice when it goes from 14 to 11.2.
• Sustaining the gains is a huge victory!
• The numbers dont always tell the story of the
  success, the faces and people we see do.

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Closing thought Imagine. A 21st century
president saying this --

• The test of our progress is not whether we add
  more to the abundance of those who have much, it
  is whether we provide enough for those who have
  little.
• FDR, 1937

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For more information and resources
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National Organizations

• The National HCH Council and HCH Clinicians
  Network
• www.nhchc.org
• HCH Information Resource Center
  www.prainc.com/hch
• National Coalition for the Homeless
  www.nationalhomeless.org
• National Alliance to End Homelessness www.endhomel
  essness.org

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Federal Agencies

• Bureau of Primary Health Care - HCH
  www.bphc.hrsa.gov
• Center for Mental Health Services
  www.mentalhealth.org
• Center for Substance Abuse Treatment
  www.samhsa.gov

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Limited bibliography

• Under the Safety Net, The Health and Social
  Welfare of the Homeless in the United States.
  Brickner et. al., W. W. Norton, 1990.
• Delivering Health Care to Homeless Persons. David
  Wood, Springer Publishing, 1992.
• Organizing Health Services for Homeless People, A
  Practical Guide. McMurray-Avila, NHCHC, 1997.
• Motivational Interviewing, Preparing People for
  Change. Miller and Rollnick, The Guilford Press,
  2002
• Some of these are oldies but goodies.

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Client Barriers A Day in the Life of a homeless
person in Denver

• 530 AM Must leave shelter, check day labor
• 730 AM No job, kill time before breakfast
• 830 AM Stand in line with 100 people to eat
• 900 AM Phone calls for jobs, lines for showers
• 1130 AM Soup kitchen line, gt 200 people
• 1200 PM Walking back from lunch, job hunt,
  library, medical appointments, check mail?
• 200 PM Walking, worrying, waiting.
• 430 PM Soup kitchen dinner w/ gt 200 people
• 500 PM Shelter hunting, lines, waits
• 900 PM Found shelter (maybe)
• 530 AM Start over again
• (imagine if you have kids or broken leg, or are
  a kid)

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• Of all forms of inequality,
• injustice in health care is
• the most shocking and
• inhumane
• Rev. Martin Luther King, Jr.

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• ANYWAY
• People are unreasonable, illogical, and
  self-centered,
• LOVE THEM ANYWAY
• If you do good, people will accuse you of
  selfish, ulterior motives,
• DO GOOD ANYWAY
• If you are successful, you win false friends and
  true enemies,
• SUCCEED ANYWAY
• The good you do will be forgotten tomorrow,
• DO GOOD ANYWAY
• Honesty and frankness make you vulnerable
• BE HONEST AND FRANK ANYWAY
• What you spent years building may be destroyed
  overnight
• BUILD ANYWAY
• People really need help but may attack you if you
  help them
• HELP PEOPLE ANYWAY
• Give the world the best you have and youll get
  kicked
• in the teeth
• GIVE THE WORLD THE BEST YOUVE GOT
• ANYWAY