ihcf presentation trends in domestic primary care ministries
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Trends in Domestic Primary
Care Ministries
Kyle Vath, BSN, RNClinical Coordinator, Crossroad Health Center,
Cincinnati, Ohio
An introductory discussion on trends in American Primary Care provided to underserved
populations
Trends in Domestic Primary
Care Ministries
“Part 2” of the Discussion:Community Medicine: Rethinking medical missions in the age of chronic disease - Robert Lawrence, M.D. in Windsor II
Trends in Domestic Primary
Care MinistriesQuestions?
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Trends in Domestic Primary
Care MinistriesObjectives:
Participants will be introduced to current statistics surrounding the underserved, chronic diseases, and health economics.
Participants will be introduced to current initiatives in American primary care (i.e. Accountable Care Organizations, Patient-Centered Medical Home, The Affordable Care Act, etc.).
Participants will be given examples of innovative initiatives that are working to improve the quality of care while reducing costs to the health system.
IntroductionBackground:
Crossroad Health Center is a non-denominational Christian, Federally-Qualified Health Center, located in inner-city Cincinnati, Ohio.Crossroad has been in existence since 1992 and serves the poor and uninsured, regardless of their ability to pay.Kyle is a graduate of Harding University Carr College of Nursing.Kyle serves as the Clinical Coordinator, leading Quality Improvement efforts, Patient-Centered Medical Home recognition, personnel management, etc..Kyle (together with wife, Melissa) served in Tanzania, East Africa at Chimala Mission Hospital for one year in 2008.
Introduction
Introduction
Trends in Domestic Primary Care Ministries – IHCF 2013
Apolitical Discussion
Square Pegs in Round Holes
Big Picture Overview
Consideration not consensus
Ground Rules
K. Vath
Trends in Domestic Primary Care Ministries – IHCF 2013
The Health Landscape
K. Vath
Trends in Domestic Primary Care Ministries – IHCF 2013
Health Outcome Measures:
Prenatal CareAfrican American mothers were 2.3 times as likely as non-Hispanic white mothers to begin prenatal care in the 3rd trimester, or not receive prenatal care at all. (CDC, 2008)
American Disparities
http://minorityhealth.hhs.gov/templates/content.aspx?ID=6907
S. Stafford – Used With Permission
Trends in Domestic Primary Care Ministries – IHCF 2013
Infant Mortality Rates, Hamilton County, Ohio, 2012
http://www.cincinnatichildrens.org/service/j/anderson-center/community-population-health/infant-mortality/
Trends in Domestic Primary Care Ministries – IHCF 2013
Infant Mortality Rates, Global, 2012
U.S.: 5.98 (168th)
Hamilton County, OH: 17.8 (102nd)
http://www.globalhealthfacts.org/data/topic/map.aspx?ind=91
Trends in Domestic Primary Care Ministries – IHCF 2013
Self-Reported Obesity Among U.S. Adults
http://www.cdc.gov/obesity/data/adult.html
Trends in Domestic Primary Care Ministries – IHCF 2013
Obesity and Diabetes
http://apps.nccd.cdc.gov/DDTSTRS/default.aspx
Trends in Domestic Primary Care Ministries – IHCF 2013
Heart Disease
http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/images/fs_heart_disease.jpg
Trends in Domestic Primary Care Ministries – IHCF 2013
Smoking Rates
http://www.cdc.gov/vitalsigns/tobaccouse/smoking/images/StateInfo_smoking1_730px.jpg
Trends in Domestic Primary Care Ministries – IHCF 2013
Racial/Ethnic Make-Up Changes
http://facts.kff.org/upload/jpg/enlarge/Distribution_of_US_Population_by_RE_2010_and_2050.jpg
Trends in Domestic Primary Care Ministries – IHCF 2013
Baby Boomer Tidal Wave, 2010
Under
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www.census.gov/compendia/statab/2012/tables/12s0009.xls
Trends in Domestic Primary Care Ministries – IHCF 2013
Baby Boomer Tidal Wave, 2015
Under
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www.census.gov/compendia/statab/2012/tables/12s0009.xls
Trends in Domestic Primary Care Ministries – IHCF 2013
Baby Boomer Tidal Wave, 2020
Under
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www.census.gov/compendia/statab/2012/tables/12s0009.xls
Trends in Domestic Primary Care Ministries – IHCF 2013
Baby Boomer Tidal Wave, 2025
Under
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www.census.gov/compendia/statab/2012/tables/12s0009.xls
Trends in Domestic Primary Care Ministries – IHCF 2013
Baby Boomer Tidal Wave, 2030
Under
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www.census.gov/compendia/statab/2012/tables/12s0009.xls
Trends in Domestic Primary Care Ministries – IHCF 2013
Baby Boomer Tidal Wave, 2035
Under
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www.census.gov/compendia/statab/2012/tables/12s0009.xls
Trends in Domestic Primary Care Ministries – IHCF 2013
Baby Boomer Tidal Wave, 2040
Under
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www.census.gov/compendia/statab/2012/tables/12s0009.xls
Trends in Domestic Primary Care Ministries – IHCF 2013
Baby Boomer Tidal Wave, 2045
Under
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ears
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www.census.gov/compendia/statab/2012/tables/12s0009.xls
Trends in Domestic Primary Care Ministries – IHCF 2013
Baby Boomer Tidal Wave, 2050
Under
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www.census.gov/compendia/statab/2012/tables/12s0009.xls
Trends in Domestic Primary Care Ministries – IHCF 2013
Nursing Labor Force Supply vs. Demand
ftp://ftp.hrsa.gov/migrated/bhpr/nursing/rnsupplyanddemandreport10.doc
Trends in Domestic Primary Care Ministries – IHCF 2013
Age Distribution of Nursing Labor Force
Chart 4: Age Distribution of RNs: 1980, 2000 and 2020 Projected
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
<25 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 >= 65
Age
1980 2000 2020
200019802020
Source: Bureau of Health Professions, RN Sample Survey and Supply Projections.
ftp://ftp.hrsa.gov/migrated/bhpr/nursing/rnsupplyanddemandreport10.doc
Trends in Domestic Primary Care Ministries – IHCF 2013
Social Measures:Food Deserts
A low-income census tract where either a substantial number or a share of residents has low access to a supermarket or large grocery store.
"Low income" tracts are defined as those where at least 20 percent of the people have income at or below the federal poverty levels for family size, or where median family income for the tract is at or below 80 percent of the surrounding area's median family income.
Tracts qualify as "low access" tracts if at least 500 persons or 33 percent of their population live more than a mile from a supermarket or large grocery store (for rural census tracts, the distance is more than 10 miles).
American Disparities
http://www.usda.gov/wps/portal/usda/usdahome?contentid=2011/05/0191.xml&contentidonly=true
Trends in Domestic Primary Care Ministries – IHCF 2013
Food Deserts
http://www.ers.usda.gov/data-products/food-desert-locator/go-to-the-locator.aspx
Trends in Domestic Primary Care Ministries – IHCF 2013
Food Deserts (Cincinnati)
http://www.ers.usda.gov/data-products/food-desert-locator/go-to-the-locator.aspx
Trends in Domestic Primary Care Ministries – IHCF 2013
Food Deserts (Searcy)
http://www.ers.usda.gov/data-products/food-desert-locator/go-to-the-locator.aspx
Trends in Domestic Primary Care Ministries – IHCF 2013
Food Deserts (DFW)
http://www.ers.usda.gov/data-products/food-desert-locator/go-to-the-locator.aspx
Trends in Domestic Primary Care Ministries – IHCF 2013
Social Measures:Unemployment rates
American Disparities
http://www.bls.gov/news.release/empsit.nr0.htm
Trends in Domestic Primary Care Ministries – IHCF 2013
The Economic Landscape
K. Vath
Trends in Domestic Primary Care Ministries – IHCF 2013
Percentage of persons of all ages without health insurance coverage at the time of interview: United States, 1997–2011
http://www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease201206_01.pdf
Trends in Domestic Primary Care Ministries – IHCF 2013
2012 Federal Poverty Guidelines
Average Household Size, 2010: 2.59
FPL, Family of 3, 2012: $19,090
FPL, Hrly, Family of 3, 2012: $9.17/hr
FPL, PayChk, Family of 3, 2012: $734.23
http://www.census.gov/newsroom/releases/archives/families_households/cb10-174.html
http://aspe.hhs.gov/poverty/12poverty.shtml
Trends in Domestic Primary Care Ministries – IHCF 2013
Models of Care
Trends in Domestic Primary Care Ministries – IHCF 2013
Models of Care
Trends in Domestic Primary Care Ministries – IHCF 2013
Models of Care
Trends in Domestic Primary Care Ministries – IHCF 2013
Models of Care
Trends in Domestic Primary Care Ministries – IHCF 2013
Models of Care
Trends in Domestic Primary Care Ministries – IHCF 2013
Models of Care
http://www.kff.org/insurance/upload/7670-03.pdf
Trends in Domestic Primary Care Ministries – IHCF 2013
Health Expenditures By Age
http://www.nihcm.org/pdf/DataBrief3%20Final.pdf
Trends in Domestic Primary Care Ministries – IHCF 2013
Common Conditions Among Elderly High-Spenders
http://www.nihcm.org/pdf/DataBrief3%20Final.pdf
Trends in Domestic Primary Care Ministries – IHCF 2013
The Pending “Perfect Storm”
Growing National Deficit
Aging Workforce
Baby-Boom Tidal Wave
Increasing Chronic Disease
Income Gap
Growing Unemployment
Substance Abuse
Breakdown of Family
Warner Brothers
Trends in Domestic Primary Care Ministries – IHCF 2013
The IHI “Triple Aim” (The Institute for Healthcare Improvement)
Improving the patient experience of care (including quality and satisfaction).
Improving the health of populations.
Reducing the per capita cost of health care.
Healthcare Delivery
http://www.ihi.org/offerings/Initiatives/TripleAim/Pages/default.aspx
Trends in Domestic Primary Care Ministries – IHCF 2013
The PPACASigned into law March 23, 2010June 28, 2012 SCOTUS Upheld
Upheld individual mandate
Medicaid Expansion constitutional – withholding existing funds is not.
Models of Care
WhiteHouse.gov
Trends in Domestic Primary Care Ministries – IHCF 2013
The PPACA (Key Features)By 2022, extend insurance coverage to 33 million.
Models of Care
Trends in Domestic Primary Care Ministries – IHCF 2013
The PPACA (Key Features)By 2022, extend insurance coverage to 33 million.
Models of Care
Trends in Domestic Primary Care Ministries – IHCF 2013
The PPACA (Key Features)Extended option to stay on parents’ insurance until age 26
Prohibits Insurance companies from rescinding coverage
Requires insurances to provide free preventative care
Eliminates lifetime insurance limits
Strengthens community health centers
Initiates external insurance appeals and reviews
By 2022, extend insurance coverage to 33 million.
Medicaid Expansion Option to States.
Insurance Premiums Capped (Incomes <400%FPL, 9.5%)
Fines For No Insurance (2.5% or $695).
Small business tax credit (to help with insurance)
Pre-Existing Condition Non-Discrimination
High Insurance Premium Tax on Employers
Insurance Company Service Expenditure Minimum
Establishes State Health Insurance Exchanges
CBO predicts slight reduction in deficit in 10 yrs
Increasing focus of quality/efficiency vs. volume/waste
Healthcare delivery reform will result in greatest savings
Models of Care
Trends in Domestic Primary Care Ministries – IHCF 2013
Three Main Stages (JAMA, January 2, 2013)
Insurance Reform (Politicians, laws)
Payment Reform (Economists, FFS to P4P and bundled payments)
Delivery Reform (Clinicians, ACOs, PCMHs)
Leadership
Incentives
Patient role
Health Reform
Trends in Domestic Primary Care Ministries – IHCF 2013
Accountable Care Organizations (ACOs)
Healthcare Delivery
Trends in Domestic Primary Care Ministries – IHCF 2013
Accountable Care Organizations (ACOs)A network of doctors and hospitals that shares responsibility (risk) for providing care to patients. Would agree to manage all of the health care needs of a minimum of 5,000 Medicare beneficiaries for at least three years.Medicare would provide P4P (pay for performance) incentives and shared savings plans.HHS estimates $940 million in savings over first 4 years (-0.1% of $556B annual budget).ACO-Look-Alikes (With private insurers, Medicaid HMOs, etc.)
Healthcare Delivery
http://www.kaiserhealthnews.org/stories/2011/january/13/aco-accountable-care-organization-faq.aspx
http://www.kff.org/medicare/upload/7305-07.pdf
Trends in Domestic Primary Care Ministries – IHCF 2013
Accountable Care Organizations (ACOs)Cons
Tremendous learning curve for the uninitiated physician and practice.
Extremely high costs of setting up the infrastructure.
Complexity of payment.
Unclear regulations.
Delayed payments.
Government involvement extremely high.
Extremely data-driven; thus, physician groups and practices will need to hire specialists in IT, database management, utilization, quality control, customer service, compliance, finance administration, and physician networking.
Close work with hospitals is essential; solo or silo practices will be increasingly vulnerable, and corporatization of medicine will happen. In fact, it already has begun.
Physicians will need to follow rules, often set by nonmedical personnel.
Patient care will become more time-consuming with the increased need for documentation, coordination of care, communication with other specialists and patients, and review of data.
Physician performance will be under the scanner of customers, vendors, peers, and the government.
Physicians will have less ability to be independent and will be held accountable.
Healthcare Delivery
https://www.phyaura.com/resources-2/accountable-care-organizations
/
Trends in Domestic Primary Care Ministries – IHCF 2013
Accountable Care Organizations (ACOs)Pros
Objectivity is brought to the care of patients.
Goals and objectives are defined and made mandatory.
Patient and peer communication will improve.
Teamwork among physicians and administrators will improve.
The patient experience will improve, along with patient care, due to continuity of care.
The horizontal and vertical integration of medicine is happening, driven by data, finances, and organizational interrelationships.
Compliance is critical and is better for patients and physicians.
Reduction of costs is possible if healthcare can be integrated.
Goals and business strategies are shared among hospitals, physician practices, and management service organizations.
A paradigm shift will occur in healthcare if appropriately drafted and implemented, and this shift this will reduce mortality and morbidity.
Healthcare Delivery
https://www.phyaura.com/resources-2/accountable-care-organizations
/
Trends in Domestic Primary Care Ministries – IHCF 2013
Health Insurance Exchanges
Healthcare Delivery
$3.50
Trends in Domestic Primary Care Ministries – IHCF 2013
Health Insurance Exchanges
Healthcare Delivery
$3.50 $2.89
Trends in Domestic Primary Care Ministries – IHCF 2013
Health Insurance Exchanges
Healthcare Delivery
$3.50 $2.89
Trends in Domestic Primary Care Ministries – IHCF 2013
Health Insurance Exchanges
Healthcare Delivery
http://statehealthfacts.kff.org/comparemapdetail.jsp?ind=962&cat=17&sub=205&yr=1&typ=
5
Updated: 1/4/13
Trends in Domestic Primary Care Ministries – IHCF 2013
Health Insurance Exchanges
Healthcare Delivery
http://statehealthfacts.kff.org/comparemapdetail.jsp?ind=962&cat=17&sub=205&yr=1&typ=
5
Updated: 1/4/13
Trends in Domestic Primary Care Ministries – IHCF 2013
Health Insurance Exchanges
ProsNew requirements to decrease administrative costs will lower premiums.New ACA requirements will mandate reviews of any premium hikes 10% or higher.Competitive market place should lower premiums.
ConsInsurance premiums are already higher.Insurance companies will be forced to cover more services.Insurance companies will be forced to cover more high risk individuals.
Healthcare Delivery
Trends in Domestic Primary Care Ministries – IHCF 2013
Models of Care
Trends in Domestic Primary Care Ministries – IHCF 2013
Models of Care
$1000 $1300
$15,000/mo
$40
$120
Trends in Domestic Primary Care Ministries – IHCF 2013
Models of Care
$1000 $1300
$15,000/mo
$40
$120
Trends in Domestic Primary Care Ministries – IHCF 2013
Patient-Centered Medical Homes(PCMHs)
Models of Care
• Traditional• Provider-centered• Provider-based treatment plans• Focus on individual treatment• Physician does it all• Reactive - patient presents• Answer patient questions• Patient as passive recipient of
care• Scheduled out for weeks• Decisions based on comfort and
tradition• Random communication within
practice
•PCMH• Patient-centered• Evidence-based treatment plans• Population/condition management• Care team• Care plans and outreach• Patient education and resources• Patient engaged in self-mgmt goals• Same-day access available• Decisions based on data and trends• Purposeful communication
Trends in Domestic Primary Care Ministries – IHCF 2013
Patient-Centered Medical Homes(PCMHs)
• 1967 - Pediatric Health Homes (AAP)
• 1978 - Tenets of MHs (WHO)• 1990 - MH in Literature (IOM)• 2002 - 37 Criteria of MHs (AAP)• 2004 - Chronic Care Model (E.
Wagner)• 2010 - PPACA Signed into Law• 2012 - ACA Funding for
PCMH/FQHCs
Models of Care
Trends in Domestic Primary Care Ministries – IHCF 2013
Patient-Centered Medical Homes(PCMHs)
• 1967 - Pediatric Health Homes (AAP)
• 1978 - Tenets of MHs (WHO)• 1990 - MH in Literature (IOM)• 2002 - 37 Criteria of MHs (AAP)• 2004 - Chronic Care Model (E.
Wagner)• 2010 - PPACA Signed into Law• 2012 - ACA Funding for
PCMH/FQHCs
Models of Care
Trends in Domestic Primary Care Ministries – IHCF 2013
Patient-Centered Medical Homes(PCMHs)
• NCQA’s Six Standard Categories (27 elements, 149 factors)
• Enhance Access and Continuity
• Identify and Manage Patient Populations
• Plan and Manage Care
• Provide Self-Care Support and Community
Resources
• Track and Coordinate Care
• Measure and Improve Performance
Models of Care
Trends in Domestic Primary Care Ministries – IHCF 2013
“Hot-Spotting”To Develop
Case Studies
Trends in Domestic Primary Care Ministries – IHCF 2013
Care Coordination (COA)To Develop
Case Studies
Trends in Domestic Primary Care Ministries – IHCF 2013
SafetyN.E.T. (Non-Emergency Transportation)
Case Studies
Trends in Domestic Primary Care Ministries – IHCF 2013
ED Alerts
Case Studies
Trends in Domestic Primary Care Ministries – IHCF 2013
ED Alerts
27% reduction$1198/diversion saved$230,016 annual savings
Case Studies
Trends in Domestic Primary Care Ministries – IHCF 2013
SafetyN.E.T. (Non-Emergency Transportation) Program
Began discussion with local FD
Some estimates show misuse of 911 – 60%
Average EMS Run: $1000
Average ED Visit: $1318 (http://meps.ahrq.gov/mepsweb/data_stats/tables_compendia_hh_interactive.jsp?_SERVICE=MEPSSocket0&_PROGRAM=MEPSPGM.TC.SAS&File=HCFY2009&Table=HCFY2009%5FPLEXP%5FE&VAR1=AGE&VAR2=SEX&VAR3=RACETH5C&VAR4=INSURCOV&VAR5=POVCAT09&VAR6=MSA&VAR7=REGION&VAR8=HEALTH&)
Average N.E.T. Transportation: $44
Average PCP Visit: $120
$2154 in savings (avoiding 911/EMS and going to PCP/NET)
Case Studies
Trends in Domestic Primary Care Ministries – IHCF 2013
Innovative Collaborative Relationships
Case Studies
Trends in Domestic Primary Care Ministries – IHCF 2013
COA
Current Model
Trends in Domestic Primary Care Ministries – IHCF 2013
COA32 shared patients
160 patients over 60yrs
10,000+ patients
Trends in Domestic Primary Care Ministries – IHCF 2013
COA
Current Model
Trends in Domestic Primary Care Ministries – IHCF 2013
COA
The Cincinnati Pilot Model
Trends in Domestic Primary Care Ministries – IHCF 2013
COA
The Cincinnati Pilot Model
Trends in Domestic Primary Care Ministries – IHCF 2013
Pay For Performance Plans (P4P)Working with Medicaid HMO to develop P4P Payment for Care CoordinationBlackstone Valley Community Health Center (http://www.blackstonechc.org), $5M in savings on 5,000 patients!
Case Studies
Trends in Domestic Primary Care Ministries – IHCF 2013
Don’t work in “silos”
Continuity vs. episodic care
Engage the healthcare reform discussion
Innovate!
Key “Take-Homes”