what is the workforce required to have a healthy country? the … · 2015-11-23 · j. lloyd...

J. Lloyd Michener, MD Professor and Chair Department of Community and Family Medicine Director, Duke Center for Community Research Duke University Health System Program on Health Workforce Research & Policy Seminar February 22, 2013

What is the Workforce Required to Have a Healthy Country? The Art of Asking and Answering Dangerous Questions

And training: Medical Students Physician Assistants Physical Therapists Nurses

How do you start to fix the foundational issue around why our healthcare system is so expensive and yet so broken??

Cost

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Exhibit 1. International Comparison of Spending on Health, 1980–2010

Average spending on health per capita ($US PPP)

$8,000 US

SWIZ $7,000

NETH

Total health expenditures as percentage of GDP 18 16

$6,000

$5,000

$4,000

$3,000

$2,000

$1,000

$0

CAN GER

FR AUS UK

JPN

14 12 10

8 US NETH

6 FR GER

4 CAN SWIZ UK

2 JPN AUS

0

Notes: PPP = purchasing power parity; GDP = gross domestic product. Source: Commonwealth Fund, based on OECD Health Data 2012.

www.commonwealthfund.org

Panel on Understanding Cross-National Health Differences Among High-Income Countries

Steven H. Woolf and Laudan Aron, Editors

Committee on Population

Division of Behavioral and Social Sciences and Education

Board on Population Health and Public Health Practice Institute of Medicine

Copyright 2013 by the National Academy of Sciences

Japan Switzerland

Australia France

Italy Canada

Spain Sweden Norway Austria

Netherlands Finland

Portugal Germany

United Kingdom United States

Denmark

273

323 330 336 342 346 351 358 363

373 377 377

394 394 401

418 440

0 50 100 150 200 250 300 350 400 450 500 Age-Standardized Deaths per 100,000 People

FIGURE 1-1 Mortality from noncommunicable diseases in 17 peer countries, 2008. SOURCE: Data from World Health Organization (2011a, Table 3).

Portugal Canada

Italy Sweden

Germany Netherlands Switzerland

Denmark France

Spain Norway Austria

Australia United Kingdom

Finland United States

15.1 15.7

19.2 19.3 20.8

27.5 30.9

36.5 43.4 43.9

47.6 52.8

66.6 73.7 75.9

120.6

0 20 40 60 80 100 120 140

Admissions for Asthma per 100,000 People Age 15 and Older

FIGURE 4-3 Hospital admissions for asthma in 16 peer countries. NOTE: Rates are age-standardized and based on data for 2009 or nearest year. SOURCE: Data from OECD (2011b, Figure 5.1.1).

Most Illness is Chronic

*Source: Paez KA, Zhao L, Hwang W. Rising out of pocket spending for chronic conditions: A ten year trend. Health Affairs, Vol 28, Number 1, pp 15-23.

MEPS Survey 2005

16.5

19.9

24

20.214.8

3.78.4

16.7

21.5

20.2

1.2 4.4

22.4

45.354.2

10.813.1

36.9

67.678.6

0%10%20%30%40%50%60%70%80%90%

100%

0-19 20-44 45-64 65-79 80+

None One Two Three or more

Green LA, Fryer GE Jr, Yawn BP, Lanier D, and Dovey SM. Ecology of Medical Care Revisited. NEJM 344:2021-205. June 28, 2001.

Most illness and care occurs in the community

commissiononhealth.org

81.3 YEARS

17 miles = 3-year life span disparity


MONTGOMERY

COUNTY 75

YEARS

PRINCE GEORGE’S

COUNTY

80.1

72

YEARS

72 72 72

YEARS YEARS YEARS YEARS


ARLINGTON COUNTY

FAIRFAX COUNTY

80.9 YEARS

12 miles =9-year life span disparity

A Short Distance to Large Disparities in Health Life span disparities reflect differences in wealth, education and environment across all community residents. The differences are even more dramatic—sometimes double—if you compare black and white residents.

commissiononhealth.org

Largest Impact

Smallest Impact

Examples

Condoms, eat healthy, be physically active

Rx for high blood pressure, high cholesterol

Poverty, education, housing, inequality

Immunizations, brief intervention, cessation treatment, colonoscopy

Fluoridation, 0g trans fat, iodization, smoke-free laws, tobacco tax

Socioeconomic Factors

Changing the Context to Make Individuals’ Default

Decisions Healthy

Long-lasting Protective Interventions

Clinical Interventions

Counseling & Education

Factors That Affect Health

Frieden TR. A framework for public health action. Am J Public Health. 2010;100(4):590–595.

1998

Obesity Trends* Among U.S. Adults BRFSS, 1990, 1998, 2007, 2009 (*BMI ≥30, or about 30 lbs. overweight for 5’4” person)

2007

1990

Source: CDC Behavioral Risk Factor Surveillance System

2009

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Source: The Quality of Medical Care in the United States: A Report on the Medicare Program. The Dartmouth Atlas of Health Care 1999. The Center for the Evaluative Clinical Sciences Dartmouth Medical School

Disease Burden/Practice Patterns Vary

Percent African American (quantiles)

0%

0.1% - 14.9%

15% - 38.5%

38.6% - 81.5%

81.6% - 100%

Communities vary locally too

Presenter

Presentation Notes

Now we take a subset of the data from the first set of slides. We focus on a particular health endpoint by selecting only those patients who had a HTN diagnosis. Note still simulated data. Left map still percent African-American. Right map now patients from same time period with HTN diagnosis. Note that while this map matches up with the population density of the county, it is more aligned with the % AA map. Middle map distinguishes between those patients with a HTN diagnosis who were seen in clinic (yellow dots) versus those seen through the ED (blue dots). Note that the pattern of blue dots is very closely aligned with the % AA map. It’s not enough to understand what’s happening at the county or zip code level. When we apply a highly resolved geographic scale, we see important differences across neighborhoods. We should be using technologies like this to shape our strategic planning around how to deliver health care more effectively.

• DM patients seen at Duke, 2007-2009 • 14,345 unique patients 8.7% of all patients >20 yo 14.3% of all patients >40 yo Durham County Stats (per CDC): 2008 ~ 10% of adults diagnosed with diabetes North Carolina (CDC): 2008 ~ 9% of adults diagnosed with diabetes By Race: 8.4% White, 15.6% AA, 12.4% NA, 4.5% Hispanic, 4.3% Other US Stats (National Diabetes Fact Sheet): 5.8 million children and adults in the US; or 8.3% of the population have diabetes Age 65 years or older: 10.9 million, or 26.9% of all people in this age group have diabetes By Race: 7.1% of non-Hispanic whites, 8.4% of Asian Americans, 12.6% of non-Hispanic blacks, 11.8% of Hispanics

We are trying to provide care through a system designed for acute care

Yes...we can

Can We do Better?

Team: MD Psychologist (PT) PA/NP Case Manager (PT) Social Worker (PT) Dietitian (PT)

Northern Piedmont Community Care of NC • 62,000 Medicaid patients, 52 primary care sites • 6 Counties: Durham, Vance, Granville, Warren, Person, Franklin • Latino population • Teams of community health workers, DSS social workers, nurses

work with patients at home - patient education and support, system navigation, self-

management skill training • Electronic links among practices, hospitals, DSS, Health

Departments, and care teams • $2.50 pmpm • $2.50 to Network - additional $2.50/$3.00 pmpm for high acuity enrollees

North Carolina Division of Medical Assistance Estimated Cost Savings Calculated Using Method 1

Fiscal Avg members PMPM Total Percent Year per month Savings Annual Savings Savings FY07 983,356 $8.73 $103,000,000 1.9% FY08 1,083,636 $15.69 $204,000,000 3.4% FY09 1,176,778 $20.89 $295,000,000 4.6% FY10 1,253,292 $25.4 $382,000,000 5.8%

Source: Milliman Client Report for the NC Division of Medical Assistance December 15, 2011

But what about patients who don’t/won’t come to an office?

Walltown and Lyon Park Clinics

Just For Us

From Improving Access in the Community to Rethinking Research with the Community Community Redesign

• Classify patients’ health risks • Use information technology • Create a “web” of options:

1. Specialist and primary-care 2. PAs and NPs 3. Care coordinators 4. Alternative care arrangements

Demographics by Neighborhood

Source: US Census Bureau, Census 2000

Northeast Central Durham Southwest and Northwest Central Durham

Demographic Information

Eastway-Albright

East Durham

Burch Avenue

West End Lyon Park Lakewood Park

Tuscaloosa-Lakewood

City of Durham

Population 7546 5765 1012 908 734 1274 1383 187,035 African American

71% 14% 38% 70% 86% 53% 40% 44%

Hispanic 22% 73% 13% 25% 11% 36% 7% 9% Median Household Income

$19,669 $24,689

$26,688 $23,343 n/a n/a n/a $41,160

Families below poverty level

37% 38%

35% 22% n/a n/a n/a 7%

NECD SWCD

Presenter

Presentation Notes

2010 Census information will be processed and made available to us through the Children’s Environmental Health Initiative in the next few months.

DHI teams are connecting community partners and working with neighborhood residents to ensure: • Healthy schools and neighborhoods • Safe places to exercise • Access to healthy foods • Access to health information For example, the Achieving Healthy Bodies for a Lifetime (AHL) team has been successful in: • Calculating body mass index (BMI) for every child

at YE Smith (n=360) • Providing raw fruit or vegetable (FV) snack to all

students at YE Smith three days/week in conjunction with Durham Public Schools (DPS) and Child Nutrition Services (CNS) USDA grant

• Achieved 100% teacher and student participation in Teacher & Student Walking Groups and 100% classroom participation in the Dine for Life program offered by DCHD Nutrition Division and augmented by AHL.

• Organized and taught first half of premier Interfaith Food Shuttle cooking class offered as “Friday Club” choice in regular school curriculum.

• Launched new aspect of “Let’s Move, Faith Communities” program in Union Baptist; expanding to other faith organizations.

DHI teams are currently evaluating their efforts and expanding them to other health ambassador sites.

Building Capacity in NECD Neighborhoods

Presenter

Presentation Notes

The AHL team has made significant strides in implementing exercise, nutrition and weight reduction programs with East Durham children and adults. Health ambassador sites like the Salvation Army and The Shephard’s House are interested in replicating some of these programs, such as Taking off Pounds Sensibly (TOPs). Like in SWCD, these sites will be connected through their health efforts and DHI will measure the impacts of healthy eating and exercise efforts in these neighborhoods. Stakeholders will be convened in the fall for a reporting out session about what we have heard and implemented thus far and to set priorities and goals for expanding healthy eating and exercise initiatives. Access to health care has also been identified as a key health priority. We are working with residents within Durham Housing Authority communities to identify strategies to address this issue. One approach we have discussed with DHA is a neighborhood health navigator program which we will describe a little later. Moreover, with the support of LATCH and a partnership with Duke Nursing, DHI intends to provide ongoing education sessions and support to these residents based upon their defined interests and needs.

Integrating social and medical resources, neighborhood assets, and community activism

to pave the way for a healthier Durham.

DHI Integrated Care

Neighborhood Health Ambassador Sites

Neighbor-hood Health

Navigators

Clinical Hubs: Lyon Park & Holton

Connected Care: Employer- &

Practice-Based Efforts

Patient

Presenter

Presentation Notes

Integration is pivotal to this model: Integration of social and medical resources; integration of neighborhood activism and assets; and integration of efforts to improve health in the home, community, and workplace. Note that Connected Care encompasses Durham County Health Department and County Employees.

Improving the health of populations means that:

Physicians need to do what only they can do

We need more than doctors

PATIENT

Public Health is Key We need to start now

PAs, NPs, nurses Physical therapists Psychologists Case managers PharmDs Health educators Social workers IT designers Dietitians

Complex care Unknown Illnesses System redesign

Local School of Public Health State Federal / CDC

ww.iom.edu/primarycarepublichealth

Degrees of Integration:

What will this require? Practice what we teach; teach what we practice; research how to do better

University • Coordinated placement/pipeline program Professional Schools • Training and practice in teamwork • Primary care leadership

PA, NP, PT • Expansion of program size; teamwork

FM Residency • Restructure around improving population health • Clinical Leadership

Faculty and Staff • Classes, Grand Rounds, online training in community engagement • Shift practice and research to improving community outcomes

AAFP Statement: Joint Statement Regarding Closure of the Duke University Family Medicine Residency Tuesday, June 13, 2006

New Challenges Require New Solutions…

…Solutions that Combine Innovation with Community Engagement

Table 2. Time Required to Meet Current Clinical Guideline Recommendations

Type of Visit Hours/Day Hours/Week % of Clinical Time Acute 3.7a 18.4 17.0

Chronic 10.6b 53.0 48.9

Preventive 7.4c 37.0 34.1

Total 21.7 1 08.4 1 00.0

a Calculated in Table 1. b Source: Østbye et al (8). c Source: Yarnall et al (7).

Centers for Disease Control and Prevention www.cdc.gov/pcd/issues/2009/apr/08_0023.htm

VOLUME 6: NO. 2 APRIL 2009 SPECIAL TOPIC Family Physicians as Team Leaders: “Time” to Share the Care Kimberly S. H. Yarnall, MD, Truls Østbye, MD, PhD, Katrina M. Krause, MA, Kathryn I. Pollak, PhD, Margaret Gradison, MD, J. Lloyd Michener, MD

Table 1. Estimated Panel Sizes Under Different Models of Physician Task Delegation to Nonphysician Team Members

Nondelegated Model

(Panel = 983)

Delegated Model 1

(Panel = 1,947)

Delegated Model 2

(Panel = 1,523)

Delegated Model 3

(Panel = 1,387)

Time Time Time Time Type Delegated Hours per Delegated Hours per Delegated Hours per Delegated Hours per of Care % Patient/Year % Patient/Year % Patient/Year % Patient/Year

Preventive 0 0.71 77 0.16 60 0.28 50 0.35 Chronic 0 0.99 47 0.53 30 0.70 25 0.75 Acute 0 0.36 0 0.36 0 0.36 0 0.36 Total – 2.06 – 1.04 – 1.33 – 1.46

ANN ALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 10, NO. 5 ✦ SEPTEMBER/OCTOBER 2012

Estimating a Reasonable Patient Panel Size for Primary Care Physicians With Team-Based Task Delegation: Justin Altschuler, MD; David Margolius, MD; Thomas Bodenheimer, MD; Kevin Grumbach, MD Center for Excellence in Primary Care, Department of Family and Community Medicine, University of California, San Francisco, San Francisco, California

Map 2. Primary Care Physicians per 100,000 Population, 2010

Source: July 1, 2010 population estimates are from the U.S. Census Bureau (Release date: February, 2011). Physician data are from the AMA Physician Masterfile (December 31, 2010).

what is the workforce required to have a healthy country? the … · 2015-11-23 · j. lloyd...

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