Minnesota s CHCs: A Medical Home. February 11, For Refugee & Immigrant Communities

Transcription

1 1 Minnesota s CHCs: A Medical Home February 11, 2008 For Refugee & Immigrant Communities

2 Purpose & Objective 2 1. Explore the latest developments of medical homes in Minnesota. 2. Why Community Health Centers (CHC) are medical homes in Minnesota. 3. Highlight CHC approaches to eliminating health disparities. 4. Present health outcomes of the CHC model of care.

3 3 What is a Community Part One Health Center?

4 What is a Community Health Center? 4 1. Not-for-profit corporation. 2. Located in a medically underserved area. 3. Provide comprehensive primary care. Primary medical care, diagnostic laboratory and radiological services, preventive services, family planning, preventive dental services, enabling services 4. Sliding fee schedule for the uninsured. 5. Community-based board.

5 CHCs in Greater MN 5 Out-State MNACHC CHCs Cook Area Health Services Sawtooth Mountain Clinic Lake Superior Community Health Center Migrant Health Services, Inc. Family HealthCare Center Open Door Health Center Crookston Moorhead 5 4 Breckendridge 8 Cass Lake Big Falls Northome Bigfork Inger Deer Ball River Club Cloquet 7 1 Cook Floodwood 3 Duluth Grand Portage Tofte 2 Grand Marais MNACHC Associate Members 7 8 Fond du Lac Tribal Health Services Leech Lake Tribal Health Services Montevideo Olivia Rochester Blooming Prairie

6 Metro CHCs 6 A B C D E F H I J K L Cedar Riverside People s Center Community Univeristy Health Care Center (CUHCC) Fremont Community Health Services Hennepin County Health Care for the Homeless Indian Health Board of Minneapolis Native American Community Clinic NorthPoint Health & Wellness Center Open Cities Health Center, Inc. South Side Community Health Services West Side Community Health Services United Family Practice Health Center H C C C D F B E J J J A I K I K L K K K K E Stillwater J

7 1 out of every 6 uninsured Minnesotan uses a CHC 7 Chart 1 - CHC, 2006 Chart 2 - MN, 2005 Medicare 6% Private, 15% MA/ GAMC/ MNCare, 10% Medicare 11% MA/ GAMC/ MNCare, 40% No Insurance 39% No Insurance 8% Private, 71% Source: BPHC 2006 MN UDS Roll-Up Source: Kaiser State Health Facts, 2005

8 8 Medical Homes In Minnesota Part Two

9 Health Care Homes in Minnesota (proposed) 9 Part of Health Care Access Commission s (HCAC) overall health care reform proposal Philosophy: Long-term, trusting physician-patient relationship Coordinate all health care and related services Deliver primary care and disease management Public reporting of quality, outcomes and costs Target Population State health care program enrollees (Medicaid, MNCare). Start with those who have, or are at risk of developing, complex, or chronic health conditions

10 Health Care Homes in Minnesota (proposed) 10 Health Care Home Criteria: Long-term relationship with primary care provider. Interdisciplinary team. Care coordination, including social services. Identifying patients with complex or chronic conditions Disease management education Patient advocate Patients involved in decision-making process. Use of health care information technology. Appropriate cultural and linguistic care. Evidenced-based medicine. Enhanced access to care such as open scheduling, expanded hours and new communication methods.

11 Health Care Homes in Minnesota (proposed) 11 Other Recommendations: Health Care Home/Care Coordination Fee. Average of $50 per person per month Require state health care program enrollees to choose a primary care provider and complete a health assessment. Patient incentive Expand funding for primary care provider and rural provider training programs. Explore scope of practice and licensure changes to implement medical home.

12 12 CHCs as Medical Homes Part Three In Minnesota

13 Barriers to Care 13 Language and Communication Lack of Knowledge of Navigating System Differing Medical Practices Fear and Mistrust of System Source: Opening Doors: Reducing Sociocultural Barriers to Health Care, RWJF

14 14 Language and Communication CHCs Responding to Barriers Sliding Fee Lack of Knowledge of Navigating System Differing Medical Practices Workforce Overcoming Barriers Community Governed Enabling Services Fear and Mistrust of System

15 Poverty as a Barrier To Health Care 15 Employer-based coverage not offered to many lowincome workers. Securing time-off from work for medical appointments. Privately insured carry highdeductible plans essentially uninsured for CHC visit. CHCs response: Expanded evening and weekend hours. Sliding fee schedule. Eligibility assistance for MHCP. Chart 3 - CHC Patient Poverty vs. 80% General MN 75% 70% 60% 50% 40% 30% 20% 10% 0% 68% 10% 26% 15% 6% Below 100% % Greater than 200% CHC MN

16 16 100% CHC Cost Areas, 2001 vs Chart 4 CHC Costs, By Area, 2001 vs % 80% 70% 60% 50% 40% 30% 20% 10% 0% 67% 15% Source: BPHC 2006 & 2001 MN UDS Roll-Up 2% 54% 17% 7% 6% 12% 2% 16% 2% Medical Dental Mental Health Pharmacy Enabling Other

17 % 10.0% CHC Cost Per Patient, By Type of Service, Average Annual Change, Chart 5 Average Annual & Change in Cost Per Patient, By Service Type 9.8% 8.0% 6.0% 6.3% 6.9% 4.0% 3.8% 2.0% 1.5% 0.0% Dental Medical ALL SVCS. Mental Source: BPHC 2006 & 2001 MN UDS Roll-Up Health Enabling

18 18 Enabling Service Case Management Transportation Outreach Patient Education Translation/ Interpretation Eligibility Assistance Enabling Services Key to CHC Success Community Need/Benefit Assist patients in navigating the health care system. Coordinate care for patients. Essential for patients with chronic conditions. Essential for patients who are not familiar with US system. Leading cause of missed appointments (urban and rural). Ranges from purchasing vans to reimbursing taxi fare. Concept of primary care may not be familiar in immigrant populations. Reliance on familiar medical practices/distrust of health care system (cultural or historical reasons). Health fairs, school-based clinics, alignment with other social service groups. Nutrition services, certified diabetes educator. Address both general and medical literacy. 28.7% -- 42,443 of CHC patients are best served in a language other than English Public health care program enrollment. Immigration legal issues.

19 19 $10,000,000 $9,000,000 $8,000,000 $7,000,000 $6,000,000 $5,000,000 $4,000,000 Dramatic Growth in Enabling Services Chart 6 CHC Enabling Services Costs, Enabling services often not reimbursed. $8,794,369 $581,058 $703,053 $859,837 $1,424,382 $1,346,854 Other Elig. Assist. Comm. Educ. Trans./Interp. Patient Educ. $3,000,000 $2,000,000 $1,000,000 $0 $2,628,615 Source: BPHC 2006 & 2001 MN UDS Roll-Up $1,275,958 $265,428 $564,709 $494,193 $795,811 $2,038,518 $230,636 $588, Outreach Transportation Case Mgmnt.

20 20 CHC WORKFORCE REFLECTIVE Nearly 69% of CHC patients are non-white. American-born Foreign-born Hispanic, 27.4% OF PATIENTS Chart 7 CHC Patient Race/Ethnicity 2006 Asian, 8.0% CHCs response: Staff reflective of the communities served. Physicians, NPs, PAs, Intake workers, front-desk staff. Oral Health Care foreigntrained dentists. Cultural competency training. White, 31.3% American Indian, 6.2% African American, 27.2%

21 21 CHC Case Studies Part Four

22 CHC Efforts 22 MHSI partners with local YMCA. Waived enrollment fee and adjusted annual membership fee. Must visit YMCA a minimum of 8 times per month to receive discount. 19 families, 77 individuals enrolled as of September Leveraging other resources Blue Cross Blue Shield Foundation funding Fargo-Moorhead Area Foundation

23 CHC Efforts 23 MHSI partners with local pharmacists. Patients bring pre-stamped postcard to pharmacy. $10 payment for a 30-day supply of roughly 50 generic medications. antibiotics, antihypertensive and diabetes medications 50 local pharmacies included in the program

24 CHC Efforts 24 MHSI partners with local pharmacists. Benefits to the PATIENTS = affordability, adherence to regimen, continuity of care. PHARMACISTS = low administrative cost, immediate payment. MHSI = reduced administrative effort (phone calls to pharmacists, tracking vouchers), clinical monitoring of care.

25 CHC Efforts 25 Bilingual and bicultural community health workers and health educators Diabetes prevention reduced HbA1c from 9.0 to 8.0 in 18 months. 66% Latino, 12% Hmong in registry Reducing oral health disease in preschool Latino children through outreach, screening and care. Outreach toward Latino women related to breast and cervical cancer screening and followup. 80% of 2,000 prenatal care visits are for Latino or Hmong women.

26 CHC Efforts to Eliminating Barriers 26 Cedar-Riverside People s Center Somali diabetes project 42% reduction in HbA1c levels after implementing a patient self-management project 80% of African-born patients present with non-organic symptoms. Taboo of mental health

27 CHC Efforts 27 Eastern European Middle Eastern Russian Other Amer. Ind. White Somali Lakota/Dakota Ojibwe Ehtiopian Other South American Other Central American North African Oromo Ecuadoran El Salvadoran Carribbean Sudanese Liberian Colombian Mexican African American Other Asian Korean Laotian Cambodian Tibetan Other African Hmong Vietnamese

28 CHC Efforts 28 Mental Health/Severe and Persistent Mental Illness (SPMI) Practitioners of the same ethnic background. Same life experience of the person seeking care. Post traumatic stress disorder 20 case managers Interpreters Serve as the connection to health care rather than the provider. Compliment the care coordination activity at CUHCC

29 CHC Efforts 29 M.Y. 57-year-old widowed Hmong refugee from Thailand Emigrates to US for her son Lifestyle change and culture overwhelms M.Y. Becomes depressed and isolated Interpreter at Open Cities Behavioral Health Services refers M.Y. for evaluation and case management. Follow-up and home visits by OCHC staff. Case management enables M.Y. to access local resources such as affordable housing. If I don t come to group, there s nowhere else I can go to learn about America.

30 30 Outcomes At CHCs in Part Five Minnesota

31 31 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 8% 31% 61% Results of Removing 6% 31% 64% st Trimester 2nd Trimester 3rd Trimester Barriers Chart 8 Trimester of Entry into Prenatal Care 25% reduction in percent of women receiving first prenatal care visit in the 3 rd trimester 5% increase in the percent of women receiving first prenatal care visit in the 1 st trimester. Source: BPHC 2006 & 2001 MN UDS Roll-Up

32 Results of Removing % 9.0% 8.0% 7.9% Barriers Chart 9 % VLBW and LBW, By Race and Ethnicity, 2001 and % 8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 4.0% 5.3% 5.9% 3.9% 2.6% 5.2% 3.8% 5.6% 4.8% 2.0% 1.0% 0.0% Asian African American American Indian White Latino TOTAL Source: BPHC 2006 & 2001 MN UDS Roll-Up VLBW=Less than 1500 grams LBW=Between grams

33 LBW: CHCs versus MN Population % 11.4% Chart 10 % VLBW/LBW CHCs vs. Population, % 8.0% 6.0% 4.0% 5.2% 7.9% 4.7% 4.2% 6.7% 6.0% 6.0% 6.6% 5.0% 5.1% 5.0% 2.0% 0.0% Asian African American American Indian White Latino TOTAL CHC State Source: BPHC 2006 & MDH Center for Health Statistics VLBW=Less than 1500 grams LBW=Between grams

34 Patient Satisfaction % 90.0% 80.0% Chart 11 - Ease of Getting Care 86% 89% 90% 81% 70.0% 60.0% 46.0% 44.0% 53.0% 35.0% 50.0% 40.0% 30.0% 20.0% 10.0% 40.0% 45.0% 37.0% 46.0% 0.0% Ability to get in to be seen Clinic hours Convenience of CHC Location Test result waiting time Source: NHCN 2007 Patient Satisfaction Survey Good Great

35 Patient Satisfaction % 90.0% 92% Chart 12 - Satisfaction with Providers 92% 90% 94% 80.0% 70.0% 60.0% 55.0% 57.0% 55.0% 66.0% 50.0% 40.0% 30.0% 20.0% 10.0% 37.0% 35.0% 35.0% 28.0% 0.0% Involves you in making decisions Explains what you need to know Takes enough time with you Treats you with respect Good Great Source: NHCN 2007 Patient Satisfaction Survey

36 Patient Satisfaction % 90.0% 80.0% 83% Chart 13 - General Issues 93% 92% 70.0% 60.0% 43.0% 60.0% 57.0% 50.0% 40.0% 93.0% 30.0% 20.0% 10.0% 40.0% 33.0% 35.0% 0.0% What you pay Appropriate care for culture/ethnicity Recommend the CHC REGULAR SOURCE OF CARE Good Great Source: NHCN 2007 Patient Satisfaction Survey

37 MHSI Diabetes Indicators % 80% Chart 14 Selected DM Indicators, MHSI, % 40% 20% 0% % with Self-Management Goal % 55+ on ACEI/ARB Microalbumin Screening Rate (%) Dec % 23.0% 10.5% Dec % 63.6% 19.7% Dec % 64.4% 23.9% Dec % 67.0% 67.9% Dec % 69.6% 65.1%

38 MHSI CVD Indicators % 80% Chart 15 Selected CVD Indicators, MHSI, % 40% 20% 0% % with Self- Management Goal % HTN with BP Under Control % with Depression Screening % Using Tobacco Dec % 4.9% 62.4% Dec % 32.7% 4.1% 58.9% Dec % 25.4% 33.0% 56.5% Dec % 61.8% 50.0% 56.5%

39 39 100% 80% MHSI Mental Health Indicators Chart 16 Selected Mental Health Indicators, MHSI, % 40% 20% 0% % with PHQ-9 in last 6 months % with self-management goal

40 40 CHCs as Cost Effective Part Five Providers

41 41 $6,000 $5,000 Mean Medical Expenditures, CHC Patient vs. Non CHC Patient, 2004 US Data $5,060 Chart 17 CHC User Cost vs. Non CHC-User Cost $4,292 $4,379 $4,000 $3,000 $2,429 $2,858 $2,132 $3,128 $2,138 $3,370 $2,569 $2,000 $1,216 $1,456 $1,000 $0 Poor Not Poor Medicaid Uninsured Private TOTAL Source: NACHC, Access Granted, 2007 CHC User Non-CHC User

42 42 Mean Medical Expenditures, CHC Patient vs. Non CHC Patient, 2004, US Data Table 1 Comparison of Per Patient Medical Expenditures, CHC vs. Non-CHC User, 2004 (Mean Medical Expenditures per Year) Non-CHC User CHC User Difference OVERALL $4,379 $2,569 $1,810 POVERTY Not Poor $4,292 $2,429 $1,863 Poor $5,060 $2,858 $2,202 INSURANCE Medicaid $3,128 $2,132 $996 No Insurance $2,138 $1,216 $922 Private $3,370 $1,456 $1,914

43 Literature Review Demonstrating CHC Savings 43 CHC patients incur lower total per-member, permonth Medicaid costs than non-chc users. (Michigan) Savings of $44.87 per member, per month in Medicaid spending CHC Medicaid patients (AL, CA, GA, PA): were 19% less likely to use the emergency department (ED) for a ambulatory care-sensitive (ACS) condition Were 11% less likely to be hospitalized for an ACS condition compared to MA beneficiaries using outpatient and office-based physicians. CHC Medicaid patients with diabetes cost the state of South Carolina $400 less per patient when compared to those treated by private family physicians Fewer ED visits, hospitalizations, as well as lower costs for specialists, and lab services.

44 Summary of CHCs As Medical Homes 44 Medical Home concept since 1967 in Minnesota. Services (e.g., dental, behavioral health) not typically seen in primary care setting. Enabling Services critical for outreach and maintaining relationship with patient Often services are not covered by private or public insurance Highest cost increases over 5-year period. Team approach to eliminating health care disparities. Often services are not covered by private or public insurance. Interpreters function as the gateway to further care/services. Case managers used to coordinate patient needs and care. Governed by members of the community CHCs serve. Demonstrating success. Clinical measures. Patient satisfaction measures.

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