Resident and Faculty Involvement in Reducing Health Care Disparities: The University of Oklahoma Tulsa Approach 2015 AHME Institute San Diego May 12, 2015 F. Daniel Duffy, MD
Learning Objectives Understand ACGME CLER Requirements in the area of Healthcare Quality that require resident and faculty education and engagement in reducing health care disparities Define health care disparities and how to identify and quantify disparities within a defined community or specific patient population Identify ways to involve faculty, residents, medical students in system responses to reduce health care disparities List measures that can be used to identify success in reducing disparities
Context CLER Assessment Sponsoring Institutions are responsible for the quality and safety of the clinical and educational environments where residents train Quality and safety includes improving the environment and systems of care and reducing disparities in healthcare
CLER Assessment Patient Safety Quality Improvement Engage residents in use of data to: improve systems of care, reduce health care disparities improve patient outcomes. Transitions in Care Supervision Duty Hours Oversight, Fatigue Management and Mitigation Professionalism
The Tulsa Story We had ignored serious healthcare disparities The Sponsoring Institution for GME, UME, and faculty development is the OU School of Community Medicine Uncover disparities and know our community Get honest about the Tulsa healthcare system Learn to improve health and care by doing it Lessons learned Questions and audience participation
Summer Institute Intern Orientation An Immersion in Community Medicine Appreciate experiences of stakeholders (including patents) working in the Tulsa healthcare system Reflect together on how our different careers can improve the health of our community Create a prototype of a small improvement in a service or product that will make health or healthcare better for specific community stakeholders
Theory U The way we look at or think about a situation determines how that situation unfolds. Principles and practices for collectively creating the future that needs us to emerge. Otto Sharmer, 2009
Learning Community 1. COME TOGETHER Listen to others and to what life calls us to do Diversity of Strengths Multiple Disciplines Trans generational Explorers Anchoring Lecturers bring new facts to our ideas about community and medicine
Dreadful Health & Healthcare Statistics
What kind of city have we shaped? A low-density environment Diffuse boundaries Weak centers, Segregated populations Isolated land uses Designed for automobiles
How is our city changing us? lower air quality, more car crashes, reduced social capital and may contribute to decreased physical activity, chronic health risks and poor mental health.
HISTORY IS IMPORTANT
UPROOTED POPULATION
OIL BOOM AND BUST
Black Wall Street Tulsa 1921
Tulsa Race Riot 1921
See and Listen with Open Mind and Heart 1. COME TOGETHER Listen to others and to what life calls us to do Car Group Interviews: Open, honest questions with appreciative responses 2. EXPERIENCE Go to community stakeholders and listen with our minds and hearts wide open
Appreciative Inquiry Interviews We use Dialogue to focus on the individual s or group's most positive potential not on their problems! We inquire in order to appreciate another s experience with an open mind, open heart and open will. Our conversations appreciate rather than criticize and judge
Patient Dialogue Challenges you face with your health Works well to help you Someone we should recognize for helping you Other people or things that have helped you Just one thing that would make the healthcare you receive better
Provider Dialogue Describe team s observations from patient How you and your practice team help patients cope What works well Someone we should recognize for their help Challenges you face Community agencies or services enlisted to help Just one thing that might improve healthcare
Social, Healthcare, & Public Services Describe team s observations about challenges and successes How you or your agency help patients and providers What works well Someone we should recognize for good work Challenges you face One thing you would change to improve your service
See and Listen with Open Mind and Heart 1. COME TOGETHER Listen to others and to what life calls us to do 2. EXPERIENCE Go to community stakeholders and listen with our minds and hearts wide open Shadow poor patient in a free clinic Poverty Simulation
Experiencing Others Lives Poverty Simulation Shadowing Patients
If you re white, have money, and live in midtown, Tulsa s a wonderful place to live. I VE LIVED HERE ALL MY LIFE I NEVER KNEW!
See and Listen with Open Mind and Heart 1. COME TOGETHER Listen to others and to what life calls us to do 2. EXPERIENCE Go to community stakeholders and listen with our minds and hearts wide open World Café turns our individual stories into a collective reality Community thinks together to develop shared insights, meaning, and themes
Hospitable Café like setting Hosts Travelers Answer meaningful questions about healthcare ecosystem Everyone contributes Cross pollination Diverse perspectives Harvest themes about the whole system World Café
Themes from Interviews
Connect To Our Core Values 1. COME TOGETHER Listen to others and to what life calls us to do 2. EXPERIENCE Go to the places of most potential and listen with our minds and hearts wide open Professional Meaning Conversations Inspiration, compassion, and creativity come from connection with our authentic self 3. REFLECT Retreat and reflect, on our moral and ethical calling Begin to see disparity as an opportunity for improving care
Change The Future By Doing Today Prototype Design 1. COME TOGETHER Listen to others Groups and to what life calls us to do Use Stakeholder 2. EXPERIENCE Go to the Feedback places of most potential and listen with our minds and hearts wide open 4. CREATE Prototype a new product or service that meets health care need Experience a better future by creating some of it today 3. REFLECT Retreat and reflect, allow our inner knowing to emerge
Co Create the Emerging Future Experience Stakeholder Needs Idea Iterate with Stakeholder Feedback Prototype & Business Model
Idea Marketplace Idea vendors set up Issue Posters Announce the idea for sale Idea shoppers Visit the vendors and ask questions Select the Issue or solution that attracts your interest to work on Groups of 6 15 go off and develop the prototype solution
Prototype Poster
Our Community Is What We Do Community Medicine Is our actions In service for the good of the whole 1. COME TOGETHER Listen to others and to what life calls us to do 5. EVOLVE COMMUNITY MEDICINE by acting from the emerging whole 2. EXPERIENCE Go to the places of most potential and listen with our minds and hearts wide open Move from self Interest to care for the whole community 4. CREATE Prototype a microcosm of the new to explore the future by doing 3.REFLECT Retreat and reflect, allow our inner knowing to emerge
PhotoVoice Celebrating Community
What Happened? Honest about quality and performance Disparities exist listen and see Know history, politics, and economy Social determinants of health matter Care coordination, interdisciplinary teams Care for vulnerable populations Social, education, and public services Exchange community healthcare information Health Information Exchange Organization More than electronic medical records All in for health system improvement Primary Care and Medical Neighborhood Payment Reform Shared Savings
Rudolph Virchow Doctors are natural attorneys for the poor If medicine is to really accomplish its great task, it must intervene in political and social life
Social Determinants of Health Matter Robert Wood Johnson Foundation Report
Is Tulsa North Being Pimped by OU? Oklahoma Eagle Headline, January 2010 Days before the ground breaking for clinic construction. To Tulsa north s rescue, Oklahoma University has come. Unquestionably, medical care is needed in Tulsa north. Why then, pose such a negative question when OU appears to be doing the right thing? Our answer.pimps use the bodies of women to make money. For whatever reason, the women are vulnerable. The residents of Tulsa north are very vulnerable because of their poor health outcomes. Hundreds of millions of dollars will be spent ostensibly for better health care for Tulsa north residents. Who gets the money for such an endeavor? OU will. Who receives $20 million dollars for building the facility? Manhattan Construction has been selected as the contractor. If a healthy community is the goal of OU, does it not recognize that a healthy community involves more than improving traditional healthcare facilities and services? A healthy community must have a good economy and a chance for good jobs for its residents. Tulsa north s personal sense of wellbeing and its ability to thrive socially and economically are tied together. It is impossible to have a healthy community without a strong educational and economic engine in its midst.
IMPROVE THE SYSTEM Shared Savings Infrastructure e.g. Comprehensive Primary Care Initiative Medical Informatics and Health Information Exchange Development e.g. Beacon Communities Grant, Pentaho for Population Health Management THE NEW MODEL FOR CARE AND EDUCATION Health Workforce Development e.g. Summer Institute, Teaching Health Center, Residency Program, Physician Assistant Medical Student and Resident Physician Training Expansion and full immersion in new models of team / medical home care, training expansion grant Patient Centered Medical Homes Medicare, Oklahoma Medicaid, Blue Cross contracts, Bedlam student led clinics, PAL PCMH at Morton Clinic Care Coordination e.g. Health Access Network Program with Oklahoma Medicaid 70,000 patients Vulnerable Populations e.g. Child Abuse Team HARUV, IMPACT Team for Mental Illness, Palliative Care team for chronic illness, Heart Intervention Program for MI and Stroke Prevention 41
Advanced Primary Care OUSCM PCMH basic model for education and patient care NCQA Accreditation Medicaid Payment BCBS Pilot Shared saving model for primary care payment CMMI Comprehensive Primary Care
Greater Tulsa OK Comprehensive Primary Care Program Multi-payer publicprivate collaboration Strengthen primary care Start-up payment to coordinate care Shared savings 64 Practices 260 Providers 42,000 Medicare
Advanced Model of Primary Care Medical Home Primary Care CPC Electronic record Care coordination 24/7 access Shared decisions Patient voice PCMH Healthy Community of Individuals & Families PCMH Multi-payer standard Pay for quality Pay for coordination Share savings in market PCHM New Workforce and Workflow Clinician team mates Care managers, health coaches, community health workers Care coordinators and practice workflow Practice data and quality managers
Transformational Services Field Service Team Help PCP practice TMF Staff Payer Staff Track Milestones Webinars Group face to face Help change PCMH Practice Transformation Primary Care Healthy Community of Individuals & Families PCHM Health Information Exchange PCMH Community Service Link EMRs Central database Clinical summary Services due lists Decision support Quality analytics
Care for Vulnerable Populations Childhood Obesity Early Life Intervention Interdisciplinary First Response Child Abuse Team Fostering Hope Clinic for foster children Clinic for homeless youth and young adults Legal aid based in OU Clinic Better Public School Performance YMCA wellness for poor with chronic illness Addiction Medicine Fellowship Student Resident care for poor After hours acute care Longitudinal care for chronic disease Urban design for health Tisdale and 36 th Street North IMPACT Team Most serious mental illness 46
2015 Support Practice Change Extend AHC to PCP Practices CME/MOC Guidelines and QI Science Two way research Data management Performance measures, GAPs, ADT notice Community level performance Connect practices and communities for health Prepare for Value Based payment
OK Primary Healthcare Improvement Cooperative Academic Detailer EHR - HIO IT Facilitator Practice Facilitator PC Practice Information Navigator AHRQ Funded R-18 Project
Conclusion Sponsoring institutions can look beyond their walls to see the needs of the community they serve and prepare new physicians to reduce disparities in care To Identify and understand healthcare disparities we need to experience them first hand, outside the institution, not only from statistics Engage faculty, residents, and medical students in improving our system of care to meet the particular needs of vulnerable populations Use technology, interdisciplinary teams, coordination of care and payment reform fuel improvement to reduce disparities