Healthcare Systems in Small Caribbean Communities

Health Care Conference Aruba: Better Together

Oranjestad, Aruba

June 1, 2015

M. Joycelyn Elders, MD

Health Care Resources - Aruba

• Population – 103,000• Health care is single payer and universal

coverage - AZV• Healthcare expenditures 8.4% of GDP• 21rst century primary, secondary, tertiary and

emergency services available for all• Medical Schools – 0 (2 private foreign schools)• Full service hospital – 1 (290 beds)• Department of Health• Eldercare (SABA)

Health Policies

• Informed by health guidelines and standards of The Netherlands as well as International Health Regulations and World Health Organization

• Health System stewardship guided by the Ministry of Health

Vision for the 21rst Century• Healthy People in Healthy Communities• Healthcare system that is available, affordable,

accessible and crisis responsive• Patient-centered, prevention-focused, purpose-

driven, solution-oriented• Fosters individual responsibility, human dignity;

improves health status & enhances quality of life• Healthcare system that is transparent, patient-

centered, equitable• Design & develop a consumer responsive

healthcare system for diverse communities.

Ancient Chinese ProverbAncient Chinese Proverb

We must transform our present Sickcare System into a Healthcare System

• Transformation of healthcare delivery is essential to the linked goals of affordability, quality of care and healthy communities. • Leveraging scientific knowledge to

transform healthcare delivery

Engineering a Better Health Care System A Report From the US President’s Council of

Advisors on Science and Technology JAMA August 27, 2014 Vol: 312, No. 8, p 787

US President’s Council of Advisors on Science and Technology (PCAST) Recommendations

• Better alignment of payment systems with outcomes• Increase access to relevant health data and analytics.• Technical assistance in systems engineering

approaches• Involve communities in improving healthcare delivery.• Shared lessons from successful efforts• Train healthcare professionals in new skills and

approaches – systems engineering

Health Goals of the USA – 2020 A Society in which all people live long healthy lives

• Overarching Goals:–Attain high quality, longer lives free of

preventable disease, disability, injury, and premature death.–Achieve health equity, eliminate disparities,

and improve the health of all groups.–Create social and physical environments that

promote good health for all.–Promote quality of life, healthy development

and healthy behaviors across all life stages.

IOM Report on Core Metrics for Health and Healthcare

• Core metrics for better health at lower cost.–Life expectancy–Well being (self-reported health status}–Overweight and obesity–Addictive behavior–Unintended pregnancy–Healthy communities–Preventive services

IOM Report, continued–Access to care (Care needed in timely

fashion)–Evidence-based care–Care matched with patient goals–Personal spending burden–Population spending burden– Individual engagement–Community engagement–Patient safety (www.iom.edu/coremetrics)

Major Problems of Healthcare Systems

• Access• Provider, Financial, Cultural, Transportation

• Cost–Costs too much, delivers too little–Lack of resources, low premiums, high

cost of meds, cost of services abroad• Quality–Gross lapses in quality of care–Major health disparities–Lack of transparency

Reasons for Increased Cost of Health Care

• Increasing number of elderly – living longer• Greater burden of chronic disease• More medications used• Improved technology• Higher rates of hospitalizations• Increased use of nursing facilities• ADL need for 40% for >age 85

Factors Affecting Our Health

• Poverty–What are the effects of poverty?• Lack of Health Care, Education, Housing, Food• Crime, Stress in children & adults, Poor environment

• Lack of education–How do we reach people for education?• Home, TV, Books, Online, Schools and Colleges, Churches

• Risky behaviors–How you live life more critical to longevity than genetics• Tobacco use, Alcohol & drug abuse, Car crashes, Obesity

• Access to health care–Provider, Financial, Cultural, Transportation, Time

Major Determinants of Health

Social and behavioral factors 50%

Environment 20%

Genetics 20%

Access to care 10%

The Social Determinants FrameworkHealth Care

EducationHousingPhysical EnvironmentWork EnvironmentIncomeTransportationRacismCriminal JusticeSocial Concerns

Social Policy

And

EconomicPolicy

Genetic

Stress

Depressed immune system & Chronic Neuroendocrine activation

Local Community

Individual

Individual Behaviors

Material Deprivation

Overall Health & Well-Being

Health Outcomes

Poor Health

Criteria for Selecting Rural Health Priorities

• Identified by rural people as high priority• Rural vs. Urban prevalence• Impact of the issue on mortality• Impact of the issue on morbidity• Risk factors on other health problems• Conditions causes are known• Solutions are available• Community interventions are known to work

Top 10 Health Concerns of People Living in Rural Areas

• Access to Quality Health Services– Physician access– Financial access– Transportation access– Cultural access– EMS, LTC

• Cancer in rural areas• Diabetes in rural areas• Heart Disease

• Maternal, infant & child health issues

• Mental health and mental disorders

• Nutrition & overweight• Oral health• Substance abuse• Tobacco use

Other Areas of High Priority in Rural Health

• Education & community based programs• Public health infrastructure• Immunizations & infectious disease• Injury & violence prevention• Family planning• Environmental health

Access to LTC in Rural Areas• By 2030, elderly pop. will double • 1/5 of US pop will be >age 65• 75% of those >65 will suffer at least 1 chronic disease• 22% of US elderly reside in rural areas• Rural elderly are 12.8% vs. urban pop elderly 12.3%• Elderly in rural areas receive fewer and narrower range of

services • Less well-educated, poorer• Assisted living – 76% urban• Nursing homes – highest rate in rural areas• Majority of LTC provided by informal network

Major Barriers to Health Care in Small Communities

• Lack of providers• Limited knowledge of resources• Isolation• Socioeconomic factors• Lack of coordination of services• Culture• Education

Ways to Improve Healthcare Delivery

• Improve transparency• Better understand social determinants of health• Encourage better health behaviors• Reward primary care• Improve information technology, HIT, EHR • Implement a team approach to care• Empower patients – Patient-centered Health Care• Create a unified system of care.

New Technologies as Aids for Rural Health Care - Telehealth

• EKG using smart phone apps + sensors• Blood drops instead of test tubes of blood

for 200 or more tests• Blood pressure with smart phone• Virtual consultations. Patient travels to

center to consult with specialist via internet• E-visits through video or Skype with

telephone or computer.• HIT, e-charts

7 Characteristics of Healthy People

• Eat breakfast

• High fiber, low saturated fat diet with 3 meals and 3 snacks daily

• Exercise 20-30 minutes

• 7 - 8 hours sleep

• Don’t smoke

• Drink only in moderation

• Responsible sexual behavior

8 Tests to Save Your Life

• Height, weight – BMI• BP• Mammogram• PAP or PSA• Lipid profile

• Hgb A1C, HIV• ECHO, EKG• Colonoscopy

Strategies for Solutions to Common Health Problems

• Collaboration strategies• Educational strategies• Access strategies• Prevention strategies• Intervention strategies• Research strategies• Political strategies• Leadership strategies

5 C’s of Leadership – Clarity of vision, Consistency, Competency, Commitment, Control

What Do We Know?Better Together

• Partners–Program, Policies, Partnerships–Aware, Advocate, Action plan–Reach out, Responsible –Technology, Together, Tools of commitment–Network, Novel ideas–Educate, Empower, Elucidate–Research, Resources–Successful, Services

What Is Our Role? Save the Community

• THE END