Karen DeSalvo, MD, MPH, MScTulane University

Chair, Medical Home Committee

Four Critical Questions

1. Why does the Patient-Centered Medical Home matter for Louisiana?

2. What demonstrations are underway?3. What is on the horizon?

Critical Questions

1. Why does the Patient-Centered Medical Home matter for Louisiana?

2. What demonstrations are underway?3. What is on the horizon?

4

5Baicker and Chandra, Health Affairs, 2004.

Quality & Spending in Louisiana

6

Source: Health Dialog, 2007; Data from 2005; www.lhcqf.orgHigher costs do not appear to correlate with low gap scores (high quality)“Gap” scores represent aggregation of quality metrics, lower gap score=higher qualityDiamonds represent Louisiana Hospital Services Areas (HSAs) with ≥ 10,000 people*Chronics: CHF, COPD Diabetes, Asthma, CAD

R2 = 0.27

0.80

0.90

1.00

1.10

1.20

1.30

1.40

1.50

1.60

$9,000 $11,000 $13,000 $15,000 $17,000 $19,000 $21,000

Chronic PMPY Paid Claims

To

tal

Gap

Sco

re (

no

Rx)

R2 = 0.27

0.80

0.90

1.00

1.10

1.20

1.30

1.40

1.50

1.60

$9,000 $11,000 $13,000 $15,000 $17,000 $19,000 $21,000

Chronic PMPY Paid Claims

To

tal

Gap

Sco

re (

no

Rx)

7

Lack of Primary Care Providers

7Baicker and Chandra, Health Affairs, 2004

Our Opportunity from Tragedy

Source: nola.com

Patients First

Governor’s Health Reform Panel (Pre-Katrina)

Bring New Orleans Back Commission

“Framework” Group

Louisiana Hospital Association

Redesign PriorityLouisiana Recovery Authority

Public Health and Healthcare Task Force

Redesign Collaborative

Louisiana Healthcare Redesign

9

DeSalvo, ASIM, July/August 2006

05

10/

05

11/

05

1/0

6

7/0

6

Major Reform Recommendations

• LA Health Care Redesign Collaborative– Expanding choice and access

Connector/Medicaid– Supporting care health information technology– Ensuring quality Louisiana Quality Forum– Improving delivery Focus on Primary Care

October 2006, http://www.dhh.louisiana.gov/offices/?ID=288

Major Reform Progress

• LA Health Care Redesign Collaborative– Expanding choice and access

Connector/Medicaid– Supporting care health information technology– Ensuring quality Louisiana Quality Forum– Improving delivery Focus on Medical Home

October 2006, http://www.dhh.louisiana.gov/offices/?ID=288

Patients FirstBring New Orleans Back Commission

“Framework” Group

Louisiana Hospital Association

Redesign PriorityLouisiana Recovery Authority

Public Health and Healthcare Task Force

Redesign Collaborative

Louisiana Healthcare Redesign

12

DeSalvo, ASIM, July/August 2006

10/

05

11

/05

1

/06

7/0

6

7/0

7

Health Care Quality Forum

Medical Home Committee

13

• Convene the state’s major healthcare stakeholders…for the purpose of developing and accelerating the adoption of standard components and criteria for the delivery of health care services via the patient-centered medical home

LA Medical Home Committee

14

• 15 committee members• Broad-based and balanced representation• Across the state, rural and urban providers• Skills or experience in one or more of the following

categories:– Operational and Clinical Requirements– Practice Management– Consumer/Patient Advocacy– Quality Measurement and Evaluation– Quality Improvement– Policy and Legal Affairs– Payers (Medicaid, Medicare, Private)

MHC Strategic Goals

1. Implement Patient-Centered Medical Home 2. Learning collaborative 3. Shape the Medical Home Systems of Care4. Implement Medical Home Systems of Care

demonstrations5. Begin an environmental scan of potential barriers to

implementation of the patient centered medical home and medical home system of care in Louisiana

Medical Home in Louisiana

16

• Louisiana has embraced the national definition of a medical home

• Joint Principles• NCQA criteria

Critical Questions

1. Why does the Patient-Centered Medical Home matter for Louisiana?

2. What demonstrations are underway?3. What is on the horizon?

LA Medical Home Projects

• Rural initiative in North Louisiana• Franciscan Missionaries of Our Lady• New Orleans• Medicaid Provider Service Networks

19

Purpose Population GeographicArea

Financing Time window Mental health

Key Outcomes

Implement Care management

Pediatrics New Orleans area

Children’s Special Health Services, Louisiana Department of Health and Hospitals

Early 2005-ongoing

Yes Family satisfaction and ability to meet medical home criteria

Develop a network of high quality and sustainable outpatient primary and behavioral healthcare entities

Public and private non-for-profit health care organizations that serve everyone, regardless of ability to pay

Greater New Orleans area

$100 million grant program with quality improvement incentives

Sep 2007 – Sep 2010

Yes AccessQualitySustainabilityInterconnectivity

Improve the coordination and quality of care for Medicaid enrollees

Medicaid recipients of all age groups

Statewide Medicaid and State appropriation

Design 2008; implementation 2010

Yes Improved access to primary careImproved qualityand efficiency

Improve the quality and efficiency of primary care

All ages and all payer groups

Statewide Internal funding and payer reimbursement

2008 No Improved health care value

Improve coordination of care and access to high quality primary care

All ages North Louisiana HHS Grant 2007 to present No InterconnectivityQualityAccess

Board of the Medical Home Task Force in Region VII

• Implement NCQA guidelines at local clinics– David Raines Community Health Center – North Caddo Medical Center– Christus Schumpert – Coushatta – Plain Dealing – Martin Luther King Health Center – Pool of Siloam Medical Ministry and Free Clinic

• Funded through HHS• Evaluation

– Implementation of EHR, NCQA certification– School performance

20

Franciscan Missionaries of Our Lady Health System

• Non-profit statewide organization• Focus on St. Bernard Parish• Model

– Franciscan Quality Trustee– the Medical Home– a Defined Population

• Internal funding with discussions to expand

21www.fmolhs.org

Primary Care Access Stabilization Grant

22

• Build upon chassis of temporary care sites still active since recovery

• Philanthropy has allowed flexible structure of care– Team care, Information technology, mental health

• Post-Katrina assistance– Congressional hearing– $100 million from HHS in 5/07– Build provider network of neighborhood based care

• Pay for performance for medical home certification

PCASG Grantee Meeting January 17, 2008

Tulane Community Health Center at Covenant House – from ice chest to medical

home

24

Results to date

• 17 funded primary care entities working together – Build fabric of the new system in New Orleans– Wide range in scope and size– Some advancing in to medical homes

• 80,000 people served – increase in 10% of those served• $43 million distributed• 12 of 17 organizations working towards MH certification• 21% increase in citizens with “usual source of care” other

than emergency rooms in past 2 years*

25*Kaiser Family Foundation, 2008; www.pcasg.org;

Medicaid Medical Home

• Louisiana Health Care Reform Act 2007– Called for Louisiana Health First

• “The medical home system of care shall incorporate the use of health information technology and quality measures to facilitate a safe, patient-centered, quality driven, evidence-based, accessible, and sustainable health care system to Medicaid recipients and low-income uninsured citizens.”

26

Provider Service Network

• = Medical Home System of Care• At least 25% ownership by a hospital and/or provider

group• Pilot in 4 regions of the state

– Mandatory enrollment• Potential coverage expansion

– Medicaid and connector• All providers must move towards NCQA certification as a

medical home

27

28

SPECIALISTSERVICES

ALLCITIZENS

ALLCITIZENS

Referral as

Medically Necessary

CareCoordination

CareCoordination

ACUTE HOSPITAL

Other Health care Providers

&Extension Services

EHR

EHR

EHR

EHR

Medical Home System of Care

SPECIALIZED

MEDICAL HOMEServices for Individuals with Complex Chronic

Illnesses or at the End of Life

PATIENT-

CENTERED

MEDICAL HOME

Adapted from the LHCRC, October 2006

Medical Home Implementation in New Orleans

29

• Build upon chassis of temporary care sites still active since recovery

• Integrate mental services• Philanthropy has allowed flexible structure of care

– Team care, Information technology, mental health• Advocacy win

– Congressional hearing– $100 million from HHS (5/07)– Build provider network of neighborhood based care

30

Results to date

• 17 funded primary care entities working together – Build fabric of the new system in New Orleans– Wide range in scope and size– Some advancing in to medical homes

• Highest density of certified medical homes in US– Winter 2009

• 21% increase in citizens with “usual source of care” other than emergency rooms in past 2 years*

31*Kaiser Family Foundation, 2008; www.pcasg.org;

Critical Questions

1. Why does the Patient-Centered Medical Home matter for Louisiana?

2. What demonstrations are underway?3. What is on the horizon?

Health is More than Getting People to a Doctor

200,000 Households flooded.And the surrounding social infrastructure of churches…schools…friends…family...libraries…

Social/Mental Determinants of Health

• Heavy burden of stress and mental health issues– 31% report mental health problems– 39% worse mental health since Katrina– 53% with higher general stress level

• Increased PTSD associated with lack of adequate housing

• Adjusted OR 2.0 (1.2-3.5)

• Lack of social support associated with for cutting back on chronic care treatment– Adjusted OR 15.0 (3.8–59.4)

The Hurricane Katrina Writing Group, JGIM, 2007; Grumbach, JAMA, 2002; DeSalvo, et al, J Urban Health, 2007; Kaiser Family Foundation, 2008.

Community Oriented Primary Care

• Systematic approach to health care based upon:– Epidemiology– Primary care– Preventive medicine– Health promotion

• Includes interventions for individuals and population at large

• Providers play multiple roles• Community involved in decisions

Tollman, Soc Sci Med, 1991; Longlett, J Am Bd Fam Pract, 2001

Neighborhood Centers

Thank you.