Presentation on theme: "Final Report Prepared for Save Our ERs July 20, 2004"— Presentation transcript:
1Final Report Prepared for Save Our ERs July 20, 2004 Re-visioning the Delivery of Health Care Services to Uninsured Patients in Harris CountyFinal ReportPrepared forSave Our ERsJuly 20, 2004
2Table of Contents Introduction Study Approach Drivers of Inappropriate Harris County ED UseKey FindingsConclusionsModels of Care in Other CommunitiesComponents of a Care Re-visioning FrameworkStrategic Options for Harris CountyStudy Conclusion and Recommendation
3IntroductionIn recent years, Harris Counties emergency care system has become increasingly overburdened by growing emergency department (ED) volume, particularly among uninsured non-emergent patients to whom ED’s are substitutes for more appropriate, yet frequently unavailable, community-based primary care.Since 2001, conditions have worsened to the point that a study commissioned by the “Save our ER’s” coalition (the Coalition) concluded that the already overburdened emergency system is likely to continue to decay to the point of collapse without corrective action in the near term.1This conclusion has helped create support among Harris Counties health care and business communities that a substantive restructuring of health care services is needed to reduce inappropriate ED use and fragmentation of care.1. Houston Trauma Economic Assessment and System Survey, Bishop+ Associates, prepared for Save our ERs, 2002.
4Introduction (cont.)The Lewin Group, Inc. (Lewin) was commissioned by the Coalition to assist them in creating a framework for re-visioning the organization and delivery of health care services in Harris County by developing and examining three conceptually distinct and credible options for reconfiguring care to safety-net populations in Harris County.Each option is arrayed by the degree of system re-organization and resources required to undertake.Expanding appropriate ambulatory care capacity.Improving coordination of care.Exploring options for restructuring city and county public health functions.Building effective governance.
5Study ApproachKey study questions and issues are complex, requiring input from many data sources and informants.Lewin’s methodology was multi-tiered.Key elements included:Collecting and analyzing survey data from Harris County providers and secondary quantitative data sources.Conducting 20 on-site key informant interviews.Conducting over 40 telephone interviews.Conducting an environmental scan of promisingpractices in five other communities that have reorganized care for safety net populations.Interacting with key Harris Co. and other state stakeholders on important study issues.Findings were synthesized to develop three credible options for reducing inappropriate ED use.
6Study Approach (cont.)Our approach to support development of three system reconfiguration options is organized around an assessment of several key study questions, including:What are the magnitude and drivers of ED overcrowding in Harris County and what are the implications of continuing the status quo?What approaches for reducing in-appropriate ED use, building capacity and better coordinating care have been successfully implemented in other communities? What are the potential benefits and challenges of these models for Harris County?What are the objectives, major components and expected outcomes of three alternative options for reducing inappropriate ED use and improving access to care for the uninsured in Harris County?The remainder of this study presents:Our findings regarding the questions outlined above; andThe key features, benefits and challenges of three distinct and progressively more comprehensive options to reduce in-appropriate ED use and improve access to care for safety-net populations in Harris County.
7Magnitude and Drivers of Inappropriate ED Use in Harris County
8Magnitude of ED Use in Harris County If current trends continue, Harris County ED use is projected to grow 38% between 2002 and 2015, after increasing 48% between 1991 and 2002.Trends in Total Harris County ED VisitsSources: AHA and the Draft HCHD Strategic Plan
9Magnitude of ED Use in Harris County: ED Use Is Concentrated Among Houston Safety Net Hospitals Source: Begley, Charles, et al. Houston Safety Net Hospitals Emergency Department Use Study: January 1, 2002 through December 31, 2002 Final Report November 18, 2003.
10Overall Harris Co. Population Magnitude of ED Use in Harris County: Age Distribution of Harris County ED UsersOverall, most Harris County ED users are adults somewhat older than the general population.Overall Harris Co. Populationn=17 hospitalsSources: Lewin Survey of Harris County Providers, 2000 Census data
11Magnitude of ED Use in Harris County: Income and Status of Harris County Hospital District ED Users The income of most HCHD ED users is above 250% of poverty and most are US citizens.n=2 hospitalsSource: Lewin Survey of Harris County Providers
12Other Hospitals Reporting ED Data. (n=15) Magnitude of ED Use in Harris County: Payer Mix of Harris County ED UsersWhile HCHD’s share of county-wide ED visits is only 14%, two-thirds are uninsured. Others have a more balanced payer mix.HCHD(n=2)Other Hospitals Reporting ED Data. (n=15)Source: Lewin 2003 Survey of Harris County Providers
13Magnitude of Inappropriate ED Use in Harris County Estimate of County-Wide Inappropriate Uninsured and Medicaid Emergency Department Visits, FY 2002 Compared to FY 2015 Estimate Assuming No System ChangeFY 2002FY 2015 (Projected)Total County-Wide ED Visits11,261,3171,742,000Percent of Inappropriate ED Visits54.5%54.50%Estimated Number of Inappropriate ED Visits687,418949,390Uninsured and Medicaid Share of Inappropriate ED Visits51.70%Uninsured/Medicaid Inappropriate ED Visits355,395490,835Over half of all ED visits are inappropriate.By 2015, if current trends continue and no action is taken:Inappropriate ED use will likely grow 38%, to about 950,000 visits.Medicaid and the uninsured will comprise half of all inappropriate use.Sources:Total County-Wide ED Visits from the AHA 2002 Annual Hospital SurveyPercent of Inappropriate ED Visits from the "Houston Safety Net Hospitals Emergency Department Use Study" Final ReportUninsured/Medicaid share of Inappropriate ED Visits from 17 hospitals responding to the Save Our ER's data request, representing 68% of county-wide ED useSource for FY 2015 estimated ED visits is the HCHD strategic plan.
14Drivers of Inappropriate ED Use in Harris County Drivers of growth in Harris County inappropriate ED use include the downstream impacts of:Projected population growthEmployment and healthcare coverage trendsLack of effective physician capacityInadequate ambulatory care capacityGaps in coordination of non-emergent careCultural predisposition towards use of EDs
15Drivers of Inappropriate ED Use: Projected Population Growth in Harris County Harris County’s population is expected to grow 26% between and 2015.Near-term growth will be concentrated among Hispanic and Asian populations.Source: 2000 U.S. Census, ESRI/CACI Demographics
16Drivers of Inappropriate ED Use: Employer Health Care Coverage Trends Between 1990 and 2000, Harris County enjoyed employment growth averaging 2.1 percent annually.2The Houston-Galveston Area Council projects similar employment gains through 2025.Much of the future growth is expected to be among small businesses, many of whom historically have provided limited or no health care coverage.These trends threaten to increase the number of uninsured and place additional pressure on Harris Counties already strained emergency care system.2. Houston-Galveston Area Council 2025 Regional Growth Forecast, May, 2003.
17Drivers of Inappropriate ED Use: Lack Of Effective Primary Care Physician Capacity Harris County has enough primary care physicians to meet population need.However, inadequate reimbursement is a serious barrier to care for the uninsured and many Medicaid recipients.Source: TX State Board of Medical Examiners, ESRI/CACI DemographicsNote: The shorter bars represent more physicians per person.
18Inadequate Ambulatory Care Capacity: Current HC Clinic Locations Are Appropriate, But More Capacity is NeededHarris County clinics appear well sited to meet the needs of safety-net populations.But more capacity is needed to meet demand and care is fragmented.Map of clinic locationsSource: HCHD “Service Delivery Throughout Harris County” Presentation prepared by Gateway to Care 2003.
19Inadequate Ambulatory Care Capacity: Primary Care Demand Exceeds Supply Available capacity addresses less than half of primary care demand among Harris County’s low income uninsured.Therefore, there are no alternative access points to redirect inappropriate ED use.Total Demand = 1.45 million visits
20Inadequate Ambulatory Care Capacity: Demand For Primary Care By Low Income Uninsured Is High A current estimate of primary care demand by uninsured Harris County residents under 200% poverty is over 1.4 million visits annually.Estimated Number of Uninsured830,000Number of Uninsured Under 200% Poverty1413,423Average Primary Care Visits per Year Nationally3.5Estimated Primary Care Demand by Uninsured Under 200% Poverty1,446,981 visitsNote: Uninsured under 200% FPL defined as Safety Net populations per AHRQ.Sources: HCHD Strategic Plan, AHRQ
21Total Primary Care Visits Estimated Uninsured Visits Inadequate Ambulatory Care Capacity: Primary Care Demand Exceeds CapacityAvailable data suggests that demand among the uninsured for primary care exceeds current capacity .Clinic TypeNumber of SitesTotal Primary Care VisitsEstimated Uninsured VisitsHCHD: Current and Approved11882,713496,085City/County DOH12184,46099,846Major non-profit7+TCPA sites1,015,98384,682School-Based1350,00028,100Teen616,6149,337FQHC219,51310,942Other (planned parenthood, mobile vans, etc.)2766,16935,489Total Estimated Capacity2,235,452764,481Estimated Need1,446,981Estimated Unmet Need682,500Sources: HCHD Office of Strategic Planning, Gateway to Care Health Home survey, Lewin Survey of Harris County providers, Dr. Chuck Begley and Lewin Group analysis
22Inadequate Ambulatory Care Capacity: Demand for Behavioral Health is Also High Demand for behavioral health services also exceeds available capacity in Harris County.According to the Harris County Mental Health Needs Council, an estimated ,000 people in Harris County have severe mental illness.About 60% are reportedly uninsured.In 2003, the public sector, including HCHD (7,305) and MHMRA (186,567) together reported seeing about 194,000 visits.Private sector capacity in Harris County was unavailable for this study.
23Conclusions Regarding Inappropriate ED Use in Harris County Analysis of available data led to a number of conclusions regarding inappropriate ED use in Harris County. These include:Inappropriate ED use is significant and, absent effective intervention, will continue to grow due in part to factors outside the health sector’s control.Continuing the status quo is risky, as future trends are likely to exacerbate stresses on the local health care delivery system and further compromise the ability of many Harris County residents to access needed care on a timely basis.Strategies focused solely on re-directing inappropriate ED use are likely to fail due to lack of adequate alternative capacity.Any adopted strategy must seek to better balance the local health care system through building new capacity and improving coordination of care.
24Environmental Scan of Models of Care Adopted in Other Communities
25Approaches Adopted In Other Communities May Be Useful Lewin conducted an environmental scan to identify promising practices and administrative and governance models successfully tested elsewhere to reduce inappropriate ED use and system fragmentation.Following are examples of models to:Build effective organization and governance.Expand healthcare coverage for small businesses.Increase physician capacity.Expand ambulatory care capacity.Improve coordination of ambulatory care.Consolidate public health services.
28Denver Health - History Prior to the creation of Denver Health, the City of Denver operated the Health and Hospital Department. The Department was in charge of all public health services, the city public hospital and clinics, as well as the Rocky Mountain Poison Control Center. The manager of the Department and all of the members of the board were appointed by the Mayor. The Department’s board acted mainly in an advisory capacity.In the 1990s, Denver was subject to aggressive movement by managed care into the market. Many of the new HMOs began cherry-picking patients from the Department (e.g., patients with private insurance), threatening the department’s financial base. To combat this problem, the Department tried different strategies such as creating an HMO for city employees, among other activities.In the mid-1990s, Denver’s mayor appointed a blue-ribbon task force to look at the organization of the department and develop recommendations for change and looked at several different options. However, the Mayor stipulated that the department could not become a private, free-standing non-profit entity.The final recommendation was to develop an authority structure. While the authority remains public (a subdivision of the State of Colorado), it is able to operate independently as its own authority. In order to transition the Department into an authority, it was necessary to obtain authorization from the Colorado State Legislature.
29Denver Health: Governance Denver Health has a contractual relationship with the City of Denver to provide health care and public health services. When Denver Health became an authority, the contract included three agreements:Transfer Agreement: All assets were transferred from the City to Denver Health.Operating Agreement: Denver Health will serve the City of Denver in perpetuity. This insures that the city will not bid out for services.Personnel Agreement: Employees from DHH are allowed to remain city employees or become employees of Denver Health. In the former case, they are leased to Denver Health.
30Denver Health: Governance – Board Structure Denver Health is governed by a nine-member board, appointed by the Mayor and confirmed by the City Council for a five-year term. Individual board members terms may be renewed for one additional term.There are no stipulations regarding who may serve on the board of directors. When seats on the board are vacant, the CEO and remaining board members provide the Mayor with a list of possible replacements. Denver Health’s CEO serves as an invited member of the Mayor’s cabinet.The City of Denver contracts with Denver Health for services. As a result, the Mayor and City Council have no direct authority over Denver Health beyond board appointments. The Board has complete authority over Denver Health.Denver Health operates eight FQHCs. Each FQHC in the system has its own board to remain compliant with Section 330 requirements. Two members of the Denver Health Board are members of each FQHC board.
31Denver Health: Organization and Structure Denver Health is directed by a Chief Executive Officer, who also acts as Medical Director for the hospital.Denver Health is divided into a number of Divisions, including:Hospital Division: The division runs the city hospital, as well as the city 911 system.Public Health Division: The division provides the majority of public health services in the city, including infectious disease clinic, communicable disease control, TB clinic, STD clinic, immunization clinic, public health laboratories, and vital records.Community Health Center Division: The division operates Denver Health’s 8 FQHCs and 13 school-based clinics.General Council and Risk Management DivisionHuman ResourcesFinanceQuality Review and Office of the Assistant Medical DirectorDirector of Managed CareRocky Mountain Poison Control Center
33Marion County, IN – Health and Hospital Corporation (HHC): Overview Program Description: Beginning in 1954, Marion County, Indiana consolidated public health and health care functions into a single authority, the Health and Hospital Corporation (HHC).Program Purpose: HHC provides medical health care, environmental health, and population health services to Marion County and the City of Indianapolis, Indiana.Key Features:HHC operates both the Wishard Memorial Hospital System and the County Health DepartmentPhysicians who work for HHC clinics all come from the Indiana University Medical Group Primary Care (IUMGPC)HHC established a program called “Advantage,” a managed care-like program for low-income, uninsured residents of Marion County, Indiana. The program is jointly owned by Wishard Hospital and Indiana University School of Medicine.
34Marion County, IN – Health and Hospital Corporation (HHC): Governance HHC is governed by a seven-member Board of Trustees, three appointed by the Mayor, two by the City-County Council, and two by the Board of County Commissioners. Historically, the board has included representation from the community, as well as legal and financial expertise.HHC has few limitations on its own authority. While the Mayor may make requests, the board is free to turn them down. HHC’s annual budget must be approved by the county council. However, modifications made by the council can be appealed to the state.As a consolidated taxing authority, HHC must work with the State Board of Accounts, which must approve all levies made by HHC. The State Board of Accounts must verify that levies do not exceed the state-mandated annual limits.HHC also works closely with the State Board of Health and State Medicaid agency.
35HHC: Organization and Structure HHC operations are overseen by an Executive Division, including the President/Executive Director. The Executive Division is able to move assets, leverage funding from various sources, and coordinate activities to maximize efficiency.The Marion County Health Department is divided into two bureaus:Bureau of Environmental Health: Services include Food Safety, Housing and Neighborhood Health, Childhood Lead Poisoning Prevention, Indoor Air Quality, and Occupational Health.Bureau of Population Health: Services include Communicable Disease Control, Chronic Disease Control, Dental Health, Immunizations, Maternal and Child Health, Nutrition Services, Public Health Laboratory Services, and Vital Records.
36HHC: Organization and Structure HHC’s Hospital Division operates Wishard Memorial Hospital and its health services. In the late 1990s, authority for all seven clinics within HHC was given over to the Hospital Division (previously the Hospital Division was in charge of only 2 of the clinics). This has brought about increased reimbursement and better integration with the Wishard Memorial Hospital for specialty care.The seven clinics affiliated with HHC are currently under review for FQHC look-alike status. This will be a co-applicant arrangement between HHC and a single community board (51% community/49% other – of which 2 seats are for HHC). HHC will maintain budgetary control, while other issues will be handled jointly. This will likely provide greater oversight of the clinics and the benefits of look-alike status. HRSA is expected to approve this arrangement.The Indiana University Medical Group – Primary Care (IUMGPC) provides staff for all of the clinics directly under HHC (i.e., Wishard clinics). IUMGPC also selects the medical director for the clinics.
38Cook County, Illinois - Bureau of Health Services Program Description: In 1991, Cook County, Illinois formerly established the Bureau of Health Services (CCBHS) to provide health, hospital, public health, and health education services to throughout Chicago and its suburbs.Program Purpose: CCBHS was designed to create a better-coordinated and more integrated system of health care delivery within Cook County.Key Features:CCBHS includes a referral network that allows integration of specialty care, in both affiliate and non-affiliate clinic, with the County Hospital.CCBHS operates over 30 community-based clinics.Provides care to specific patient populations, including HIV/AIDS, chronic care, and detainees in the correction system.
39Cook County, Illinois Bureau of Health Services - Governance Cook County Bureau of Health Services (CCBHS) is an executive agency of Cook County, under the President of the County. The Cook County Board of Commissioners acts as the governing board for the Bureau’s operating entities.CCBHS is run by a the Bureau Chief. The chief operating officer of each operating division reports to the Bureau Chief. CCBHS includes seven separate divisions.The Bureau Chief is appointed by the President of the County with the consent of the Board of Commissioners.
40Cook County, Illinois Bureau of Health Services - Structure CCBHS includes seven separate divisions:Ambulatory & Community Health Network: The Network coordinates primary and specialty outpatient care in community, school-based and hospital outpatient settings.Cermak Health Services: Cermak provides health services to roughly 10,000 detainees at the Cook County Department of Corrections and the Department of Community Supervision and InterventionDepartment of Public Health (DPH): DPH provides public health services in all of Cook County, except for Chicago and four other cities/towns in the County.Ruth H. Rohnstein CORE Center: The CORE Center provides outpatient care to those with HIV/AIDS and other infectious diseases.John H. Stroger, Jr. Hospital: Cook County’s main hospital has 464 beds and a Level 1 Trauma Center.Oak Forest Hospital: Oak Forest provides long-term, chronic disease, and rehabilitation services, and includes over 600 staffed beds.Provident Hospital: Provident is a full-service hospital serving more than 50,000 patients annually.
41Cook County, Illinois Bureau of Health Services - Org. Chart
43Health Access – Muskegon County, Michigan Program Description: “Health Access,” a subsidized health care program for uninsured employees of small businesses and their dependents in Muskegon County, Michigan, established by the county with an initial grant from the Kellogg Foundation.Program Purpose: To provide a basic health insurance-like product for low income workers who do not have access to health insurance, either on their own or through their employer.Funding Source: Employers and employees each pay for 30 percent of product’s costs, while the community picks-up the rest utilizing DHS funds.Key Features: Businesses that have not offered insurance for the past 12 months and have a median employee salary of no more than $11.50 are able to enroll in the program. Employees receive a basic benefits package and have their care managed by a primary care physician. The program only covers care given by providers located in Muskegon County and pays them on a fee-for-service basis. High-cost specialty care is covered by Medicaid by employing spend-down strategies.
44Muskegon County, Michigan Pros for Harris CountyThe program could provide access to health care for many working uninsured in Harris County.The product is not insurance, so reserve requirements do not take effect.Cons for Harris CountyBecause DSH funds are being maximized by Harris County, an alternative source of funding would have to be found.Dedicated providers would have to be found to act as primary care physicians for program beneficiaries.A current or new entity would have to take responsibility for managing claims and administration.RecommendationsSOER should consider this option if a dedicated funding source can be found to subsidize the program. Business and provider buy-in is also critical for such a program.
45Advantage – Marion County, Indiana Program Description: “Advantage,” a managed care-like program for low-income, uninsured residents of Marion County, Indiana, established in 1997 by the Marion County Health and Hospitals Corporation and jointly owned by Wishard Hospital and Indiana University School of Medicine.Program Purpose: To reduce inappropriate Emergency Department use and unnecessary hospital admissions, and to better track and monitor quality care.Funding Source: Local taxes and redirected hospital federal disproportionate share funding.Key Features: Uninsured residents are enrolled and assigned to a primary care provider who coordinates their care. The program includes an urgent visit center to complement Wishard’s Level I trauma center, a 24-hour call center that can redirect emergency calls to primary care providers and a focus on referring patients back from specialist to the primary care provider of record.
46Advantage – Marion County, Indiana History: When Advantage began, only clinics under the purview of HHC were utilized. Clinics outside the network were not integrated. As a result, a number of problems developed.The outside clinics wanted to offload their non-paying patients to the HHC system. However, they could not make referrals to specialty care at Wishard Hospital. So, the clinic physicians would make a diagnosis and then refer their patients to the Wishard ED where they would be re-diagnosed and admitted for specialty care.Outside clinics did not have access to the integrated data network of HHC. As a result, they could not maintain continuity of care for patients who were using both systems.
47Advantage – Marion County, Indiana History (cont’): As a result of these problems, HHC decided to expand the network for Advantage to include a number of outside clinics. As a result:the outside clinics have referral privileges to Wishard Hospital;the Advantage system can make sure that these clinics adhere to protocols for referring specialty care (e.g., certain tests must be conducted before a referral can be made);an electronic medical record can now be used for all Advantage patients throughout the entire system. This helps to maintain continuity of care. EDs also have access to this integrated data network; andAdvantage members, in some cases, may also access specialty care from hospitals outside of HHC through the outside clinics.
48Advantage – Marion County, Indiana Pros for Harris CountyPhysicians are under a capitated arrangement, so they are encouraged to have patients using the most appropriate care.This type of program utilizes the current health care system and does not necessitate major functional changes.Cons for Harris CountyThis type of a program requires total subsidization. The population served does not qualify for other programs like Medicaid.RecommendationsAlthough the capitated arrangement with participating physicians is attractive, SOER should be cautioned from replicating this model without first finding multiple sources of funding.
49Increased Ambulatory Care Capacity and Coordination
50Federal New Access Point Initiative Program Description: The “New Access Point Initiative” was developed by the Bush Administration in August 2001 to expand current FQHCs and add new FQHCs around the country.Program Purpose: To expand health coverage to the uninsured.Funding Source: Federal appropriations distributed by the Bureau of Primary Health Care within the Health Resources and Services Administration (HRSA)Key Features: The five-year program calls for $1.2 billion to fund 1,200 new or expanded FQHCs. Of the 1,200 sites, 570 will be expansions of current FQHCs. Of the 630 remaining sites, 420 will be expansions of existing health centers and 210 will be new start community health centers. New sites will receive a maximum grant of $650,000 per year and expansion sites will receive a maximum grant of $550,000.
51Federal New Access Point Initiative Pros for Harris CountyThis program makes available funds for additional sites and expansions of current sites.The Texas Legislature created an FQHC Incubator Program to facilitate existing clinics in their attempt to obtain FQHC status.Obtaining FQHC “look-alike” status would still be beneficial in the interim.Cons for Harris CountyThe process for obtaining FQHC status is very competitive and a great deal of effort can be expended without receiving approval.The governance requirements for FQHCs are strict, with 51 percent of the board coming from the community.RecommendationsFQHC expansion should be continued as part of a broader capacity building strategy.
52Chicago’s Access Community Health Network Program Description: “Access Community Health Network,” a large FQHC system serving residents located on the South and West sides of Chicago.Program Purpose: To provide underserved areas with high-quality health care in a clinic setting.Funding Source: The program receives Section 330 funds for the clinics with FQHC status. The program also receives federal grant money for infant mortality, state grants for breast and cervical cancer, and foundation and individual philanthropic support. The most significant amount of funding comes from Medicaid, Medicaid HMO wrap-around, and Medicare.Key Features: The Network operates 42 clinics under single corporate structure. Federal funds for FQHCs are passed through the Network to those clinics. The Network itself enjoys some of the benefits of the FQHC status, including medical malpractice coverage. The Network has relationships with a number of hospitals, allowing patients to be seen in a number of different places for specialty care.
53Chicago’s Access Community Health Network Pros for Harris CountyHaving FQHCs and other clinics in an integrated network helps to reduce administrative costs and provides economies of scale.The network structure allows funding and contracting to be leveraged throughout the system.An integrated Network can more easily facilitate continual growth, particularly with regard to adding additional FQHCs.Cons for Harris CountyAn integrated Network approach requires substantial upfront coordination and a willingness of various entities to work together.The board for such a Network would have to have diversity so as to prevent overrepresentation by a single entity.RecommendationsIf SOER proceeds with efforts to bring additional FQHCs to Harris County, this model should be considered as a method to coordinate the effort. However, buy-in among all participants is critical for it to work.
54FQHC Look-Alike Initiative – Marion County, IN Program Description: The Health and Hospital Corporation (HHC) of Marion County is currently seeking FQHC Look-alike status for each of its seven clinics.Program Purpose: To obtain the benefits of FQHC look-alike status for clinics serving the HHC.Key Features:The seven clinics affiliated with HHC are currently under review for FQHC look-alike status. This will be a co-applicant arrangement between HHC and a single community board (51% community/49% other – of which 2 seats are for HHC). HHC will maintain budgetary control, while other issues will be handled jointly. This will likely provide greater oversight of the clinics and the benefits of look-alike status. HRSA is expected to approve this arrangement.
55FQHC Look-Alike Initiative – Marion County, IN Pros for Harris CountyFQHC Look-alike status is not competitive, yet still provides a number of FQHC benefits, including enhanced revenue due to Prospective Payment System reimbursement, PHS Drug Pricing Discounts, access to DHHS outstationed eligibility workers, and “first dollar” Medicare reimbursement.Cons for Harris CountyWhile the FQHC Look-alike status is not competitive, all of the Section 330 requirements must be met, including board requirements.HHC has a co-applicant arrangement with the FQHC Look-alike boards. It may be difficult to isolate a single entity in Harris County to assume this responsibility.RecommendationsSOER may want consider finding CHCs that are near FCHC Look-alike status to sponsor. Various entities could take on the responsibility of incubator.
56Referral Network: Cook County, Illinois Program Description: Since 1985, Cook County has maintained a referral system for non-affiliate clinics, allowing patients to receive specialty care through the County Hospital.Program Purpose: To allow uninsured and indigent patients access to specialty care through referrals from primary care physicians.Key Features:This network allows both clinics in Cook County’s Ambulatory & Community Health Network (~30) and non-affiliated clinics (~60) to refer patients to Cook County Hospital for specialty care, as well as allowing Cook County’s ED the ability to re-direct patients to clinics for more appropriate care.Clinics also have access to the hospitals labs and pharmacy (although pharmacy is now being scaled back to some degree).Clinics in the network now use a Web-based referral system for their patients.Primary Care Physicians must abide by referral rules detailed in the Web-based system. Approximately 10,000 patients per month are being referred through this system. The hospital uses the Web-based system as well to help patients locate clinics near their homes for primary care.
57Referral Network: Cook County, Illinois Pros for Harris CountyThis system would allow clinics not affiliated with Ben Taub or LBJ Hospitals to utilize a systematized method of referral.A Web-based system would provide efficiencies to the referral process.Hospitals would have a means to find primary care homes for non-emergent patients.Cons for Harris CountyWhile Cook County has one dominant health body, Harris County has many. It may be difficult to coordinate among the different stakeholders in Harris County.A Web-based system might require infrastructure improvements from already cash-strapped clinics.RecommendationsSOER should consider an integrated system for referrals. At the same time, careful planning should occur to make insure that no one hospital system or clinic is overrun.
58Project Access – Buncombe County, North Carolina Program Description: “Project Access,” a volunteer physicians program for uninsured and indigent residents in Buncombe County, North Carolina, established in late 1995 in collaboration with the Buncombe County Medical Society.Program Purpose: To match uninsured and indigent patients in need of specialty care with physicians willing to provide care for freeFunding Source: All services are donated by physicians and hospitals to which they are affiliatedKey Features: Physicians who participate in the program agree to see approximately 20 patients for free each year. Participating physicians are then put on a list available at local clinics and at the health department. Those who are in need of specialty care and do not have a means to pay for such care are referred to the appropriate and available doctor on the list. The physician is responsible for the needed care for that patient for three months, when the patient is re-evaluated to assess whether further specialty care is needed. The program currently has an average enrollment of 900-1,000 patients.
59Issues to Consider Project Access – Buncombe County, North Carolina Pros for Harris CountyThe program could reduce the number of indigent patients who receive specialty care from Ben Taub and LBJ Hospitals.Costs are limited to program administration and physician recruitment.Physicians are able to limit the number of patients they see under this arrangement to prevent being overrun.Cons for Harris CountyThis type of program involves significant buy-in from the physician community, as well as hospitals for testing and labs.An administrative system would have to be established that could be used in the many clinics and hospitals around the county.RecommendationsSOER should consider this option in order to include private physicians as part of the solution. To maintain continuity of care, physicians should be required to commit to at least one-year of service for each patient.
61Health Services Consolidation – Marion County, IN Program Description: Beginning in 1954, Marion County consolidated public health and health care functions into a single authority, the Health and Hospital Corporation (HHC)Program Purpose: To improve coordination of care and gain operating efficiencies.Funding Source: Local tax levies approved by the State Board of Accounts.Key Features:HHC is a consolidated taxing authority. HHC’s Executive Division oversees the corporation, with the heads of the Hospital Division and Department of Health Division reporting to the Executive Director of HHC. HHC also acts as the board of health for the county.HHC maintains a seven-member board (3 appointed by the Mayor, 2 appointed by the City-County Council, and 2 appointed by the Board of Commissioners).Eight years ago, the hospital division assumed control over all seven clinics under the jurisdiction of HHC in order to maximize reimbursement from patients and other payers, and better integrate care with the Hospital.
62Health Services Consolidation – Marion County, IN Key Features (cont’):The Indiana University Medical Group – Primary Care (IUMGPC) provides staff for all of the clinics directly under HHC (i.e., Wishard clinics). IUMGPC also selects the medical director for the clinics.The medical director of Wishard Hospital (i.e., public hospital for Marion County) is a faculty member from Indiana University. However, the University’s contract with Wishard is up soon and changes are likely to occur, including finding a new medical director. The change is due to the current and other recent medical directors’ difficulties with hospital management.
63Health Services Consolidation – Marion County, IN Pros for Harris CountyConsolidating clinics and hospitals into an integrated delivery model would allow for better patient management (e.g., specialty care) and data collection. This could help alleviate fragmentation in Harris County.As a consolidated entity, public medical care and public health activities could be coordinated to maximize their benefit and eliminate duplicity.Cons for Harris CountyHHC’s role as a consolidated taxing authority would be difficult to replicate in Harris County due to the multiple jurisdictions involved.While HHC oversees one hospital system and one department of health, consolidation in Harris County would include numerous entities in both medical care and public health.RecommendationsHarris County should examine the legal feasibility of any consolidation efforts before proceeding. Harris County may want to consider a step approach, with consolidation happening in stages over time.
64Summary Of Lessons Learned From Examining Other Communities After examining other communities, several common success factors emerged that are relevant for Harris County as it considers options for strengthening service delivery and coordination of care. These include:Strong leadership is essential for success.Consensus may be difficult to achieve but it is important to keep stakeholders engaged in the process.It is important to anticipate and flexibly plan for potential future policy, economic and other environmental developments.Sound financial analysis and planning are critical to ensure the long term financial viability of alternative models and to make the “business case” for investment.The need to establish transition planning, including leadership succession planning, as implementing meaningful change takes time.
65Components of a Framework for Re-visioning Care in Harris County
66Framework for Re-visioning Care Lewin created a framework around which to develop, compare and assess three actionable strategic options for Harris County. The framework evolved from:Analysis of the magnitude and drivers of in-appropriate ED use.Feedback from Harris County stakeholders.Approaches adopted by other communities.The framework is grounded in a conclusion that the problem calls for a multi-faceted and well coordinated approach.This chapter describes the framework’s components and summarizes stakeholder feedback regarding current status and future opportunities.
67Options to Address the Problem in Harris County Feature Five Coordinated Components Expand AmbulatoryCare CapacityImproveCoordinationof CareRestructurePublicHealth FunctionsEstablishEffectiveGovernanceAssure AdequateFinancing
68Expanding Ambulatory Care Capacity: Harris County Stakeholder Feedback Most stakeholders believe new capacity is needed to relieve pressure on EDs, but approaches differ.Many agree that a public/private solution includes a mix of:New specialty clinics.Expanded hours at HCHD and City and County public health clinics.Development of new public and private FQHC and FQHC look-alike capacity.Additional urgent care centers adjacent to private hospitals.More school-based health services.More physician capacity. Potential sources include volunteers, medical schools, and National Health Service Corps.
69Expanding Ambulatory Care Capacity (Cont.) Progress is being made in many areas.Specialty Care: Two new HCHD clinics providing 106,000 annual visits received conceptual County approval.Expanded Hours: HCHD clinics will expand hours in 2004, growing capacity by 160,000 visits annually.FQHCs: HCA converted a clinic to an FQHC in 2003 and several other clinics are planning to apply in 2004.Urgent Care Centers: Several private providers are exploring opening urgent care centers to redirect inappropriate ED use.School-Based Care: Houston school district is working to expand the number of clinics.
70Improving Coordination of Care: Stakeholder Feedback Many Harris County stakeholders believe any growth in capacity must be accompanied by improved care coordination.Components of a public-private solution cited include.Establish contractually-based patient referral guidelines a la the Chicago model to reduce fragmentation.Hire additional full time community “Navigators”* to assist in overcoming barriers to care.More effectively advertise and expand the number and hours of telephone nurse triage services to help persons find alternatives to ED use.Integrate patient medical records to follow patients across sites of care.Expand educational tools and outreach strategies to promote appropriate use of health care services and improve access to insurance.Develop a coordinated patient transportation strategy.* Defined as individuals who can help direct care towards appropriate sites within the community.
71Assuring Adequate Financing: Opportunities and Challenges Funding will be needed to develop and operate new ambulatory care capacity.Stakeholders noted opportunities, including:Support for change by the Mayor, Commissioners Court and the business community.Conceptual county approval of funding for new ambulatory care capacity called for by the HCHD strategic plan.Active efforts by coalitions such as Gateway to Care to plan and coordinate FQHC expansion and other capacity building.Interest by private providers in new FQHCs and urgent care centers to redirect inappropriate ED use.Foundation support.Efforts by The Houston Independent School District’s to expand school-based health programs.
72Assuring Adequate Financing: Opportunities and Challenges (cont.) Challenges to overcome are significant, including:Limited potential for additional federal DSH funding due to cutbacks and stricter oversight.Limited availability of federal funding for FQHC expansion. HRSA received about 1,280 applications in FY , but only 418 were funded.State cutbacks in Medicaid and CHIP eligibility.Little likelihood that the Texas legislature will increase Medicaid outpatient and physician payment rates.Passage of the Governor’s tax cap proposal would limit property tax revenue growth and county funding available for healthcare.
73Restructuring Public Health Functions Most Harris County stakeholders favor consolidation of City and County public health departments. Reasons cited include:Opportunities for improved integration of services.Opportunities for cost efficiencies by eliminating and consolidating redundant services and functions.Opportunities to maximize use of underutilized capacity.Opportunity to establish a centralized point of accountability.Opportunity to provide a county-wide unified response to public health emergencies.
74Restructuring Public Health Functions Those opposed cite:Concern that public health priorities and funding would be diminished if merged with larger HCHD.Little real potential for cost efficiencies, as both departments have independently achieved economies of scale.Cost of standardizing information and other systems and potential for disrupting implementation of the HCHD IS strategic plan if merged with HCHD.Cost of upgrading public health sites providing primary care services to JCAHO standards if merged with HCHD.The strongest opposition centers around merging with HCHD.
76OverviewWe created a framework around which to develop and compare three actionable strategic options after assessing:The extent of inappropriate ED use and other stresses on Harris County’s delivery system.Feedback from key Harris County and other stakeholders.Models developed in other communities.The framework for each option includes five key components.
77Overview Each option features a different mix of five key components: ImproveCoordinationof CareRestructurePublicHealth FunctionsAssure AdequateFinancingExpand AmbulatoryCare CapacityEstablishEffectiveGovernance
78OverviewIn developing three conceptually distinct strategic options, two categories emerged:A minimalist or reactive option, which seeks to improve system efficiency while minimizing new funding commitments.Two more proactive responses, which seek to expand health system capacity through multiple access points and improve system efficiency and coordination.The following slide illustrates our framework for revisioning the delivery of health care services in Harris County.
79Range of Configuration Options Framework for Revisioning Health Care in Harris CountyCurrentSystemCapacity/CoordinationHeightenedEfficiencyNew CapacityandFullyRebalanced123LeastComprehensiveMostCoordinatedCommunityHealth SystemOptionStrategicRealignmentReactiveRange of Configuration Options
80Framework for Revisioning Health Care in Harris County The following describes key features and projected outcomes of three options for re-visioning organization and delivery of health care services in Harris County.These options are arrayed by the magnitude of system change required.Options are designed to be additive, with each more complex option building upon the components of less ambitious options.This approach acknowledges variation in the scope of change required and provides stakeholders flexibility to move up or down the continuum of change.
81Range of Configuration Options Strategic Options for Harris County: A Reactive OptionMostComprehensive3Range of Configuration Options2ReactiveOption1CurrentSystemLeastComprehensiveCurrentCapacity/CoordinationHeightenedSystemEfficiency
82Reactive Reconfiguration Option: Objectives and Key Features Under this option, Harris County would move incrementally and opportunistically toward its revisioning goals.The focus of this “small fix” approach would center around maximizing the efficiency of the current system.County providers would minimize new investment and maximize reimbursement through the selective conversion of existing community-based ambulatory care capacity to better reimbursed FQHCs and FQHC look-alikes and modest expansion of urgent care centers.
83Reactive Reconfiguration Option: Objectives and Key Features Major components of this “closed system” reactive option include:Several new urgent care centers built by private hospitals near EDs to redirect nonemergent care and reduce financial losses.Opportunistically converting selected community clinics to FQHCs or FQHC look-alikes to maximize reimbursement, but little investment in new capacity or referral linkages to other providers.Maximizing revenue and reducing inappropriate ED use through improved billing and collections, along the lines of HCHD’s “Everyone Pays” initiative.No change in the organization of city and county public health departments.No new organizing or governance structure.
84Reactive Reconfiguration Option: Summary Assessment We examined the dimensions of such a system, including benefits and risks for Harris County, and compared its outcomes with the status quo.We concluded that, despite some improved system efficiencies and financial performance, this option will not:Infuse enough new capacity to meaningfully improve access to care reduce inappropriate ED use.Will not build needed coordination linkages across provider sites and levels of care to reduce system fragmentation.
85Framework for Revisioning Health Care in Harris County: Proactive Options In contrast to the reactive option, proactive options seek to build a system with greater capacity and coordination that is maximally efficient and effective.Both proactive options developed present more ambitious scenarios to improve access and reduce fragmentation of care, but differ with respect to such factors as:Community orientation.Expansion of linkages between public and private not-for-profit health systems.Scale of commitment to investment in new ambulatory care access points.Creating new coordinating entities that consolidate currently fragmented efforts.
86Framework for Revisioning Health Care in Harris County: Proactive Options We developed two proactive options:Strategic Realignment; andThe Coordinated Community Health SystemWe then assessed their expected outcomes and recommended a preferred option for Harris County
87Range of Configuration Options Strategic Realignment Reconfiguration OptionCurrentSystemCapacity/CoordinationHeightenedEfficiencyNew CapacityandFullyRebalanced123LeastComprehensiveMostStrategicRealignmentOptionReactiveRange of Configuration Options
88Strategic Realignment Reconfiguration Option: Objectives and Key Features This proactive option assumes that investment in new capacity and coordination is imperative to offer appropriate lower cost alternatives to non-emergent ED use and reduce system fragmentation.The proposed new capacity, scheduled to phase-in by 2015, is diverse, featuring a variety of access points to care. It is grounded, however, on a pragmatic assumption that funding and commitment may not be available to support the full complement of new capacity needed to address current unmet need among safety net populations in Harris County.
89Strategic Realignment Reconfiguration Option: Objectives and Key Features This option also calls for establishing a limited referral network for redirecting inappropriate ED visits to clinics, FQHCs, FQHC look-alikes and urgent and specialty care centers and transferring selected patient care services from the city and county public health departments to the Harris County Hospital District (HCHD).
90Strategic Realignment Reconfiguration Option: New Capacity System components include new capacity and ambulatory care access points, including:A network of seven new FQHC and FQHC look-alikes sufficient to treat 175,000 annual visits, or about 25% of current unmet need for primary care by the uninsured in Harris County.New outpatient specialty clinics and urgent care centers to accommodate referrals from new ambulatory care access points and other community providers.
91Strategic Realignment Reconfiguration Option: Financing New Capacity The new FQHC/FQHC look-alike network will require support of annual operating deficits.Financing of about $31 million will be required to meet operating deficits that are projected to occur between as new capacity is phased in.Annual operating losses are projected to peak at about $4.6 million between and then fall.Caveat: Converting HCHD clinics to FQHCs requires careful legal assessment, due to possible adverse impacts on federal disproportionate share payments to HCHD.
92Strategic Realignment Reconfiguration Option Estimated Annual Operating Losses of Seven New FQHCs and FQHC Look-alikesNotes: Assumes each site has 25,000 visit capacity and a $4.5 million annual operating budget; analysis excludes capital costs; assumes initial annual operating deficits of $1.5 million for FQHCs and $2.0 million for look-alikes; assumes sites are phased-in between ; assumes deficits are eliminated in 3 years for FQHCs and 4 years for look-alikes through revenue diversification.
93Strategic Realignment Reconfiguration Option: Coordination of Care Selective new initiatives for better coordinating care include:Establishing a limited referral network between hospitals and ambulatory care centers to refer non-emergent patients from EDs to appropriate ambulatory care sites and refer patients from those sites to hospitals for specialty and diagnostic services.Expanding the current county telephone nurse triage system and current community health education efforts.Potential funding sources might include Greater Houston provider organizations and grants.
94Strategic Realignment Reconfiguration Option: Coordination of Care Formation of a coordinating board to provide oversight and a unified planning structure for the FQHC and FQHC look-alike network.Board representation should reflect the diversity of Harris County and include community, government and private and public health sector representation.The Board would be authorized and funded to plan and begin implementing network expansion.
95Strategic Realignment Reconfiguration Option: Continued City/County Public Health Autonomy Maintain each agency’s autonomy, but transfer selected women’s and children’s primary health care services to HCHC and explore greater collaboration between city and county health departments.CityCountyHCHDPatient CareServicesCollaborate
96Strategic Realignment Reconfiguration Option: Summary Assessment The pragmatic approach of meeting a pre-defined scope of need limits the risks of implementation failure, and:This option carefully phases-in meaningful capacity in a manner that limits annual deficit funding and other financial risk.This option builds some coordination between hospitals and ambulatory care sites to improve coordination of care and reduce inappropriate ED use.This option may lower system-wide costs to the extent non-emergent care can be appropriately redirected to lower cost alternatives.Transfer of selected patient care services to HCHD improves care coordination and facilitates “one stop shopping” for consumers.This option may prove a useful fallback if the implementation risks of the option described below prove too daunting.
97Strategic Realignment Reconfiguration Option: Summary Assessment Conclusion After examining the dimensions of the Strategic Realignment option in the context of its likely effectiveness in addressing issues of concern, we concluded that this approach is superior to the Reactive option.In return for some investment, it partially rebalances the system by adding valuable primary care and other capacity, builds some system coordination infrastructure and creates a foundation for future expansion.However, we believe implementing this option will, at best, buy time, as significant unmet need and fragmentation of care will remain and ED overcrowding, and its effects, will likely continue.
98Range of Configuration Options The Coordinated Community Health System (CCHS) OptionCurrentSystemCapacity/CoordinationHeightenedEfficiencyNew CapacityandFullyRebalanced123LeastComprehensiveMostCoordinatedCommunityHealth SystemOptionStrategicRealignmentReactiveRange of Configuration Options
99The CCHS Option: Overview Efficient and effective health care requires a balanced and integrated system of services designed to move patients rapidly to the most appropriate treatment setting.The framework of this second proactive option is designed to help put in place the infrastructure to help achieve this in Harris County.It encompasses the elements of both previous options, but is bolder and more far-reaching and is the strategy of choice.The cornerstone of such a system for meeting the needs of Harris County residents is a strong, well coordinated ambulatory care network.
100The CCHS Option: Summary By 2015, CCHS calls for:Substantial investment in new capacity sufficient to meet current demand for primary care by the uninsured.Significant improvements in system-wide coordination through a county-wide patient referral network similar to Chicago’s.Expanded and coordinated medical and behavioral health patient call center and community health education center capacity.Consolidation of city and county public health functions.Establishing a high level public/private governance structure to maintain the oversight and coordination required for effective system functioning.
101The Recommended Option: Coordinated Community Health System
102The CCHS Option: Investment in New Capacity CCHS calls for a county-wide coordinated network of new ambulatory care access points, including:Five new FQHCs and nine FQHC look-alikes, each able to see 50,000 visits annually, to address unmet need for primary care by the uninsured.Additional outpatient specialty clinics and urgent care centers as called for by the HCHD strategic plan to accommodate referrals from new ambulatory care access points and other community providers.Additional school-based health services and education.
103The CCHS Option: Investment in New Capacity The FQHC/FQHC look-alike network meets primary care demand with less financial risk than other clinic models:FQHCs/FQHC look-alikes are eligible for enhanced Medicare and Medicaid funding and discounted drug pricing.FQHCs also may receive malpractice coverage and federal Section 330 grant funding up to $650,000 annually.Sites are required to provide primary, preventive and behavioral health services directly or by arrangement.
104The CCHS Option: Investment in New Capacity The new FQHC/FQHC look-alike network will require financing substantial operating deficits during the network phase-in period.Total estimated operating losses of about $158 million are projected between as new capacity is phased in.
105Harris County CCHS Option Estimated Annual Operating Losses for 14 New FQHCs and FQHC Look-alikesNotes: Assumes each site has 50,000 visit capacity and $9 million operating budget; excludes capital costs; assumes initial annual operating deficits of $3.4 million for 5 FQHCs and $4.0 million for 9 look-alikes; assumes sites are phased-in between ; assumes deficits are eliminated in 3 years for FQHCs and 4 years for look-alikes through revenue diversification.
106The CCHS Option: Improving Care Coordination Improving care coordination will require community-wide involvement and linkages.At the provider level, these include:Establishing county-wide, contractually-based patient referral linkages between hospital EDs, clinics and urgent care centers a la the Chicago model, to reduce fragmentation of care.Use of a Web-based system to coordinate patient referrals.Use of common IT and data reporting systems and integrating patient medical records to follow patients across sites of care.Integrating behavioral health and primary care services in FQHC/FQHC look-alikes.
107The CCHS Option: Improving Care Coordination At the community level, these include:Expanding the telephone nurse triage system to add a 24/7 mental health and substance abuse call center to provide counseling and referral services county-wide.Developing a health education center and establishing linkages to the telephone nurse triage system.The health education center would teach consumers how and when to access both providers and insurers.The education and telephone triage and counseling centers coordinate in sharing information to better target educational strategies, message development and consumer outreach.Goal: To improve coordination of behavioral and physical health services and reduce inappropriate ED use.
108The CCHS Option: Improving Care Coordination Proposed call center and health education linkages.Call CenterHealth EducationLiaison/CollaborateAnalyze call volume to identify issues and trends.Tailor health education topics and outreach strategies to address major issues and trends.
109The CCHS Option: Restructuring Public Health Functions Under CCHS, City and County population health functions are consolidated and selected women and children’s patient care services are transferred to HCHD.City and CountyHCHDPatient CareServices
110The CCHS Option: Restructuring Public Health Functions Consolidating public health departments, as proposed in the past, would provide county-wide centralized administration of public health functions and provide a consistent level of services across city and county.
111The CCHS Option: Restructuring Public Health Functions This reorganization would also establish a focal point for public health accountability and allow for a county-wide unified response to public health emergencies. Other expected benefits of consolidating public health departments include:Flexibility to deploy resources county-wide where needed.Maintains autonomy of the local public health sector, while streamlining and rationalizing services.Improves care coordination through “one stop shopping ” for consumers.Serves as a useful transition for possible future consolidation with HCHD and possibly MHMRA.
112The CCHS Option: Restructuring Public Health Functions Consolidation of public health departments could be conducted under the guidance of a transition plan that describes:The transfer of selected patient services to HCHD.The merger of city and county health departments.The establishment of county-wide administrative and governance structures.The development of a sustainable funding mechanism.
113The CCHS Option: Create a High Level Governance Structure An independent governance structure with representation and strong leadership by senior community leaders is an important element of the CCHS option.The Board would provide oversight and coordination.
114The CCHS Option: High Level Governance Structure Board membership should reflect the diversity of Harris County and should have sufficient credibility to enjoy the strong support of elected officials. To help achieve these goals, board membership might include:Senior city and county political leadership.Senior leaders with acknowledged credentials from the medical community.Representation from business community leaders.Representation from not-for-profit sector leaders.
115The CCHS Option: High Level Governance Structure Essential principles of a framework to guide effective board operation should include:Sufficient independence from day-to-day political pressure to operate effectively, but remain accountable for results.An independent and reliable funding base.A leadership succession strategy to ensure continuity of commitment.Ongoing Board training and education.
116The CCHS Option: Assessment of Benefits Implementing CCHS offers Harris County residents many benefits, including:A much better balanced network of health care providers and services.Significantly reduced inappropriate ED use.Greatly strengthened system coordination and linkages across levels of care.Improved public health efficiency and effectiveness.Expanded community access to appropriate care, emphasizing lower cost primary and preventive services.Better integration of behavioral health with community-based primary care.More appropriate and cost efficient use of health care by consumers through expanded and coordinated health education and call center capacity.
117The CCHS Option: Assessment of Challenges The relative boldness of this option also carries with it a number of implementation challenges. These include:The need for significant investment in new capacity in the face of possible funding constraints, including:Stiff nation-wide competition for and limited availability of federal funding for future FQHC expansion.State cutbacks in Medicaid and CHIP eligibility.Little likelihood that the Texas legislature will increase Medicaid outpatient and physician payment rates.Maintaining continuity of strong and committed leadership over time.Clinical staff recruitment for the expanded network may be challenging in the face of nation-wide work force shortages.
118The CCHS Option: Conclusion and Recommendation On balance, CCHS appears to be the best strategic option for Harris County. While challenging to implement, we believe CCHS will, more than the other two options examined:Reduce inappropriate ED use and fragmentation of care in the most efficient and effective manner.Assure optimal use of public and private financial resources.Proactively position Harris County for the future.Implementing this approach may also heighten Harris County’s health care leadership profile nationally and enhance its ability to attract new businesses to spur continued regional economic growth.