Karen DeSalvo, MD, MPH, MSc Tulane 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?

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5 Baicker and Chandra, Health Affairs, 2004.

Quality & Spending in Louisiana 6 Source: Health Dialog, 2007; Data from 2005; Higher costs do not appear to correlate with low gap scores (high quality) “Gap” scores represent aggregation of quality metrics, lower gap score=higher quality Diamonds represent Louisiana Hospital Services Areas (HSAs) with ≥ 10,000 people *Chronics: CHF, COPD Diabetes, Asthma, CAD

7 Lack of Primary Care Providers 7 Baicker and Chandra, Health Affairs, 2004

Our Opportunity from Tragedy Source: nola.com

Patients First Governor’s Health Reform Panel (Pre-Katrina) Governor’s Health Reform Panel (Pre-Katrina) Bring New Orleans Back Commission “Framework” Group Louisiana Hospital Association Louisiana Hospital Association Redesign Priority Louisiana Recovery Authority Public Health and Healthcare Task Force Redesign Priority Louisiana Recovery Authority Public Health and Healthcare Task Force Redesign Collaborative Louisiana Healthcare Redesign 9 DeSalvo, ASIM, July/August /05 11/05 1/06 7/06

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,

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,

Patients First Bring New Orleans Back Commission “Framework” Group Louisiana Hospital Association Louisiana Hospital Association Redesign Priority Louisiana Recovery Authority Public Health and Healthcare Task Force Redesign Priority Louisiana Recovery Authority Public Health and Healthcare Task Force Redesign Collaborative Louisiana Healthcare Redesign 12 DeSalvo, ASIM, July/August /05 11/05 1/06 7/06 7/07 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 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 Care 4.Implement Medical Home Systems of Care demonstrations 5.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 PurposePopulationGeographic Area FinancingTime windowMental health Key Outcomes Implement Care management PediatricsNew Orleans area Children’s Special Health Services, Louisiana Department of Health and Hospitals Early ongoing YesFamily 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 YesAccess Quality Sustainability Interconnectivity Improve the coordination and quality of care for Medicaid enrollees Medicaid recipients of all age groups StatewideMedicaid and State appropriation Design 2008; implementation 2010 YesImproved access to primary care Improved quality and efficiency Improve the quality and efficiency of primary care All ages and all payer groups StatewideInternal funding and payer reimbursement 2008NoImproved health care value Improve coordination of care and access to high quality primary care All agesNorth LouisianaHHS Grant2007 to presentNoInterconnectivity Quality Access

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 21

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;

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 SPECIALIST SERVICES SPECIALIST SERVICES ALL CITIZENS ALL CITIZENS Referral as Medically Necessary Care Coordination Care Coordination ACUTE HOSPITAL Other Health care Providers & Extension Services EHR Medical Home System of Care SPECIALIZED MEDICAL HOME Services 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

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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 % increase in citizens with “usual source of care” other than emergency rooms in past 2 years* 31 *Kaiser Family Foundation, 2008;

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 l ack of adequate housing Adjusted OR 2.0 ( ) 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.