1. PRESENTATION TO DSHS PUBLIC HEALTH IMPROVEMENT STAFF PRESENTATION TO DSHS PUBLIC HEALTH IMPROVEMENT STAFF November 9, 2010 Mike Gilliam, Jr., M.S.W., M.P.H. Office of Priority Initiatives Coordination

2. 2 ORGANIZATIONAL CHANGES: Mike Gilliam (Assessment & Benchmarking Specialist) moved from Centers for Program Coordination, Policy & Innovation to the Office of Priority Initiatives Coordination (OPIC). Mike Gilliam (Assessment & Benchmarking Specialist) moved from Centers for Program Coordination, Policy & Innovation to the Office of Priority Initiatives Coordination (OPIC). Olga Rodriguez is Director of OPIC. Olga Rodriguez is Director of OPIC. Assessment & Benchmarking Specialist will “conduct benchmarking activities, preventable hospitalization efforts and activities associated with performance management, quality improvement and data analysis.” Assessment & Benchmarking Specialist will “conduct benchmarking activities, preventable hospitalization efforts and activities associated with performance management, quality improvement and data analysis.”

3. 3 REQUESTING A COMMUNITY HEALTH ASSESSMENT INVOLVING OPIC: 1. County judge emails DSHS Regional Director (RD) requesting assistance in developing a community health assessment. 2. If RD approves county judge’s request, RD sends an email to Mike Gilliam requesting OPIC work with PHI in developing a Plan of Action for the community health assessment. 3. Mike Gilliam sends Plan of Action to RD and OPIC Director for approval. 4. Project begins once RD and OPIC Director approve Plan of Action in writing (via email).

4. 4 QUESTIONS TO ASK BEFORE REQUESTING ASSISSTANCE FROM OPIC IN DEVELOPING A COMMUNITY HEALTH ASSESSMENT: Why does the county want to develop a community health assessment? Why does the county want to develop a community health assessment? Do county leaders have a need to obtain community health assessment data/information for a specific health-related purpose? Do county leaders have a need to obtain community health assessment data/information for a specific health-related purpose? Who will the county judge appoint to work with DSHS in developing the community health assessment? Can this “appointed” person devote a significant amount of time to the project? Who will the county judge appoint to work with DSHS in developing the community health assessment? Can this “appointed” person devote a significant amount of time to the project? Are county leaders committed to post-assessment activities? Are county leaders committed to post-assessment activities? During the project period, can PHI staff devote at least 50% of their time to the project? During the project period, can PHI staff devote at least 50% of their time to the project?

5. 5 POSSIBLE PARTNERS IN PLANNING/IMPLEMENTING A COMMUNITY HEALTH ASSESSMENT: Non-profit Hospitals Non-profit Hospitals EMS/Trauma Regional Advisory Councils EMS/Trauma Regional Advisory Councils

6. 6 ONLINE DATA/INFORMATION COLLECTION (Question Pro): DSHS has a corporate license to Question Pro (www.questionpro.com). Mike Gilliam is DSHS’ license administrator. www.questionpro.com 1. Program emails Mike hard copy of survey. 2. Mike puts the survey online in a draft format. 3. Program reviews/tests/approves draft online survey. 4. Mike provides program with web-link of final online survey to send via email to target audience. 5. Mike provides program with real-time web-link to monitor survey results. 6. Program requests Excel file of survey data/information when survey closes.

7. 7 ADULT POTENTIALLY PREVENTABLE HOSPITALIZATIONS: Exceptional Item (2011/12) Exceptional Item (2011/12) MHSA Co-morbidity MHSA Co-morbidity Presentations (e.g., TMA, TACHC, EMS/Trauma RAC) Presentations (e.g., TMA, TACHC, EMS/Trauma RAC) HHSC HHSC 2009 Data 2009 Data

8. 8 The purpose of this information is to assist in improving health care and reducing health care costs in Texas. The purpose of this information is to assist in improving health care and reducing health care costs in Texas. This information is not an evaluation of hospitals or other health care providers. This information is not an evaluation of hospitals or other health care providers. The preventable hospitalization conditions were selected by the Agency for Healthcare Research and Quality (AHRQ). AHRQ (www.ahrq.gov) is the lead federal agency responsible for research on health care quality, costs, outcomes and patient safety. The preventable hospitalization conditions were selected by the Agency for Healthcare Research and Quality (AHRQ). AHRQ (www.ahrq.gov) is the lead federal agency responsible for research on health care quality, costs, outcomes and patient safety.www.ahrq.gov The data comes from the Texas Health Care Information Collection in the Center for Health Statistics at the Texas Department of State Health Services (www.dshs.state.tx.us/thcic). The data comes from the Texas Health Care Information Collection in the Center for Health Statistics at the Texas Department of State Health Services (www.dshs.state.tx.us/thcic).www.dshs.state.tx.us/thcic Adult Potentially Preventable Hospitalizations in Texas

9. 9 Hospitalizations for the following ten conditions are called “potentially preventable,” because if the individual had access to and cooperated with outpatient health care, the hospitalization would likely not have happened: o Bacterial Pneumonia; o Dehydration; o Urinary Tract Infection; o Angina (without Procedures); o Congestive Heart Failure; o Hypertension (High Blood Pressure); o Asthma; o Chronic Obstructive Pulmonary Disease; o Diabetes Short-Term Complications; and o Diabetes Long-Term Complications. Adult Potentially Preventable Hospitalizations in Texas

10. 10 Adult Potentially Preventable Hospitalizations in Texas From 2005-2008, adult residents (18+) of Texas received $24.9 billion in hospital charges for the ten conditions. This amount equals $1,418 for every adult Texan. From 2005-2008, adult residents (18+) of Texas received $24.9 billion in hospital charges for the ten conditions. This amount equals $1,418 for every adult Texan. Bacterial Pneumonia and Congestive Heart Failure comprise 52% of these hospital charges. Bacterial Pneumonia and Congestive Heart Failure comprise 52% of these hospital charges. Hospital Charges Billed: Hospital Charges Billed: Medicare$16.0 billion(64%) Private Health Insurance$ 4.4 billion(18%) Uninsured$ 2.2 billion(09%) Medicaid$ 1.7 billion(07%) Other$ 600 million(02%)

11. 11 Adult Potentially Preventable Hospitalizations in Texas (2005-2008) ConditionNumber of Hospitalizations Average Hospital Charge Total Hospital Charges Average $ Impact for All Adult Texas Residents Bacterial Pneumonia216,727 (*6 days)$27,277$5,911,741,178$336 Dehydration60,225 (*4 days)$16,512$994,426,460$57 Urinary Tract Infection123,228 (*5 days)$18,843$2,322,012,868$132 Angina (without procedures)14,319 (*2 days)$16,319$233,676,275$13 Congestive Heart Failure254,611 (*5 days)$27,998$7,128,562,258$405 Hypertension38,054 (*3 days)$18,380$699,414,834$40 Asthma61,306 (*4 days)$20,545$1,259,543,126$72 Chronic Obstructive Pulmonary Disease109,581 (*5 days)$25,203$2,761,769,189$157 Diabetes Short-term Complications33,341 (*4 days)$21,151$705,191,762$40 Diabetes Long-term Complications84,631 (*7 days)$34,506$2,920,646,232$166 TOTAL996,023 (*5 days)$25,036$24,936,584,181$1,418 * Average Length of Hospital Stay Source: Center for Health Statistics, Texas Department of State Health Services

12. 12 Source: Center for Health Statistics, Texas Department of State Health Services Adult Potentially Preventable Hospitalizations in Texas (2005-2008) EXPECTED SOURCE OF FIRST PAYMENT Source of PaymentNumber of Hospitalizations PercentHospital Charges Medicare – Part A594,654 60%$14,887,757,544 Medicaid67,399 07%$1,687,401,364 Self-Pay57,352 06%$1,435,864,672 Preferred Provider Organization51,754 05%$1,295,713,144 HMO – Medicare Risk41,408 04%$1,036,690,688 Commercial Insurance38,819 04%$971,872,484 HMO36,713 04%$919,146,668 Blue Cross/Blue Shield36,527 04%$914,489,972 Self Pay/Charity/Indigent/Unknown (2005)22,133 02%$554,121,788 Other Non-Federal Program10,697 01%$267,810,092 Charity, Indigent or Unknown10,008 01%$250,560,288 Other28,559 03%$715,003,124 ALL996,023 100%$24,936,584,181

13. 13 Source: Center for Health Statistics, Texas Department of State Health Services Adult Potentially Preventable Hospitalizations in Texas (2005-2008) EXPECTED SOURCE OF FIRST PAYMENT ConditionTOTALMedicarePrivate Health Insurance UninsuredMedicaidOther Bacterial Pneumonia216,727147,155 (68%) 39,964 (18%) 15,471 (07%) 11,252 (05%) 2,885 (01%) Dehydration60,22538,880 (65%) 14,698 (24%) 2,952 (05%) 3,055 (05%) 640 (01%) Urinary Tract Infection 123,22881,668 (66%) 20,961 (17%) 10,802 (09%) 7,851 (06%) 1,946 (02%) Angina (without procedures) 14,3196,097 (43%) 4,918 (34%) 1,951 (14%) 909 (06%) 444 (03%) Congestive Heart Failure 254,611189,542 (74%) 29,105 (11%) 17,460 (07%) 14,831 (06%) 3,673 (01%) Hypertension38,05417,255 (45%) 10,575 (28%) 6,441 (17%) 2,662 (07%) 1,121 (03%) Asthma61,30626,737 (44%) 18,030 (29%) 8,533 (14%) 6,507 (11%) 1,499 (02%) Chronic Obstructive Pulmonary Disease 109,58180,367 (73%) 14,718 (13%) 5,969 (05%) 7,081 (06%) 1,446 (01%) Diabetes Short-term Complications 33,3416,316 (19%) 10,542 (32%) 10,319 (31%) 4,777 (14%) 1,387 (04%) Diabetes Long-term Complications 84,63146,989 (56%) 17,207 (20%) 9,595 (11%) 8,474 (10%) 2,366 (03%) ALL996,023641,006 (64%) 180,718 (18%) 89,843 (09%) 67,399 (07%) 17,407 (02%)

14. 14 Source: Center for Health Statistics, Texas Department of State Health Services Adult Potentially Preventable Hospitalizations in Texas (2005-2008) ConditionNumber of Hospitalizations Average Age FemaleMale Bacterial Pneumonia216,72767 Years56%43% Dehydration60,22564 Years64%36% Urinary Tract Infection123,22865 Years74%26% Angina (without procedures)14,31959 Years57%43% Congestive Heart Failure254,61169 Years54%46% Hypertension38,05458 Years64%36% Asthma61,30654 Years75%25% Chronic Obstructive Pulmonary Disease109,58168 Years56%44% Diabetes Short-term Complications33,34139 Years52%48% Diabetes Long-term Complications84,63157 Years49%51% ALL996,02364 Years59%41%

15. 15 Source: Center for Health Statistics, Texas Department of State Health Services Adult Potentially Preventable Hospitalizations in Texas (2005-2008) ConditionNumber of Hospitalizations WhiteAA/BlackOtherHispanic Bacterial Pneumonia216,72773%11%17%19% Dehydration60,22572%11%16%18% Urinary Tract Infection123,22870%11%19%23% Angina (without procedures)14,31967%14%19%23% Congestive Heart Failure254,61164%19%17%22% Hypertension38,05452%31%17%21% Asthma61,30662%21%17%20% Chronic Obstructive Pulmonary Disease 109,58181%09%10%11% Diabetes Short-term Complications33,34155%26%19%26% Diabetes Long-term Complications84,63154%20%26%36% ALL996,02367%16%17%21%

16. 16 Source: Center for Health Statistics, Texas Department of State Health Services Adult Potentially Preventable Hospitalizations in Texas (2005-2008) DISCHARGED TO ConditionNumber of Hospitalizations Home/ Self-Care Skilled Nursing Facility Home Health Other Bacterial Pneumonia216,72762%12%10%16% Dehydration60,22565%12%09%14% Urinary Tract Infection123,22857%18%10%15% Angina (without procedures)14,31975%02% 21% Congestive Heart Failure254,61161%10%13%16% Hypertension38,05486%03%06% Asthma61,30686%03%06%05% Chronic Obstructive Pulmonary Disease 109,58168%08%12%13% Diabetes Short-term Complications33,34186%02%04%07% Diabetes Long-term Complications84,63160%09%16%15% ALL996,02365%10%11%14%

17. 17 Source: Center for Health Statistics, Texas Department of State Health Services Adult Potentially Preventable Hospitalizations in Texas (2005-2008) DemographicsALL 996,023 Medicaid 67,399 Uninsured 89,843 Average Age645045 Female59%66%56% Male41%34%44% White67%51%54% African American/Black16%26%24% Other (Race)17%21%20% Hispanic21%34%31% Discharged to Home/Self Care65%79%89% Discharged to Skilled Nursing Facility10%03%01% Discharged to Home Health Services11%07%03% Discharged to Other14%10%07%

18. 18 Source: Center for Health Statistics, Texas Department of State Health Services Sixty-three (63) high impact counties whose adult residents had a rate more than 50% higher than the state rate/average for adult potentially preventable hospitalizations for 2005, 2006, 2007 and 2008. …Angelina, Atascosa, Brooks, Brown, Burleson, Caldwell, Camp, Coke, Collingsworth, Comanche, Crosby, Delta, Dickens, Duval, Fannin, Franklin, Freestone, Gray, Grayson, Gregg, Grimes, Henderson, Hill, Hockley, Houston, Howard, Hunt, Jasper, Jefferson, Jim Hogg, Jim Wells, Johnson, Kleberg, Lamar, Lampasas, Leon, Liberty, Limestone, Maverick, Moore, Morris, Nacogdoches, Navarro, Orange, Palo Pinto, Panola, Polk, Red River, Robertson, Runnels, Sabine, San Augustine, San Jacinto, Shelby, Sutton, Terry, Tom Green, Trinity, Upshur, Victoria, Willacy, Wood and Zapata County. Adult Potentially Preventable Hospitalizations in Texas

19. 19 Source: Center for Health Statistics, Texas Department of State Health Services Adult Potentially Preventable Hospitalizations in Texas 63 High Impact Counties

20. 20 Adult Potentially Preventable Hospitalizations in Texas Potentially Preventable Hospitalizations (2005-2008) Hospitalizations for Adult Residents of Travis County Number of Hospitalizati ons Average Hospital Charge Total Hospital Charges Average $ Impact for All Adult County Residents Bacterial Pneumonia4,726$24,782$117,120,977$164 Dehydration970$16,516$16,020,347$22 Urinary Tract Infection3,329$17,363$57,802,570$81 Angina (without procedures)228$16,104$3,671,690$5 Congestive Heart Failure5,942$24,905$147,986,462$207 Hypertension (High Blood Pressure)851$17,040$14,501,152$20 Asthma1,951$17,931$34,983,318$49 Chronic Obstructive Pulmonary Disease2,075$24,393$50,615,186$71 Diabetes Short-term Complications972$18,743$18,218,527$26 Diabetes Long-term Complications2,337$32,090$74,995,296$105 TOTAL23,381$22,921$535,915,525$751 Source: Center for Health Statistics, Texas Department of State Health Services

21. 21 Adult Potentially Preventable Hospitalizations in Texas Potentially Preventable Hospitalizations (2005-2008) Hospitalizations for Adult Residents of Liberty County Number of Hospitalizations Average Hospital Charge Total Hospital Charges Average $ Impact for All Adult County Residents Bacterial Pneumonia1,474$35,013$51,609,738$889 Dehydration419$18,279$7,658,779$132 Urinary Tract Infection983$24,751$24,329,914$419 Angina (without procedures)64$21,035$1,346,230$23 Congestive Heart Failure1,445$40,714$58,831,545$1,013 Hypertension (High Blood Pressure)215$22,546$4,847,396$83 Asthma433$30,164$13,061,015$225 Chronic Obstructive Pulmonary Disease1,255$29,945$37,580,633$647 Diabetes Short-term Complications124$33,980$4,213,509$73 Diabetes Long-term Complications379$43,169$16,361,162$282 TOTAL6,791$32,372$219,839,921$3,787 Source: Center for Health Statistics, Texas Department of State Health Services

22. 22 Results of Community Interventions: Under the leadership of the county judge, community health coalitions in Freestone and Red River County used the potentially preventable hospitalization data to implement community interventions (e.g., vaccine outreach campaign) to reduce hospitalizations for Bacterial Pneumonia. Freestone County: 32% decrease in hospitalizations for Bacterial Pneumonia for 2008 as compared to 2007 ($1,055,448 in hospital charges were avoided). Red River County: 29% decrease in hospitalizations for Bacterial Pneumonia for 1 st Quarter 2008 as compared to 1 st Quarter 2009 ($317,658 in hospital charges were avoided). Adult Potentially Preventable Hospitalizations in Texas

23. 23 Upcoming Community Interventions : Community interventions to reduce hospitalizations for Bacterial Pneumonia are currently being planned for the following counties:  Fannin County (Health Service Region 2/3)  Montague County (Health Service Region 2/3)  Runnels County (Health Service Region 2/3)  Stonewall County (Health Service Region 2/3)  Liberty County (Health Service Region 6/5S)  Waller County (Health Service Region 6/5S) Adult Potentially Preventable Hospitalizations in Texas

24. 24 Adult Potentially Preventable Hospitalizations in Texas Website (www.dshs.state.tx.us/ph): www.dshs.state.tx.us/ph Profiles on all 254 counties in Texas; Profiles on all 254 counties in Texas; Clinical Interventions; and Clinical Interventions; and Maps illustrating the impact of the ten adult potentially preventable hospitalization conditions. Maps illustrating the impact of the ten adult potentially preventable hospitalization conditions.Contact: Mike Gilliam, Jr., M.S.W., M.P.H. Texas Department of State Health Services mike.gilliam@dshs.state.tx.usmike.gilliam@dshs.state.tx.us (512)458-7111 (Ext. 2708) mike.gilliam@dshs.state.tx.us