Transcript VCU Health System - EPID 600

Role of Academic Medical Centers
In Safety Net Health Care Delivery Systems
Sheryl L. Garland, M.H.A.
Vice President, Community Outreach
VCU Health System
November 28, 2005
Outline
Overview of Healthcare Safety Net
Role of the Academic Medical Center
Partnership Opportunities
OB Dilemma in the Greater Richmond Area
Slide 2
In March 2000, the Institute of Medicine
released a study entitled “America’s Health Care
Safety Net: Intact but Endangered” that defined
A Safety Net as:
“Those providers that organize and deliver
a significant level of health care and other
health-related services to uninsured, Medicaid
and other vulnerable patients.”
Institute of Medicine, America’s Health Care SafetyNet: Intact but Endangered (Washington, D.C:
National Academy Press, 2000) p.21.
Slide 3
Safety Net Health Systems Have Two
Distinguishing Characteristics:
They maintain an “open door”, usually
offering access to both inpatient and
outpatient services to uninsured or
under-insured patients
They represent a significant proportion
of the preventive, acute and chronic
health care services delivered to
uninsured, Medicaid and other
vulnerable populations in their region
“America’s Health Care Safety Net: Intact, but Endangered”,
Institute of Medicine Report, 2000
10
Slide 4
The nation’s health care safety net for low
income and uninsured has grown somewhat
stronger….The safety net varies from
community to community and can include
various configurations of public and private
hospitals, community health centers
(CHC’s), local health departments, free and
school-based clinics and physician charity
care .
Laurie E. Felland, Kyle Kinner, John F. Hoadley, “The Health Care Safety Net: Money Matters but
Savvy Leadership Counts”, Issue Brief No. 66, August 2003, p.1.
Slide 5
Strategies Used to Strengthen Safety Nets
• Develop strong partnerships
• Create managed care programs for the
uninsured
• Construct prescription formularies
• Develop disease case management and care
coordination programs
• Increase enrollment in Medicaid and SCHIP
programs (FAMIS)
• Capture all public and private funding sources
• Develop low cost health insurance options for
working poor
Slide 6
Outline
Overview of Healthcare Safety Net
Role of the Academic Medical Center
Partnership Opportunities
OB Dilemma in the Greater Richmond Area
Slide 7
The Commonwealth of Virginia
• Population is approximately 7.1 million
people
• Approximately 30% of Virginians are
below 200% of the FPL
• Nearly 2/3 of the counties are
designated as full or partially medically
underserved areas
• An estimated 12-15% of the population
lacks basic health insurance
“An Opportunity for Unprecedented Growth”, Virginia Primary Care Association, Sept. 2002
20
Slide 8
Virginia’s Indigent Care Program
•
•
•
•
Established in the late 1970’s to provide
coverage to the uninsured
Virginia’s Medicaid program only covers
those who are pregnant, under 18, aged,
blind or disabled
Indigent Care Program marries federal DSH
dollars and State General funds (50/50
match)
Eligibility criteria:
- Reside in the Commonwealth
- U.S. Citizen
- At or below 200% FPL
- Meet asset test criteria
Slide 9
VCU Health System
• Part of Virginia Commonwealth University’s Medical
Center
• Formerly known as MCV Hospitals and Physicians
• Located in downtown Richmond, Virginia
• 779 Bed Teaching Hospital
• Level I Trauma Center
• Over 31,000 admissions
• Estimated 80,000 ED visits
• Over 500,000 Outpatient visits
• Approximately 600 housestaff
• Over 700 full time faculty in
the School of Medicine
Slide 10
Leading Providers of Charity Care
2000
Percentage of Entire Charity Care
for the Commonwealth
34.2%
16.5%
7.0%
Inova
6.0%
6.2%
UVA
Carillion
VCU Health
System
Sentara
Sources: VHI 2000 Hospital Financial Data Report, VCUHS Financial Services, VCUHS Strategy & Marketing
VHI Definition of Charity Care: Charity Care represents (unreimbursed) charges to individuals at 100% of the federal
non-farm poverty level
Slide 11
VCU Health System Indigent Care Distribution
In d ig e n t Ca re Co st in D o lla rs
4 7 , 2 7 0 , 0t o
0407 , 3 0 0 , 0 0 0
2 , 0 0 0 , 0 t0o 1 5 , 0 0 0 , 0 0 0
7 0 0 , 0 0t o1 2 , 0 0 0 , 0 0 0
1 5 0 , 0 0t o1 7 0 0 , 0 0 0
1 0 , 0 0t o
1 1 5 0 ,0 0 0
5 , 0 0 t1o
1 0 ,0 0 0
0 to
5 ,0 0 0
FY03 Budget $107.3M in Indigent Cost
Slide 12
The total population of the Richmond Metro area exceeds
850,000
“Examining Access to Health Care in the Greater Richmond Area”, Presentation at the RACE for Health 2003,
Stephen Horan, Ph.D., Community Health Resource Center
Slide 13
26
More than 186,000 have incomes below 2x poverty (22%)
“Examining Access to Health Care in the Greater Richmond Area”, Presentation at the RACE for Health 2003, Stephen Horan,
Ph.D., Community Health Resource Center
Slide 14
27
More than 48,000 (estimated) are below 2x poverty and uninsured
“Examining Access to Health Care in the Greater Richmond Area”, Presentation at the RACE
for Health 2003, Stephen Horan, Ph.D., Community Health Resource Center
Slide 15
28
The Ecology of Safety Net Care
Catastrophic
event
Acute
hospitalization
Healthy
with
unmet
needs
Healthy
with
episodic
needs
Chronically ill
Presentation: Governor’s Covering the Uninsured Conference, Dr. Sheldon M. Retchin, 2003
Slide 16
29
With the increasing pressures to
identify funds and reduce the cost
of caring for
the uninsured and the underinsured,
the VCU Health System
has developed innovative strategies to
continue to provide services
to these populations
Slide 17
Pieces of the Puzzle
• VCUHS purchased Medicaid HMO in
the mid 1990’s
• In 1999, a work group explored idea of
using managed care principles to
coordinate care for the uninsured
• Virginia Coordinated Care for the
Uninsured (VCC) program
launched in November, 2000
Slide 18
Goals of the VCC Program
• Utilize managed care principles to support a
defined population
• Support a centralized/automated Financial
Screening process
• Establish Primary Care Physician (PCP)
centered care
• Partner with Community Primary Care
Physicians and Specialty Physicians
• Reduce the average cost per unit of service
• Improve the health status of the population
Slide3119
Number of Uninsured Patients Qualifying for the
Indigent Care Program at the VCU Health System
Number of
“Indigent” Patients
0.321
4.805
Hanover
Other Areas
0.885
Tri-City Area
0.977
Chesterfield
2.576
Henrico
10.056
Richmond
14.814
VCC Eligible
Full IndigCategory 1
19.619
Total
50
40
30
20
10
0
FY 2000
Thousands
38.781
Slide 20
The VCC Service Area
C a r o l in e
G o o c h la n d
H anove r
K in g W il lia m
H e n ric o
P o w h a ta n
A m e lia
R ic h m o n d C it y
N e w
K e n t
C h a r l e s C it y
C h e s te r fie ld
H o p e w e ll
C o lo n ia l H e ig h t s
D in w i d d i e
P e te rs b u rg
P r in c e G e o r g e
Slide 21 33
VCC Program
• VCC is NOT an insurance program
• VCUHS partnered with Primary Care
Physicians in the Greater Richmond and
Tri-Cities Communities, as well as the
academic medical center
• Enrollment for first year was 11,000
• All ancillary and diagnostic services
provided at VCUHS and BSR-Richmond
Community Hospital
• All inpatient admissions referred to the
VCUHS and BSR-Richmond Community
Hospital
34
Slide 22
Program Components
• Primary and
Specialty Care visits
• Medications
• Well Child Visits
• Ancillary and
Diagnostic Services
• Family Planning
• Outpatient Services
• Inpatient Services
• VCC does NOT
cover:
– Home Health
Care
– Dental Services
– Elective Services
such as cosmetic
surgery or
sterilizations
35
Slide 23
VCC Patient Utilization Issues
• Utilization of the Emergency Room
for non-acute services remained
high
• VCC population had a lower
average inpatient acuity than other
patients
• 50% of the population enrolled in
VCC remained with the program for
12 months or less
36
Slide 24
Emergency Room Visits for Uninsured:
Reason for Visit
48% of visits could have
been avoided
22%
27%
2%
2%
18%
17%
8%
4%
Visits = 30,273
Not Emergency
Primary Care
Emergency/Avoidable
Emergency/Not Avoidable
Injury
Psych
Alcohol/Drug
Unclassified
FY2002
Slide 25
Emergency Room VCUHS Visits for the Uninsured
Diagnosis
Chest Pain
Abdominal Pain
Sprains and Strains
Back Problems
Upper Respiratory
Infections
Urinary Tract Infections
Headaches/Migraines
Dental Services
Total ED Visits = 30,191
Visits
1,001
1,346
1,567
1,127
%
3.9%
4.9%
7.1%
3.7%
1,131
765
822
1,095
3.7%
2.5%
2.7%
3.6%
Slide 26
39
Jenkins Foundation Care Coordination Model
Community*
Safety Net
Providers
Care Coordinators
Human Services
Agencies
Jenkins Care
Coordination Program
Outreach Workers
*Community = Community
physicians who serve uninsured
patients, community-based Safety Net
Providers and local agencies
Community
Physicians
Nurse
Case Managers
LEGEND
Stand. Op. Procedures
Information System
Communications System
Slide 27
VCC ED Utilization
12000
10000
9956
8160
Visits
8000
7798
7735
6000
4000
2000
0
FY01
FY02
FY03
FY04
Slide 28
41
Classification of ED Visits for VCC Patients
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
FY01
FY02
FY03
FY04
1.6%
1.7%
2.3%
2.3%
18.2%
19.0%
20.5%
20.4%
5.0%
5.7%
6.2%
6.3%
Emergent - Primary Care Preventable
30.7%
34.8%
36.6%
35.0%
Non Emergent
44.5%
38.7%
37.6%
36.2%
Flags Only
ED Care Needed - Not Preventable/
Avoidable
ED Care Needed - Preventable/ Avoidable
Fiscal Year
Slide 29
Bon Secours - Richmond Community
Hospital Partnership
• Richmond Community
Hospital (RCH) is a 100-bed
community Disproportionate
Share Hospital (DSH) that has
excess capacity
• In January 2004, partnership
developed to provide inpatient,
diagnostic, ancillary and
emergency services for the
VCC patients
• Goal is to reduce the overall
cost of caring for the VCC
population by providing care in
a lower cost setting
Slide 30
VCC Today
• Enrollment in FY05 was approximately 17,000
patients
• 31 Community Physicians and 9 Safety Net
Providers participate
• Community partnerships are driving costs
down (primary care visits dropped from $180
to $90/visit)
• In the process of requesting CMS approval to
utilize DSH funds to support the Bon Secours
– Richmond Community Hospital affiliation
Slide 31
Outline
Overview of Healthcare Safety Net
Role of the Academic Medical Center
Partnership Opportunities
OB Dilemma in the Greater Richmond Area
Slide 32
Other Innovative Partnerships
• Richmond Enhancing Access to
Community Healthcare (REACH)
initiatives
• Healthy Community Access Program
(CAP) grant
• The Healing Place – Social
Detoxification Unit
• Richmond City Department of Public
Health - Hayes E. Willis Health Center
• Collaboration with CrossOver Health
Ministries to provide continuity of care for
undocumented pregnant women
43
Slide 33
Collaboration with REACH
• REACH stands for Richmond
Enhancing Access to Community
Healthcare
• REACH is a non-profit organization that
serves as a catalyst for community
Safety Net providers to enhance access
to health care services for the uninsured
and underinsured in the Greater
Richmond Metro area
Slide 34
• Developed a coalition with 9 Safety
Net provider organizations
• Primary goal is to identify mechanisms to
improve access to health care for the uninsured
and underinsured in the region
• Enrollment of undocumented pregnant patients
into Emergency Medicaid
• Collaborating with area providers to develop a
low cost pharmaceutical model for uninsured
• Researching models to improve access to
behavioral health services
44
Slide 35
Healthy Community Access Program
(HCAP)
• With VCU as the fiscal intermediary,
REACH has been awarded over $2.5
million from HRSA
• Funding has been utilized to develop a
web-based program (MOREAccess)to
assist Safety Net providers in financially
screening patients to determine
eligibility for programs such as
Medicaid or FAMIS
Slide 36
47
Greater Richmond Safety Net Health Care Providers
VCUHS
HCA
Bon
Secours
RCDPH
Free
Fan Clinic
Craig
Health Center
Community
Physicians
Vernon J. Harris
Health Center
CrossOver
Ministries
Daily
Planet
45
Slide 37
Vision: Safety Net Health Care Delivery System
Acute Care Providers
HCA
VCUHS
Acute
Patients
Bon
Secours
Acute
Patients
Funding
Support
Free
Community
Fan Clinic Physicians
Funding
Support
CrossOver
Ministries
Vernon J. Harris
Health Center
Daily
Planet
Craig
Health Center
RCDPH
Primary Care Access
Slide 38
52
The Healing Place Social Detoxification Unit
• Partnership established a 6-bed
detoxification unit for patients who were
seen in the VCUHS ER
• Provided an alternative treatment
program for those with a primary
diagnosis of alcohol or substance abuse
problems
• A total of 428 patients were cared for
over a 12 month period
• For a subset of 165 clients, there was a
reduction of 182 ED visits and 16 fewer
inpatient admissions for a cost savings
of approx. $150,000
Slide 39
48
Hayes E. Willis Health Center
• Began as a collaboration between
Richmond City Department of Public
Health and VCUHS in 1993
• Goal was to integrate traditional Public
Health services into a primary care
setting in South Richmond
• Grew out of SJR 179 study that found
there was adequate primary care
capacity, but an unequal distribution of
services
Slide 40
Hayes E. Willis Health Center
• Community-based health center in
South Richmond that offers Family
Medicine, Women’s Health and
Pediatric services
• Center also provides screening and
treatment for STD’s
• Houses the Arthur Ashe Early
Intervention Program
Slide 41
49
Hayes Willis Center Plays a Major Role
• Approximately 4,000 patients with
15,000 annual visits
• Approximately 45% of the patients have
no insurance; another 34% are
Medicaid recipients
• 10% of patients are Hispanic
• In the process of researching federally
qualified health center status
Slide 42
50
Outline
Overview of Healthcare Safety Net
Role of the Academic Medical Center
Partnership Opportunities
OB Dilemma in the Greater Richmond Area
Slide 43
The OB Dilemma
Slide 44
2002 Birth Data for Richmond Metro Area
• Approximately 12,200 births
• Approximately 890 were classified as
“Self Pay”
• It is “guestimated” that approximately
400 of these mothers did not qualify for
Medicaid (“Self Pay”)
• Over 37% of the “Self Pay” births were
for mothers classified as Hispanic
Horan, Stephen, Ph.D., 2002 Birth Profile for Metro Richmond, February 3, 2004
Slide 45
Of the 890 Self Pay Mothers
• Over 36% reported receiving “late”
prenatal care (after the 1st trimester)
• Approximately 13% delivered infants
with Low Birth Rates (as compared to
7.9% for patients with private insurance)
• Over 17% were under the age of 20
Horan, Stephen, Ph.D., 2002 Birth Profile for Metro Richmond, February 3, 2004
Slide 46
Results of 2003 Immigrant Health Needs
Assessment for the Greater Richmond Area
• The greatest health needs for Hispanic and Asian
women were OB/Gyn services and preventative
care
• Between 2000 and 2001, there was a 25% increase
in births for Hispanic women
• Approximately 20% of all Hispanic births
experienced complications during the same time
period
Immigrant Health Needs Assessment for the Greater Richmond Area, August 2003
Slide 47
VCU Health System Issues
• Cost for uncompensated care
for OB patients in 2003 was
approximately $1 million
• Over 200 births in 2003 were to
mothers with no Social Security Number
• Over 65% of the mothers with no SSN were
Hispanic
• Patients who were not U.S. Citizens did not
qualify for the Commonwealth’s Indigent Care
program
Slide 48
REACH Members Identified Issues
• Difficulty making appointments for
prenatal care at area health
departments
• No “free clinics” or FQHC’s in the region
offering service
• Accessing care at VCUHS was
problematic
Slide 49
The Community Responds
• Cross Over Ministry initiated the Healthy Homes
Campaign: Health Care and Education for Mothers,
Babies and Families in 2003
• REACH convened the Access to Perinatal Care Task
Force in 2004
• VCU Health System began developing programs
specifically to support the Hispanic OB population in
2004
• Virginia Premier Health Plan offered transportation to
VCUHS L&D tours for Healthy Homes patients in
2004
• Virginia League for Planned Parenthood began
development of a Prenatal clinic for Hispanic women
in 2005
Slide 50
REACH Perinatal Care Model
ACCESS POINTS
Health department
Safety net providers
Planned Parenthood
Emergency department
Private practices
Community
Initial Screening
& RISK ASSESSMEENT
(Coordinating Agency)
Medicaid Eligible
(Refer to Private Practice)
Low Risk
Perinatal Passport Program
Assigned Care
Coordinator
Assigned OB
Risk Assessment
Clinical, perinatal services
Medicine
Laboratories
Inpatient care (non-delivery)
Care coordination/case management
Specialty care
Interpretation
Transportation
Emergency care
Health education
Family planning
Social Service referrals
Transfer of records to delivery site
Assistance with Medicaid applications
Non-Medicaid Eligible
Due to income or citizenship
(Refer to Passport Program)
High Risk
Assigned Care
Coordinator
Assigned OB
Mom
Delivery Site Identified (Records
Family support (e.g., Healthy Start)
Family planning
Health education
Primary care home
Transferred Pre-Delivery)
BABY
FAMIS/FAMIS Plus
Pediatrician
Slide 51
Estimated uninsured below 2x poverty by zip code
2000 Census
2000 Uninsured and <200% Poverty (Estimated)
2,890 to 5,090 (8)
1,100 to 2,890 (6)
680 to 1,100 (15)
340 to 680 (8)
70 to 340 (9)
Hanove r
I-2
95
I-64
I-1
95
I-95
Che s te rfie ld
He nrico
Richm ond
Colonial He ights
Pe te rs burg
I-85
Slide 52
Perinatal Access Program
• In 2004, the Perinatal Access Program was
piloted with Cross Over Ministry, REACH and
VCU Health System as partners
• Cross Over Ministry developed case
management to enhance services for
Hispanic women
• Volunteer physicians, including faculty from
the VCU Department of OB/Gyn provided
prenatal care and ultrasounds
• REACH Community Health Advocates
assisted patients with Emergency Medicaid
applications
• VCUHS agreed to provide OB services
• Lab Corp provided free prenatal labs
Slide 53
Outcomes
• 367 women have enrolled in CrossOver’s
Healthy Homes campaign since its inception
• Over 200 moms delivered babies at the
VCUHS
• Over 70% of the mothers had their deliveries
covered by Emergency Medicaid
• REACH received a March of Dimes grant to
provide prenatal education classes in Spanish
• VCUHS provides IS link to CrossOver to
access patient discharge summaries
Slide 54
Moving Forward
• Perinatal Access Partnership for NonMedicaid Eligible Women received Honorable
Mention by the National Association of Public
Hospitals and Health Systems for its 2005
Community and Patient Safety Award
• Virginia League for Planned Parenthood has
implemented a prenatal program for Hispanic
women utilizing the same model
• VCU Center of Excellence in Women’s Health
is researching opportunities to apply for
national grants to support this partnership
Slide 55
Conclusion
• The role the Academic Medical Center
plays is critical in a Safety Net System
due to the resources (financial, human,
clinical) available
• Communities in Virginia continue to
create opportunities to enhance access
to care for the Uninsured
• Providers in the Greater Richmond
Metro area are partnering to develop a
Safety Net Health Care Delivery System
51
Slide 56
“University-based urban
academic medical centers….
function most
effectively and for the greater good
when their care is a complement to,
and not a substitute for,
community health care providers.”
Hill, Laurence and Madara, James, “Role of the Urban Academic Medical Center in US Health Care”,
Journal of the American Medical Association, November 2, 2005 – Vol 294, No. 17, p.2219.
Slide 57