Transcript Program - Jacksonville Sheriff`s Office

Kenyatta Lee, MD
Medical Director , Community Affair Department
University of Florida/Shands Jacksonville
Disparities:
Now You See Them,
Soon You Won’t!
Objectives
• Overview of Shands and the History of the
Community Affairs Department.
• The Perfect Storm
• Exciting Time to be in Ambulatory medicine
• The Bridge – EHR, Northside Virtual Healthcare
Model (Virtual Community Disparity Network)
• JUDI's unique Qualifications
• The Plan
• Priorities
Historical Overview
Community Affairs Department, 1989-Present
• Elizabeth Means, VP established the department to
address unmet medical needs in underserved communities
• The initial goal was to provide health education, health promotion,
and community outreach in targeted communities
• Programs are primarily funded through grants, strategic
partnerships, faith-based organizations and community support
• The goal has expanded to provide free and
reduced comprehensive health care to the
medically underserved in the urban core.
The Perfect Storm…for health disparities
•
•
•
•
•
•
•
•
•
•
•
Population
Gender
Adolescents ages 10-19
Adult ages 20-64
Senior adults 65 and older
Race
Median family income
Children below poverty level
Percent of population below poverty
Unemployment
Uninsured
•
Leading health disparities health zone of the 6 health zones in Jacksonville and Duval County,
Florida, in cancer, strokes, diabetes, HIV/AIDS, teen pregnancy, STD’s and infant mortality.
-
*(Parentheses denote figure for Duval County, Florida.)
127,512 (850,251)
53% female (48.7%)
15.9% (14.2%)
55.8% (61%)
14.5% (10.7%)
83% African American (29%)
$28,307 ($44,740)
38.4% (15.4%)
28% (11.9%)
9.9% (4.8%)
45% (9%)
Community Affairs Department
“Community Responsive Medicine”
Medical Director
Consultant
Vice President
JUDI
Clinical Programs
Free Script
Community Programs
Heal Thy
People
Little
Miracles
D-RAP
Shop Talk
REACH
HY-LIP
Healthy
Start
Virtual Community
Disparity Network
Proposed
Clinics
Disparity
Hybrid
Traditiona
l
Health
Fairs
MRA
HIV/AIDS
Sickle Cell
Brown Bag
CARE
Grant Writing
PQRI
Durkeeville
Brentwood
Paxon
Soutel
Eastside
Murray Hill
C. B.
McIntosh
Wellness
C. B.
McIntosh
Pediatric
College
Park
Hep. C
Anti-Coag
Renal
Delta Care
Hispanic
Initiative
Women’s
Health
Initiative
Case
Management
Childhood
Obesity
Disease
Mgmt.
Case
Mgmt.
Soutel
Winn Dixie
Was formed to help reduce health
disparities identified by the US center of
Disease Control and prevention that
adversely impact low socioeconomic
individuals in Jacksonville and Duval county
recently acknowledge by AMA as a major
problem and concern for the nation.
Goals are:
A. Promoting health care
B. Educating the general public and
medical community
C. Exploring scientific and related
charitable purposes
D. Proposed Virtual Community Disparity
Network
Issues on the
Horizon that could
have a devastating
Impact on the
Urban Core
PQRI P4P MRA
Healthcare Bubble
“Healthcare Bubble?”
Who will be most affected?
•
Individuals
a) Much like the housing BUBBLE those individuals on the lower
end of the economic spectrum are the most likely to be affected
(Urban Core – Jax Healthzone 1)
b) Will access to care be affected?
•
•
•
•
Health insurance
Medications
Physicians
Providers
– The Governments response to the BUBBLE seems volitional
(EMR, EHRs, MRA and performance based reimbursement)
and will become mandatory. Those institutions/physicians that
are unable to adapt rapidly to the changing healthcare
environment will be vulnerable.
“Healthcare Bubble?”
• When the “healthcare bubble” bursts, is it
perhaps better to be Ford than GM?
• It is JUDI's mission to develop
mechanisms (Virtual Community
Disparity Network) that allow us to
position urban core patients and
physicians to bridge the void and prepare
for a worse case bubble scenario.
Chronic Disease Crisis
“According to the Centers for Disease
Control and Prevention (CDC), chronic
diseases are responsible for”
– seven out of every 10 deaths in the United
States
– 75 percent of the more than $2 trillion dollars
spent each year on health care in the United
States.”
WHY Chronic Disease Crisis?
1) Provider disconnect:
a. Apprehension by PCP to see patient more than once a month and
specialist more than 2 times per year.
b. Fear of presumed perception of churning by payor and patient
c. Hesitancy to treat if not at goal and will attribute diseases not to goal
to patient issues (non-compliance)
d. Provider hesitancy to adopt electronic medical records which is key to
managing and addressing medical disparities (Journal Watch-Aug.
08). Benefit does not justify expense.
2)
Patient disconnect:
a. Lack of trust that disease is life threatening or is of eminent cause of
morbidity
b. Lack of funds
c. Presumed system (provider) is churning for financial gain
Proposed Models of
Chronic Disease Care
• Proposed models: Chronic Care Model
(CCM), Future of Family Medicine (FFM),
Medical Home Model (MHM).
• Regardless of what you ultimately call this
(CCM, FFM or MHM) a new model of chronic
care must emerge.
• Regardless of the model it will take 2-3 years
for a system to mature and for us to begin to
see improvement.
Pay for Performance (P4P)
Implications for the Urban Core
• Pros
– Improved systems Virtual Community Disparity
Network
– The light will be focused on disparities
• Cons
– Medical Darwinism
– Margins are tight
– Barely Funded Mandate (presently reward does
not justify the expense).
PQRI and MRA
Physician Quality Reporting Initiative (PQRI)
• On December 20, 2006, President Bush signed the Tax Relief
and Health Care Act of 2006 (TRHCA).
• Division B, Title I, Section 101 of the TRHCA authorizes a
financial incentive for eligible professionals to participate in a
voluntary quality reporting program.
• Schedule and report on a designated set of quality
measures… may earn a bonus payment of 1.5% of their
charges during that period, subject to a cap.
PQRI and MRA
• Medicare Risk Adjustment (MRA) is the
payment methodology mandated by the
Balanced Budget Act of 1997.
• It is used by the Centers for Medicare &
Medicaid Services (CMS) to improve
payment accuracy to Medicare Advantage
(MA) organizations.
PQRI and MRA
• CMS makes funding and other program decisions
based upon the accuracy of the information that MA
organizations supply to CMS. Risk adjustment helps
to improve the accuracy of that information.
• Consider installing an electronic medical records
(EMR) system.
• Talk to CMS about medical coding training for your
office staff.
• Check Web sources for medical coding assistance.
"Americans can always be counted on to
do the right thing (Virtual Community
Disparity Network)...after they have
exhausted all other possibilities.”
[Winston Churchill]
The Bridge – Virtual Community
Disparity Network
• Community Affairs Department will
use its leverage to assist physicians
in the transition to incorporate
performance based medicine and
the MRA initiative.
• We believe that it is essential that
we maintain the diversity of
providers in the urban core.
• That we determine our own destiny
and not be dependent on others.
Virtual Community
Disparity Network
What's the plan?
Disparity centers which through the Virtual Community
Disparity Network offers:
•
•
•
•
•
No charge to patients regardless of ability to pay
Disease Management
Chronic Disease Registries for the providers
Community Programs
PQRI registries to all participating providers that can be submitted for improved
reimbursements
 Confidentiality bound by the IRB and HIPPA from sharing using information in a way
different from that then that outlined
•
•
•
•
•
•
MRA support and advice
Provide computer access
E Prescribe
Access to free scripts
Infrastructure to adjust to the dynamic market place
Levels the playing field for America’s Urban Core vs. more affluent areas
• What uniquely qualifies JUDI for this
responsibility?
• Lets talk:
– Community Programs
– Clinical Programs
– Clinics
Community Programs
•
•
•
•
•
•
•
Shop talk
Little Miracles
Healthy Start
Ryan White
Sickle Cell
Brown Bag Luncheon
Women’s Health
Initiative
•
•
•
•
•
•
Hep. C Screening
Hispanic Initiative
Health Fairs
Heal Thy People
Case Management
Childhood Obesity
Program: Shop Talk
• Shop Talk: The Touch of Life is a program dedicated to increasing
breast cancer awareness and promoting optimal breast health for
women in Duval and surrounding counties.
• Health educators go into beauty salons, with learning materials and
videos, to teach self-exam techniques
• 2,689 customers reached in 2008
• Self Testicular and Self Breast Examination Education
• Quarterly Breast & Cervical Cancer Luncheons
Program: Healthy Start/Little Miracles
• Healthy Start Program was started at
Shands Jacksonville in November 2001.
• Little Miracles began in October 2000 by
Shands Jacksonville in an effort to make
a difference in the alarming increase in
infant mortality in Duval County.
2008 Statistics
• Healthy Start Face to Face Encounters
– 10,368
• Little Miracles Enrollments - 5,212
• Little Miracles Deliveries - 3,160
Program: Ryan White Title I
• This program was implemented March 1999
funded by Federal HRSA grant focus to decrease,
navigate and educate the large volume of persons
living with HIV/AIDS that were utilizing the ER as
their primary care into medical clinics that
specialized in HIV/AIDS.
2008 Statistics
• Over 1,600 patients were served
Program: Sickle Cell
Community Partnership and Public Support
• Sickle Cell program expanded to include adolescent, adult and
traits.
• Sickle Cell Disease and Trait Seminar 2007 – 103 participants
• Sickle Cell Walk-a-Thon 2008 – 310 participants
• Sickle Cell Health Symposium and reception
2008 – 286 participants
• 116 customers were reached in 2008 with
education
Program: Brown Bag Luncheon
Background
• Developed in response to the overwhelming need to
increase compliance and decrease morbidity
secondary to medications
• Targets seniors many of whom take on average of 5
medications daily
• Seniors meet daily at more than 20 local sites
• Meets monthly
2008 Statistics
• 199 customers were served
Program: Hep. C Screening
Goal:
– Provide health education and public information (HCV) for
2,000 or more individuals in Jacksonville, Duval County
– To complete HCV testing for 500 or more ILA, Inc
members
• Aug. 2007, Shands Jacksonville Eastside Family Medicine
Center initiated the Hepatitis C project with the International
Longshoremen Association (ILA) Inc
• The project was funded by Roche Pharmaceuticals, Inc.
• 2008 screened 171 customers from the ILA population
Program: Hispanic Initiative
• Health fairs at Hispanic Churches
• Third Sundays
• Serving the Hispanic populations of Duval County
– *2006 total Hispanic population 57,765 (6%)
– *Anticipated growth rate for 2010 - 76,894
• 703 customers were reached in 2008 with education and health
screening
* Florida Statistical Outlook – 2007; Bureau of Economic and Business Research
University of Florida, Gainesville, FL.
Program: Health Fairs
• Free health screenings provided to all participants
• Screening for:
• High Blood Pressure
• Diabetes
• High cholesterol
• Disease specific education handouts
• 2008 Back to School Rally and Health Fair Statistics:
• 1,000+ total participants
• 2,200 backpacks filled with school supplies given out
• 508 Physicals
• 214 Immunizations for children
• 101 Adult Health screenings
• 8,630 customers reached with education/health
screening
P. Riley, RN
Program: HealThy People
 Heal Thy People Health Sunday rotates churches every 3rd & 4th
Sunday for health education by a physician and health screening
makes great fellowship.
 Other churches are involved in Saturday health fairs
 Quarterly newsletters chock full of information go out to participating
churches
 The initiative builds trust, removes barriers, educates and
collaborates with pastors and other community stakeholders
 More than 1,361 customers were
reached in 2008 with education
and health screening
Program: Case Management
 Began May 2005
 Bi-annual review of ER encounters for the uninsured to identify those that
make the ER their primary care home and redirect them to a more appropriate
setting (Eastside, Brentwood or Disparity Clinic).
 Number of Patients Converted from Uninsured to Insured 2005 - 2008
Eastside and Brentwood Combined – 4,378
 There are 4,330 patients in the program of which there were 83 new patients
January 2009
*NOTE: After eliminating out of county, there is an 80% success rate of in county conversions.
 Number of Patients with funding sources found:
2007
2008
City Contract
512
389
Medicare
17
27
Medicaid
193
131
Commercial
66
41
Program: Childhood Obesity
• Scientific common sense approach to Childhood
metabolic obesity
• Recently acknowledged by ACP (American College
of Pediatrics). They have recognized that Metabolic
Syndrome is a major cause of Childhood Obesity
• Reducing Childhood Obesity through early
identification of DM, Hy-Lip, Thyroid disease and
dietary consult
• Labs being reviewed for Metabolic Syndrome i.e.
Lipid Profile, Glucose, Hypertension and Thyroid.
Clinical Programs
• D-RAP
• Pharmacy/Anti-Coag
• REACH
• Free Scripts
• HY-LIP
• Renal
• CARE
• Delta Care
DIABETES RAPID ACCESS PROGRAM
THE DISEASE
MANAGEMENT PROTOTYPE
• Historically started with A1c > 9.0 since the inception of the
program all diabetics are in the D-RAP program
• Educated concerning diabetes and lifestyles changes
• Assessed as to whether or not they are taking medication or
can afford medication/co-pay
• We use long acting long acting insulin and generics.
• The patient is an active participant in the program
• Patients are assessed each visit through PQRI and outliers
are followed-up by the nurses in disease management
Results:
• Program began in June 2006 with study group of
300, average A1c - 11.0
• 11 months into the program average A1c - 8.5 at
which time all diabetics enrolled
• 265 letters sent for month of January 2009
• Seeing a fast growing population of UF nonCommonwealth patients
D-RAP
Start long
acting insulin
A1C >= 8.0/
glucose>200mg/dl
fasting
Follow-up every 2-3
days
A1c checked every
3 mnths
Short acting
insulin before
meals
NC w/multiple
injections
add Januvia
increase Lantus
Metformin (start at
500mg – qd
(max)/Education
No
Add Symlin/Januvia
Short acting insulin
(? Covered)
BMI >= 40
Waist circumference
Female >= 35
Male >= 40
Review lifestyle
changes
Continue
f/u
Review
barriers
Cost an
issue
Life Style
Changes
A1c <= 8.0/
fasting < 150
Yes
Follow-up
every 2-3 days
Freescript
pgm.
Taken meds
as ordered
A1c checked
every 3 mnths
A1c <= 7.0/fasting <
110
glucose <150 fasting
Yes
No
Edu.
No
yes
Continue
to f/u
add Januvia ( ? Covered)
BMI = 40
Waist cir.
female >= 35
Male >= 40
Not covered
consider insulin
Diabetes Spreadsheet
DM TRACKING
Patient name
RESULTS AT START
Date of
Birth
SEX MRN
Date
A1C LDL CK
ABRAHAM,FRANCISCA 24-Oct-52
F
1335382
9/10/07
6.9
103
ADAMS,RANDY
1-Jan-66
M
754699
4/23/08
6.2
218
ALLEN,LENORA
21-Nov-48
F
624164
8/24/06
6.2 N/D
ALVIN,NELLIE
27-Mar-33
F
3402106
6/5/08
13.3
134
AUSTIN,CHARLENE
18-Jan-58
F
640401
10/22/07
8.4
111
BANKS,MICIAH
15-Jun-66
M
101307
5/7/08
6.0
139
BARTLEY,JAMES
16-Feb-60
M
9373
9/29/07
15.3
BARTLEY,STEVE
22-Jun-60
M
615467
12/15/06
BENTON,JOANN
27-May-50
F
194254
BESHEARS,JOE
6-Sep-46
M
BLUE,JUNE
18-Feb-30
BOSTIC,JANICE
BROOKINS,ORSIE
1st RESULTS AFTER START
Date
A1C LDL CK
2nd RESULTS
Date
A1C LDL CK
1/14/08
7.9
124
6/19/08
7.4
2/8/07
6.7
127
6/13/07
7.4 N/D
2/19/08
8.4
114
6/23/08
7.4
104
138
3/27/08
6.8
149
14.4
163
2/13/07
11.2
141
7/17/07
10.5
111
6/30/08
6.7
170
580352
1/18/08
8.7
96
7/7/08
8.4
80
F
182430
10/26/07
11.9
127
3/31/08
7.2
137
7-Apr-53
F
317714
5/9/08
8.8
100
15-Aug-21
F
66693
6/26/07
Averages
7.0 N/D
9.2 136
8/3/07
Averages
9.3 N/D
8.2 125
12/20/07
Averages
140
6.4 N/D
7.8 118
AVERAGE A1C RESULTS
12.0
10.0
11.0
8.6
8.0
8.8
8.4
6.0
4.0
2.0
0.0
1st Avg.
2nd Avg.
3rd Avg.
4th Avg.
*NHANES III A1c Avg. – 7.7
Average A1C Result Per Office
10.0
9.0
8.0
7.0
6.0
8
8
. 8
. 7 7
9 .
3 2 . .
9 7
5.0
7
7 7 7
7
.
. . .
.
9
6 4 4
3
8
8
. 8
.
6 .
1
1
7 7
. .
9 9
8
7 7
.
. . 7 7
1
7 5 . .
3 1
8 8 7
. . . 7 7
2 0 9 . .
8 7
8
7
7 7
. 7
.
.
. .
0
5 5 3
4
Murray Hill
Paxon
Soutel
4.0
3.0
2.0
1.0
0.0
Brentwood
College Park
Baseline
Eastside
First
Second
Third
Fourth
National A1c Average – 7.7
Eastside Family Medicine, OB/GYN & Pediatric Center
Average A1c Range
50.00%
46.30%
45.00%
40.90%
38.40%
40.00%
35.00%
30.00%
34.70%
33.70%
31.60%
37.40%
34.10%
36.70%
33.00%
32.10%
28.50%
26.10%
24.90%
25.00%
21.60%
7-9
20.00%
>9
15.00%
10.00%
5.00%
<7
Total Pts - 297
Total Pts - 237
Total Pts - 182
Total Pts - 134
Total Pts - 88
0.00%
Baseline
First
Second
Third
Fourth
Brentwood Primary Care Center
Average A1c Range
60.00%
52.50%
50.00%
39.10%
40.10%
40.00%
30.20%
30.00%
30.70%
39.60%
32.90%
32.40%
31.80% 28.10%
40.00%
28.00%
<7
30.00%
27.10%
7-9
>9
17.50%
20.00%
10.00%
Total Pts - 212
Total Pts - 157
Total Pts - 111
Total Pts - 70
Second
Third
Total Pts - 40
0.00%
Baseline
First
Fourth
College Park Primary Care
Average A1c Range
60.00%
50.00%
56.20%
46.60%
40.00%
48.60%
48.00%
45.30%
38.50%
37.40%
32.40%
29.10%
30.00%
28.50%
7-9
24.30%
20.00%
16.20%
>9
19.00%
15.30%
14.60%
10.00%
Total Pts - 206
Total Pts - 192
Total Pts - 171
Total Pts - 148
Total Pts - 130
0.00%
Baseline
<7
First
Second
Third
Fourth
Murray Hill Family Practice Center
Average A1c Range
57.30%
60.00%
47.80%
50.00%
44.40%
42.20%
41.00%
40.00%
32.60%
36.20%
39.60%
36.70%
28.20%
30.00%
7-9
26.40%
19.40%
20.00%
18.20%
>9
15.50%
14.50%
10.00%
Total Pts - 488
Total Pts - 412
Total Pts - 346
Total Pts - 289
Total Pts - 234
0.00%
Baseline
<7
First
Second
Third
Fourth
Commonwealth Family Practice at Paxon
Average A1c Range
50.00%
45.00%
45.90%
43.50%
42.30%
41.60%
39.40%
40.00%
35.00%
30.00%
34.30%
33.40%
33.10%
30.60%
29.90%
27.50%
26.60%
25.00%
24.10%
24.30%
23.50%
7-9
20.00%
>9
15.00%
10.00%
5.00%
<7
Total Pts - 573
Total Pts - 455
Total Pts - 397
Total Pts - 338
Total Pts - 268
0.00%
Baseline
First
Second
Third
Fourth
Soutel Plaza Family Practice
Average A1c Range
45.00%
42.00%
44.80%
40.00%
35.00%
47.70%
50.00%
50.00%
43.40%
41.70%
40.20%
38.40%
36.90%
35.60%
30.00%
25.00%
<7
22.40%
7-9
20.00%
15.00%
15.40%
14.90%
15.00%
11.60%
10.00%
5.00%
Total Pts - 295
Total Pts - 261
Total Pts - 235
Total Pts - 190
Total Pts - 149
0.00%
Baseline
First
Second
Third
Fourth
>9
Review Evaluate And Control Hypertension
Disparity Program: REACH
• Disparity Centers used for monitoring and modification of
treatment
• Medication assistance provided
• Pharmacist routinely review medication protocol
• Disease specific education
• Patients contacted via letter/phone
• Registry – > 7,000 for quarterly evaluation by Physicians
Results
•
•
•
•
400 letters sent for the month of January 2009
City Contract patients - 1,477
FCA patients - 370
Humana patients - 1,173
REACH
Pharmacist
Systolic > 140
Diastolic > 90
Life Style
Changes/ Review
barriers and labs
HCTZ
ACE
Calcium Channel
Blocker
ARB
Alpha Blocker/
Beta Blocker
Tekturna/Other
Renal
Hypertension Spreadsheet
PATIENT PROFILES (HYPERTENSION)
Wellness
PATIENT PATIENT PATIENT PATIENT
NAME MRN NUM.
Bailey, Elizabeth3387976
Elphyles, Timbuk
13454655
Mack, Eugene 1520326
Davis, Bettie 1222651
Baggett, John11792286
Autry, Mary 81370
Andrews, Alice 1323458
Alvin, Nellie 34021066
Holmes, Wil ie 2317052
Kierce, Kelvin 7082258
Jones, Katrina 8765375
Morgan, Cyntia91216876
Nelson, Eva 12181035
Summers, JoAnn
13589399
Vickers, Tina 5291666
DOB SEX
04/30/1958 F
12/04/1945 M
06/09/1952 M
01/09/1947 F
05/11/1945 m
03/14/1965 f
04/12/1949 f
3/27/1933 f
01/20/1941 M
7/14/1957 M
12/22/1978 F
09/21/1954 F
10/18/1951 F
11/28/1945 F
10/07/1962 F
RESULTS AT START
Date
5/22/08
2/28/08
8/23/07
3/17/08
2/5/08
8/15/07
1/31/08
6/4/08
2/1/08
5/29/08
4/3/08
4/8/08
3/10/08
5/16/08
4/9/08
1st RESULTS AFTER START
Systolic Diastolic
BP
BP
Date
183.0
161.0
188.0
179.0
203.0
222.0
197.0
229.0
182.0
175.0
166.0
166.0
200.0
211.0
170.0
75
98
103
72
99
125
113
104
91
97
91
99
102
110
95
5/30/08
3/3/08
9/20/07
3/31/08
2/11/08
8/29/07
4/18/08
6/6/08
2/7/08
5/30/08
2nd RESULTS
Systolic Diastolic
BP
BP
Date
170
149.0
197.0
181.0
171.0
190.0
140.0
188.0
190.0
148.0
87
71
115
68
96
107
92
78
88
82
5/30/08
3/11/08
10/4/07
4/2/08
2/18/08
8/30/07
4/22/08
6/9/08
2/14/08
6/2/08
MEDICATION
Systolic Diastolic
BP
BP STATIN
149
70
145.0
78 lipitor
186.0
95
147.0
67 vytorin
149.0
84 lipitor
167.0
76
146.0
84
152.0
70
157.0
81 N
134.0
71
POD OPTHAL ENDO
RECENT
BUN /
ARB / ACE ASA
none (Pletter81sent)mg
lisinopril 81 mg
hyzaar
altace n
lisinopril n
diovan
none (Pletter sent)
PHYSICALMICROALBUMINCREATINE
pending pending pending 08/2006 06/2006
10
pending pending pending
10/2006 11/2006
11/2006 11/2006
pending pending pending
8.8
0.8
11/2006 11/2006 11/2006
10/2006 10/2006
10/2006 10/2006
pending pending pending
07/2005 05/2006
Diovan 81mg
pending pending pending
6/2/08
111.0
137.0
59
75
6/5/08
140.0
82 lipitor
altace
altace
lisinopril y
4/11/08
121.0
73 4/15/08
107.0
52 vytorin
hyzaar
N
07/2006
06/2006 06/2006
09/2006 01/07--15/1.0
12/06--30/1.6
02/2006 09/2006 09/2006 05/2006 11/2006 11/2006
HYperLIPidemia
Disparity Program: HY-LIP
Background:
• Recognized as a significant risk for morbidity and
mortality
• Decreasing risk of heart attack and stroke by lowering
LDLs
Methods:
• Monitor all labs for elevated lipids and triglycerides
• To include women of child bearing age with LDL > 100
• Guidelines based on NCEP/ATP III
HY-LIP
Trig > 200
LDL > 100
Yes
Life Style
Changes/ Review
barriers and labs
No
Female of child
bearing age
LDL > 100
Questeran
LDL > 100
Endocrinologist
Yes
No
Zocor
Trig > 200
Lipitor
Tricore
Zetia
Endocrinologist
Endocrinologist
Disparity Program: HY-LIP
AVERAGE LDL RESULTS
200
180
160
181
140
137
120
100
80
60
40
20
0
HY-LIP
1st Avg.
2nd Avg.
HY-LIP Spreadsheet
PATIENT PROFILES (HYPERLIPIDEMIA)
wellness study
PATIENT
PATIENT PATIENT PATIENT PATIENT phone call
Patient 1st Lipid Result
Triglycerid
e
NAME
MRN# DOB
SEX PCP PHONE CALL Date LDL
Adorno, David * 91232537 07/16/1958 M Stewart c 7/07
11/2006
204
163
Anderson, Diana 5827442 09/07/1949 F Day
c 7/07
11/2006
171
556
Arnold, Niieman 2601079 02/27/1977 M Registre c 7/07
12/2006
184
226
Arthur, Kim Marie * 5747201 08/09/1967 F Pratt
04/2007
192
130
Ashton, Floyd 91344882 08/04/1936 M Day
l--7/07
10/2006
176
359
Bailey, Shenekia 313956 08/31/1979 F Jerome l--7/07
02/2007
205
115
Baker, Doris
706690 02/08/1949 F Gajda c 7/07
01/2007
165
56
Baker, Lil ian
9959807 05/27/1943 F Day
c 7/07
11/2006
152
102
Bartley, Steve
6154671 06/22/1960 M Jerome
10/2006
153
302
Baxter, Lincoln * 1515497 10/08/1971 M Najafi
03/2007
192
204
Hodges, Mildred 432768 04/29/1962 F Day
c 7/07
10/2006
151
812
Hoefling, James 12813597 04/22/1963 M Day
c 7/07
09/2006
171
261
Holly, Wil iam * 13128839 09/29/1970 F Day
03/2007
176
372
Patient 2nd Lipid Result
PATIENT MEDICATIONS
PRIMARY
Triglycerid
e
Date LDL
statin zetia questran niaspan fish oiltriglyceride agent
INSURANCE
04/2007 136
86 y
Vytorin 10/20
Medipass
06/2007 136
531
Zetia 10
Medicare
y
Lipitor 40
SP
07/2007 113
167
02/2007 153
375
Zetia 10
Humana
n
n
n
n
n
Medicare
07/2007 118
87 y
Lipitor 40
Medicare
09/2007 151
152 n
n
n
n
n
CC
02/2007 111
227 y
Lovastatin 40
Medicare
07/2007 285
224
Simvastatin 80, Pravastatin 40 SP
n
n
n
n
n
CC
06/2007
27 1268
COPD/Asthma and Respiratory Enhancement
Disparity Program: CARE
METHODS:
 To assist patients to achieve and maintain optimal lung function with
effective control of COPD/Asthma based on 2007 GOLD and GINA
guidelines
 To decrease mortality and morbidity associated with COPD/Asthma
 To Education patients regarding COPD/asthma
 To assure appropriate, safe, and cost-effective treatment strategies
are provided to patients
RESULTS:
 Currently 251 patients enrolled in CARE Program
CARE
Baseline
Baseline
Asthma
COPD
PCP Clinical
Spirometry/PFTs/
Spirometry/PFTs/
Assessment/Diagnosis
Classification of Severity
Classification of Severity
Initiate Treatment
Initiate Treatment
A.
B.
C.
A.
ICS/LABA
LTRA
SABA
B.
C.
D.
E.
Nebulizer Tx;
repeat Spirometry
ICS/LABA
LTRA
SABA
LA AM/AC RB
Monitor Response
Patient
Education
Document encounter
/results in Allscripts
& forward to PCP
Abbreviation Key:
ICS/LABA: inhaled corticosteroid/long acting beta-2 agonist
LTRA: leukotriene receptor antagonist
SABA: short acting beta 2 agonist
LA AM/AC RB: long acting amtimuscarinic/anticholinergic receptor blocker
Patient
Education
Disparity Program: Anti-Coagulant Clinic
Pharmacy
• Pharmacy clinic at Soutel Wellness Clinic on
Thursdays
• Patients INR done at Disparity Clinics
• No co-pay
• Follow-up visit at Soutel Wellness with Pharmacist
• Letter sent for patient to be seen at Soutel Wellness
• Number of Patients Seen in the Coumadin Clinic - 209
FREE SCRIPTS
FREE SCRIPTS
•
•
•
•
•
•
•
Part of JUDI Disparity Clinic System: No Cost Access
to Medical Care
Part of JUDI Disease Management: No Cost
Screening and Medication Management
Patient given No Cost/free generic or negotiated
brand medications
Takes pressure off patient concerning financial
priorities “Do I buy meds, gas or food?”
Gains patient trust
Increases patient compliance
Decreases ER and Hospital encounters
Program: Free Script
Results:
• To date, greater than 10,000 prescriptions have been
filled.
• Patients in program – 418
Future Initiative:
• Negotiation to expand the Free Script program with
Winn-Dixie/ILA (done)
Data Management
Registry Specialist
• PQRI Initiative
• MRA Initiative
• Health Maintenance Notification
Communication to Patient
Addressing Areas of Disparities
• Letters are mailed on a continuous basis for patient to come
in and follow-up on labs and PCP visits
• Patient on registry are assessed quarterly through the registry
program
• Forms go to Registry Specialist to enter data into the
registries
• 2,492 letters were sent for the month of January 2009 for
Health Maintenance
• Approximately 710 letters sent to patients concerning
abnormal labs for the month of January 2009
Diabetes PQRI Form
PHYSICIAN'S PQRI DATA COLLECTION SHEET - DIABETES
PATIENT NAME:
PROVIDER:
DATE:
MRN:
A1C
A1C – Patients aged 18-75. Report with 99201-99215, 99341-99350, 99304-99310, 99324-99337, G0344.
Report at least once per reporting period.
Measure & result
Actual Last Value Date of Last Value
Most recent A1C level within 12 months <7.0%
Most recent A1C level within 12 months 7.0% to 9.0%
Most recent A1C level within 12 months >9%
A1C not performed within 12 months, reason not otherwise specified
Code
3044F
3045F
3046F
3046F-8P
CREATININE LEVEL:
TODAY'S GLUCOSE READING
LABS DRAWN:
YES ___________ NO _____________
A1C ____________ LIPID ___________ CREATININE _________
LABS SENT TO: SHANDS _________QUEST ________ LABCORP ________
SHANDS JACKSONVILLE
655 W. 8TH STREET
JACKSONVILLE, FLORIDA 32209
Chief Complaint
• Patient is here for BP check-up, glucose check-up.
PCP is Dr. Reluctant.
Vital Signs
Recorded by bmarcus on 09 Sep 2008 03:29 PM
BP: 158/100, LUE, Sitting,
HR: 76 b/min,
Height: 68 in, Weight: 240 lb, BMI: 36.5 kg/m2.
Assessment
• Benign essential hypertension (401.1); on HCTZ- 25mg
• Diabetes mellitus (250.00); A1c– 3/08– 11.0 due 6/08
Accu-Check
Fasting: 230mg/dl
denies hypoglycemia
Fasting whole blood sugar glucose reference range: 60-99mg/dL
Notes
Are you having trouble getting your medications? No
Are you taking your medications daily? Yes
Have you been to the ER? No
Have you had any low blood sugars? No
When is your next scheduled visit with your provider? appointment next week with PCP
Coun/Edu
Patient is made aware of the importance of monitoring HgbA1c every three months, having a yearly
dilated eye exam, checking feet regularly for damage to the skin, monitoring cholesterol, seeing an
endocrinologist yearly and maintaining a diet consistent with diabetes care.
discussed results of A1C, to return for labs
Teaching re: Hypertension, accurate monitoring includes daily BP check by viable tester, nurse,
health care provider, fire department to be taken same time each day. Documentation card to
patient. Agrees to return in one week for re-evaluation.
Plan
Decrease salt intake
Check blood sugar twice a day at different times regularly and bring log to next appointment.
Discussed with patient how to take medication prescribed.
Reviewed medications, bottle dated within 30 days
Patient:
MRN:
APPLE TEST
13650730
Encouraged patient on medication compliance.
Return in 3 days.
F/U with PCP at appointment next week
denies dizziness or headache. Instructed pt to go to ER or call PCP if he should start having symptoms
consider adding ACE
consider increasing Lantus to 25units nightly
Signature
Signed By: Bobbie Marcus ; 09/09/2008 3:58 PM EST.
Other Providers
# of
Providers
# of
Patients
Diabetes
66
88
DCHD – 2
VA CLINIC – 6
Hypertension
74
115
DCHD – 1
VA CLINIC – 6
VOLS IN MEDS – 2
Hyperlipidemia
6
6
Program
Provider not specified
(# of patients)
Clinics
• Improved Access
– Strategically located throughout the Urban Core
– Flexible hours of operation
– Same day Walk-ins
• Disparity clinics have access to Electronic Medical Record System
(Allscripts) (Virtual Community Disparity Network – proposed)
• Disparity clinics have access to the Shands Hospital’s Electronic Medical
Record System (Portal)
• All clinics have access to Case Management
• Participating clinics have access to our Registry Specialist.
• Office MAs send PQRI forms to clinic for registry and actions.
• Hispanic based system available.
JUDI-affiliated clinics and programs reflect the major
causes of morbidity and mortality in Jacksonville, in both
purpose and location.
5
Disparity
Hybrid
32 2 1 8
Traditional
Winn Dixie (Coming Soon)
32 2 1 9
Soutel
Wellness
322 08
Durkeeville
Shands
322 09
32 2 7 7
Soutel
2 2 2College
0
Park
322 54
1
322 04
322 06
322 02
Commonwealth
Murray Hill
Eastside
32 2Brentwood
11
C.B.
McIntosh
32 2 0 5
32 2 0 7
2
Hybrid Clinics
Eastside
Brentwood
C.B. McIntosh
• Provides care for both uninsured
and insured patients.
• Decrease inappropriate utilization
of ER as source or primary care.
– Hospital discharges
– ER discharges
• Pediatric patients
• Total encounters for FY08 – 12,528
Eastside
 Opened: September 2003
 Location: 1155 East 21st Street
 Services:
 Adult Medicine
 Pediatrics
 Obstetrics and Gynecology
 Providers: 2
 FY08
 Patient visits – 8,439
 Special programs:
 Case Management
 Free Script
 HIV Clinic
 ER/hospital discharge - safety net
 Opened: June 2007
 Location: 3465 Village Center
Drive
 Services: Adult Medicine
 Providers: 1
 FY08
 Patient visits 3,333
 Special programs:
 Case Management
 Free Script
C.B. McIntosh Pediatric Center
• Sickle Cell Services
– Patient visits FY/08 - 756
– Pediatric Services
– Adolescent Services
– Transition Program
– New Sickle Cell Trait Initiative
• Pediatric Service – 5/07
– Center for uninsured
Paxon
• Located in zip code 32254
• FY08 Patient visits - 16,287
Soutel Plaza
• Located in zip code 32208
• FY08 Patient visits – 6,485
Traditional Clinics
College Park
• Located in zip code 32209
• FY08 Patient visits - 5,612
Murray Hill
• Located in zip code 32205
• FY08 Patient visits – 12,820
Total encounters for FY08 – 41,204
THE NUMBER OF WALK-INS FROM THE
COMMONWEALTH GROUP.
College Murray
CB
2008 Paxon
Park
Hill
Soutel Eastside Brentwood McIntosh
March
805
70
174
78
243
74
6
April
929
73
106
61
214
68
3
May
994
77
110
43
287
106
3
Total 2,728
220
390
182
744
248
12
Registry Impacting ER Utilization
• Query of the non-emergent uninsured
encounters from the Shands ER population
• 4,075 Patients sent letter offering a Community
Affairs Clinic as an alternative
• Number of Uninsured Patients Sent from Shands
ER and patients discharged from hospital
between 2005 - May 2008 to Eastside and
Brentwood were a combined total of - 1,654
ER impact on an annual basis with
an average cost per visit saved.
Overall Number of Walk-ins by Clinic 2004 - May 2008
Cost Savings
Eastside
Brentwood
14,422
695
$4,687,150.00
$254,425.60
Number of ER Follow-ups by Clinic 2005 - May 2008
Cost Savings
Eastside
Brentwood
1,816
135
$590,200.00
$49,420.80
Number of Hospital Discharges by Clinic 2005 - May 2008
Cost Savings
Eastside
Brentwood
368
51
$701,040.00
$97,155.00
What makes the Disparity Clinics
different?
Payment source/Staffing/HER
– Disparity - no payment required
– Staffing - Pharmacist/Registry Specialist/Nurse/MA
– Virtual Community Disparity Network - proposed
Disparity Clinics
Services:
 No cost (funded and Un-funded)
 Screening (HTN, Diabetes, Hyperlipidemia)
 Monitoring
 Education
 Treatment
Programs:
 Disease Management
 Pharmacy Initiative
Statistics:
 Soutel patient visits FY08 – 5,992
 Durkeeville patient visits FY08 – 4,336
 NEW – CB McIntosh/Winn Dixie
Soutel
Durkeeville
CB McIntosh
Number of ER self-pay cases.
35,000
32,641
28,912
30,000
2001
24,969
25,000
2002
22,142
20,031
20,000
15,000
10,000
18,977 18,029 18,042
2003
2004
2005
2006
2007
2008
5,000
0
Questions and
Discussion