Transcript A network approach to facilitating continuity of care for

A network approach to facilitating continuity
of care for patients with chronic diseases in
the aftermath of a natural disaster
Martha I. Arrieta, MD, MPH, PhD
Nicole Guidry, BSW, MA
Tracey L. Henry, MS, MSII
Susan Y. Nelson, MA
Rachel D. Foreman, MA
Marjorie L. Icenogle, PhD*
Errol D. Crook, MD
Center
for Healthy Communities Research Office
University of South Alabama (USA)
Department of Internal Medicine
USA College of Medicine
* Mitchell College of Business, USA
A network approach to facilitating continuity of
care for patients with chronic diseases in the
aftermath of a natural disaster: Objectives
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Identify critical chronic disease management needs in
the immediate aftermath of a disaster
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Provider
Support organizations (HIV/AIDS)
Patient
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Identify the elements of a community based network to
cover identified needs
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Define resources required to make such a network
functional
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Provider
Patient
Community
The Gulf Coast
MS and AL Gulf Coast
USA Medical Center
Mobile County Health Department
Franklin Community
Health Center, Inc
Coastal Family Health Center, Inc.
Singing River Hospital
Mostellar Medical Center
Bayou La Batre Rural
Health Clinic
A network approach: Methodology
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Phase I
 Key informants
 Focus groups with patients
 Advisory Board
Phase II
 Advisory Board formulates recommendations
Phase III
 Work groups review recommendations
 Formal report produced
Institutions and Key Informants
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Hospital (2)
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Administrator (3)
Medical Director (1)
Community Health Center (3)
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Administrator (2)
Medical Director (1)
Nurse/Nurse Practitioner (4)
Social Worker (1)
Risk Coordinator (1)
Health Department (2)
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Clinic Administrator (1)
Dir. of Social Services (2)
Dir. of Nursing (1)
Emergency Management (1)
HIV/AIDS Agency (2)
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Non-Profit Pharmacies (2)
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Exec. Dir. (2)
Retail Pharmacies (5)
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Exec. Dir. (2)
Case/Program Manager (2)
Administrator (3)
Pharmacist (1)
Pharmacy Tech (1)
Closed Door Pharmacy (1)
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Administrator (1)
Phase I Key Informants (N = 30)
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Location
 Mississippi
 Alabama
Gender
 Female
 Male
Ethnicity
 African American
 Caucasian
 Other
N
%
14
16
47
53
19
11
63
37
3
25
2
10
83
7
Phase I Focus Group Participants (N = 28)
Focus Groups (4)
 Location
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21
7
75
25
Female
Male
Missing
18
9
1
64
32
4
12
13
2
1
43
46
7
4
15
13
54
46
Ethnicity
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%
Gender
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Mississippi
Alabama
N
African American
Caucasian
Other
Missing
Patient Type
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HIV/AIDS
Various Chronic Diseases
Phases II and III Key Informants
II. Advisory Board (N = 11, 79%)N
 Location
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Mississippi
Alabama
5
6
%
45
58
III. Report Feedback (N = 19, 63%)
 Location
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Mississippi
Alabama
8
11
42
58
5
2
12
26
11
63
Feedback Type
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Work Group
Interview
Electronic
Critical Chronic Diseases Identified
Number of Quotes by …
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Key Informant
HIV/AIDS
131
Mental health
93
Diabetes mellitus
83
Hypertension
53
Respiratory illness
49
End stage renal disease
27
Cardiovascular disease
20
Cancer
5
Focus Group
41
35
15
13
19
2
1
Major need: maintaining continuity of medication
regimens
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“Diabetics could not get their insulin. Or they could not
keep their insulin refrigerated. Then blood sugar was a
big problem. Appropriate food—and so they are eating
4,000 calorie Meals Ready to Eat with no insulin. For
hypertensives, it was getting medicines and keeping
control of their blood pressure. …with Human
Immunodeficiency Virus, giving the medicines. Getting
medicines. Keeping medicines.”
Key Informant Transcript (KIT) 9:69
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Advanced prescriptions: “Hurricane override”
Prescription medications (N = 333 quotes)
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Patients’ knowledge (or lack thereof) of medications
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“I had lost (my) medication. I had to go to the
hospital…and try to remember what all my medication
and how much I was taking.” Focus Group Transcript 3:12
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“The people who were coming from Louisiana and
Mississippi… We had people that showed up and
they had no medication. And they did not even know
what they were taking. They said, “Oh, I take the blue
pill and the green pill and the yellow pill”… they didn’t
even have their bottles…or even a list of what they
were taking.” KIT 1:39
Medical records, health history records
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“People came with no health records…no prescriptions,
no medicines. Certainly having an electronic version of
the health record at some point, would help.” KIT 12:55
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“…. There needs to be some type of product …some
type of chip, CD, DVD with your medical history, and
people could take it with them… that would be so
helpful.” KIT 26:32
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“…I admitted tons and tons of patients from New
Orleans…who (had come in) say a week before Katrina
and had a breast biopsy done. And said, ‘This is my
doctor’s name.’ When we called the doctor, the office
was completely destroyed…we had to repeat the breast
biopsy. We had to repeat the colonoscopy. We had to
repeat a brain biopsy…That is, in my opinion,
inexcusable…” KIT 26:227
Medication procurement (N=119 quotes)
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Cash based economy
Financial need
Insurance: communications, loss of
 Vouchers: churches, pharmaceutical companies
Regulatory
 Refills allowed
Donated medications and supplies
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Inappropriate
Unsorted
Close to expiration date
Critical medications needed
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“Our main focus is on maintenance medications for chronic-type
conditions …like high blood-pressure, high cholesterol, heart
disease, diabetes, …G.I. disorders…In addition to the people who
are being treated for conditions such as those who needed to make
sure that they had a continuation of their medicine, there was quite a
spike in demand for anxiety medications…(and) various forms of
heart disease. Probably (also) a considerable spike in asthma
medication (and) for pulmonary conditions.” KIT 15:2.
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“…But regular diabetic medicine, not insulin… wasn’t coming in.
Anti- hypertensives, you couldn’t find them, you couldn’t find the
anti-depressants…What you could find, and what we still have is
two types of antibiotics with short shelf-life…
KIT 7:5
Suggested formulary
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Antibiotics
Anti-hypertensives
Oral glucose lowering agents
Insulin
Medications for anxiety and depression
Asthma medications
Provider and patient disaster planning
PROVIDER
 Backing up medical
records
 Stocking and protecting
essential medications
 Insuring all staff know the
organization’s plan and
their role in it
 Back-up communications
PATIENT
 Acquiring extra supply of
medications
 Portable documentation
of health and medication
information
Provider disaster planning
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“(Before , our disaster plan was to) make your way back to your clinic as
quickly as possible and start organizing from there. And that is what 70% of
the employees did…To pull things up of the floor in case there might be a
little water. Has our disaster plan changed (since Katrina)? We have not met
to alter it.” KIT 9:34
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We have what we call the Emergency Response Team…strictly on a
volunteer basis. When there is a hurricane or any type of natural disaster, I
activate the team. We will shelter here. We can open up immediately after a
disaster. We make plans to be here for at least two days…staying here
along with our families…I am working on getting air mattresses, I got
microwave food in our freezers…I have caps for us to wear and T-shirts so
the patients can recognize us. (We also plan to) make contracts with
vendors to insure that they will re-supply us…We are going to have at least
25 staff members sleeping (here). I have a floor plan, guidelines, policies
and all that.” KIT 21:3
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DIFFERENCE: Administrative commitment and resource allocation (Brown
BI et al. Integrating Hospitals into community emergency preparedness planning. Ann Intern Med
2006;144:799-811)
Operational and networking issues
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Coordination of internal and external aid
What they needed initially was some kind of registry or control. They
didn’t need to stop (outsiders) from setting up, because that’s what
made the difference. If you could be accessible, then people could
use you. But you need some kind of standard for folks coming in or
some way to move medicine and to move supplies. You need to be
able to have those contacts..” KIT 7:84
“Whatever it takes to create a network, whether hospitals or clinics,
pharmacies. (All) that are involved (in) health care, to facilitate
sharing of information…both about general services and patient
specific information.” KIT 15:64
Operational and networking issues
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Grassroots efforts with leadership (or co-leadership)
originating from within the disaster area
 Decentralized model to maximize contact with
community
 Greater potential for sustainability
Operational and networking issues
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Coordination of donated medications
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Pre-event networking
Communication
Centralized coordination of receipt and sorting
Decentralized distribution
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Distribute medication/healthcare information at basic
needs distribution points
Policy Recommendations
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Advance Prescriptions
 Relax public and private insurance
stipulations of refill periodicity
Patient Knowledge of Medication
 Enhanced patient education
 Providers distribute summary
health/medication information
Paper
 Electronic
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Policy Recommendations
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Medical Records
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Support CHC to attain electronic medical
records capacity
Storage
 Distant access
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Promote interoperability of EMR systems
Policy Recommendations
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Coordination of Aid
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Facilitate coordination of external aid to work
alongside indigenous organizations
Communication systems improvement
 Improved record-keeping
 Centralized receipt, decentralized distribution
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Promote long-term impact and sustainable
recovery
Acknowledgements
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Supported by the Regional Coordinating Center for Hurricane
Response through grant number US2MP02001 from the U.S.
Department of Health and Human Services, Office of Minority
Health, with support from the National Institutes of Health, National
Center on Minority Health and Health Disparities.
Mary Mc Lean for substantial contributions in the data collection
process
Institutional partners in MS and AL which graciously allowed their
employees to participate in the project
Sincere gratitude to our 30 key informants and 28 focus group
participants who so willingly shared their experiences of surviving,
living and working in the aftermath of Hurricane Katrina