of Role 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
InMarch2000,theInstituteofMedicine releasedastudyentitledAmericasHealthCare SafetyNet:IntactbutEndangeredthatdefined ASafetyNetas: Thoseprovidersthatorganizeanddeliver asignificantlevelofhealthcareandother healthrelatedservicestouninsured,Medicaid andothervulnerablepatients.
InstituteofMedicine,AmericasHealthCareSafetyNet:IntactbutEndangered(Washington,D.C: NationalAcademyPress,2000)p.21.
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SafetyNetHealthSystemsHaveTwo DistinguishingCharacteristics:
They maintain an open door , usually offering access to both inpatient and outpatient services to uninsured or underinsured 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
Americas Health Care Safety Net: Intact, but Endangered, Institute of Medicine Report, 2000
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10
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 .
LaurieE.Felland,KyleKinner,JohnF.Hoadley,TheHealthCareSafetyNet:MoneyMattersbutSavvy LeadershipCounts,IssueBriefNo.66,August2003,p.1.
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StrategiesUsedtoStrengthenSafetyNets 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
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Outline
Overview of Healthcare Safety Net Role of the Academic Medical Center Partnership Opportunities OB Dilemma in the Greater Richmond Area
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TheCommonwealthofVirginia 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
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VirginiasIndigentCareProgram
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
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VCUHealthSystem
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
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LeadingProvidersofCharityCare
2000 Percentage of Entire Charity Care for the Commonwealth
34.2%
16.5% 7.0%
Inova
6.0%
UVA VCU Health System
6.2%
Carillion
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
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VCUHealthSystemIndigentCareDistribution
Indigent Care Cost in Dollars
47,270,000 to 47,300,000 2,000,001 to 15,000,000 700,001 to 2,000,000 150,001 to 700,000 10,001 to 150,000 5,001 to 10,000 0 to 5,000
FY03 Budget $107.3M in Indigent Cost
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ThetotalpopulationoftheRichmondMetroareaexceeds850,000
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
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26
Morethan186,000haveincomesbelow2xpoverty(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
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27
Morethan48,000(estimated)arebelow2xpovertyanduninsured
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
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TheEcologyofSafetyNetCare
Catastrophic event
Acute hospitalization
Healthy with unmet needs
Healthy with episodic needs
Chronically ill
Presentation: Governors Covering the Uninsured Conference, Dr. Sheldon M. Retchin, 2003
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Withtheincreasingpressuresto identifyfundsandreducethecost ofcaringfor theuninsuredandtheunderinsured, theVCUHealthSystem hasdevelopedinnovativestrategiesto continuetoprovideservices tothesepopulations
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PiecesofthePuzzle
VCUHS purchased Medicaid HMO in the mid 1990s 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
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GoalsoftheVCCProgram 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
31 Slide 19
Number of Uninsured Patients Qualifying for the Indigent Care Program at the VCU Health System
Number of Indigent Patients
50 40 30 20 10 0 Thousands 38.781 19.619 14.814
FY 2000
10.056 Richmond
2.576 Henrico
0.977 Chesterfield
0.885 Tri-City Area
0.321 Hanover
4.805 Other Areas Slide 20
Full IndigCategory 1
VCC Eligible
Total
The VCC Service Area
C a r o l in e
G o o c h la n d
H anover
K in g W il lia m
H e n ric o
P o w h a ta n
R ic h m o n d C it y
N e w
K e n t
A m e lia
C h e s te r f ie ld
C o lo n ia l H e ig h t s D in w i d d i e
C h a r l e s C it y
H o p e w e ll
P r in c e G e o r g e
P e te rs b u rg
Slide 2133
VCCProgram
VCC is NOT an insurance program VCUHS partnered with Primary Care Physicians in the Greater Richmond and TriCities 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
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34
ProgramComponents
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
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35
VCCPatientUtilizationIssues 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
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36
EmergencyRoomVisitsforUninsured:Reason forVisit
48% of visits could have been avoided
22% 2% 2%
27%
18% 8%
Visits=30,273
Not Emergency Emergency/Not Avoidable Alcohol/Drug Primary Care Injury Unclassified
17% 4%
Emergency/Avoidable Psych
FY2002
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EmergencyRoomVCUHSVisitsfortheUninsured
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 1,131 765 822 1,095
% 3.9% 4.9% 7.1% 3.7% 3.7% 2.5% 2.7% 3.6%
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39
Jenkins Foundation Care Coordination Model
Community*
Safety Net Providers Human Services Agencies Community Physicians
Care Coordinators
Jenkins Care Coordination Program
Nurse Case Managers
Outreach Workers
*Community = Community
physicians who serve uninsured patients, community-based Safety Net Providers and local agencies
LEGEND
Stand. Op. Procedures
Information System Communications System
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VCCED U t iliza t ion
12000 10000 8000 Visit s 6000 4000 2000 0 FY01 FY02 FY03 FY04
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9956 8160 7798 7735
Classification of ED Visits for VCC Patie nts
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Flags Only ED Care Needed - Not Preventable/ Avoidable ED Care Needed - Preventable/ Avoidable Emergent - Primary Care Preventable Non Em ergent
FY01 1.6% 18.2% 5.0% 30.7% 44.5%
FY02 1.7% 19.0% 5.7% 34.8% 38.7% Fiscal Year
FY03 2.3% 20.5% 6.2% 36.6% 37.6%
FY04 2.3% 20.4% 6.3% 35.0% 36.2%
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BonSecoursRichmondCommunity HospitalPartnership
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
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VCCToday
Enrollment in FY05 was approximately 17,000 patients 31 Community Physicians and 9 Safety Net Providers participate Community are partnerships 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
OtherInnovativePartnerships 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
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Slide 33
CollaborationwithREACH
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
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44
HealthyCommunityAccessProgram (HCAP) With VCU as the fiscal intermediary, REACH has been awarded over $2.5 million from HRSA Funding has been utilized to develop a webbased program (MOREAccess)to assist Safety Net providers in financially screening patients to determine eligibility for programs such as Medicaid or FAMIS
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47
GreaterRichmondSafetyNetHealthCareProviders
VCUHS HCA
Bon Secours
Free FanClinic
RCDPH
Community Physicians VernonJ.Harris HealthCenter CrossOver Ministries
Craig HealthCenter
Daily Planet
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45
Vision:SafetyNetHealthCareDeliverySystem AcuteCareProviders HCA
Acute Patients
VCUHS
Bon Secours
Acute Patients
Funding Support
Funding Support
Free FanClinic
Community Physicians
CrossOver Ministries
VernonJ.Harris HealthCenter
Daily Planet
Craig HealthCenter
RCDPH
PrimaryCareAccess
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TheHealingPlaceSocialDetoxificationUnit
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
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HayesE.WillisHealthCenter 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
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HayesE.WillisHealthCenter 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
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HayesWillisCenterPlaysaMajorRole 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
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Outline
Overview of Healthcare Safety Net Role of the Academic Medical Center Partnership Opportunities OB Dilemma in the Greater Richmond Area
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The OB Dilemma
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2002BirthDataforRichmondMetroArea
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
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Ofthe890SelfPayMothers 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
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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
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VCUHealthSystemIssues
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
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REACHMembersIdentifiedIssues 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
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TheCommunityResponds
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
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REACHPerinatalCareModel
ACCESS POINTS
Health department Safety net providers Planned Parenthood Emergency department Private practices Community
Low Risk
Assigned Care Coordinator Assigned OB
Perinatal Passport Program
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
Initial Screening & RISK ASSESSMEENT
(Coordinating Agency)
Non-Medicaid Eligible
Due to income or citizenship (Refer to Passport Program)
Medicaid Eligible
(Refer to Private Practice)
High Risk
Assigned Care Coordinator Assigned OB
Mom
Family support (e.g., Healthy Start) Family planning Health education Primary care home
Delivery Site Identified (Records
Transferred Pre-Delivery)
BABY
FAMIS/FAMIS Plus Pediatrician
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Estimateduninsuredbelow2xpovertybyzipcode 2000Census
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)
Hanover
I-2 95
I-64
Chesterfield
I-95
I-1 95
I-85
Henrico
Richmond
Colonial Heights
Petersburg
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PerinatalAccessProgram
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
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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
MovingForward
Perinatal Access Partnership for Non-Medicaid 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
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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
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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.
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