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AHRQ Annual ConferenceProgress of a Learning Network: Working to Reduce Disparities by Improving Access to Care

Bethesda, MarylandSeptember 14, 2009

Jim Walton, DO, MBABaylor Health Care System – Dallas, TX

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Baylor Health Care SystemOverview

• Baylor Health Care System (BHCS)– Dallas-Ft. Worth metropolitan area of N. Texas– 15 owned, leased, or affiliated hospitals and 6 short-stay

hospitals– Affiliated physician organization, Health Texas Provider

Network, has 450+ physicians in 110+ practices in the region

– Baylor’s flagship hospital, Baylor University Medical Center, is a 1000-bed inner city hospital with Level 1 trauma designation

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Addressing Disparities:BHCS Office of Health Equity

• The BHCS Office of Health Equity– Responsible for the identification, measurement, and elimination

of health disparities within the Baylor Health Care System and the communities it serves

• Health Care Access

– Insuring Equal Access to Care & Decreasing Unnecessary Utilization

• Health Care Delivery

– Insuring Equal Quality of Care & Decreasing Adverse Events

• Health Care Outcomes

– Improving Health Outcomes & Decreasing Mortality and Morbidity

BHCS Equity Triangle

Equity inHealthcare

Health Care Access

Health Care Delivery

Health Care Outcomes

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Disparities in DFW:Limited Access to Health Care

The Problem:

• Approximately 23.6% of the population in the Dallas-Ft. Worth metropolitan area are without health insurance coverage.

• Translates to 1.3 million individuals with limited access to care1.

• That number increases when you consider the number of Medicare and Medicaid patients struggling to access care.

• BHCS facilities bear much of the burden of uncompensated care in our community.

Uninsured

Medicare

Medicaid

Insured

1Parkland Health & Hospital System, 2006 Estimates

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Office of Health Equity:Health Care Access Goals

Primary Objective: By increasing access to needed health services in community and home-based settings, underserved patients will experience less health disparities and require less frequent utilization of hospital services (ED and admissions), resulting in decreased uncompensated care for BHCS facilities.

Health Care Access Strategies:

1. Facilitate access to medical services (Medical Home, Ancillary, and Specialty Care)

2. Facilitate access to affordable prescription medications

3. Care coordination to overcome barriers (i.e. low SES, language, health literacy)

Relationship between Access and Uncompensated Care

Access to Health Services Uncompensated Care

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Care Coordination & Pathways: An Adaptive Model

• Leveraging Baylor’s infrastructure – Physicians• Adjunctive support - Community Health Workers• Pathways model – Care protocols to ensure

connection with and delivery of evidence-based care• BHCS has adapted the CCC model over the past eight

years to improve:– Access to primary care– Health outcomes– Financial savings – Innovation in care delivery

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Care Coordination-First Steps: Community Health Navigation

• A collaboration with Project Access Dallas:– A network of volunteer providers across Dallas Co.

organized to provide care to uninsured working poor

• Community Health Navigation was created to help patients overcome barriers to care:– Translation, Transportation, Medication assistance– Health Education to improve patient knowledge and

behaviors– Coordination of referrals within the PAD program

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Adapting Care Coordination:1. BHCS Vulnerable Patient Network

• A unique “house-calls” program utilizing a multi-disciplinary team to provide home-based primary care services to underserved patients with complex medical and social conditions– Neuro-trauma and Heart Failure

• Specially-trained CHW supports the care team with physicians and nurse practitioners:– CHW’s have medical assistant training– Utilize clinical and social “Equity care-path” tools– Serve as a single point-of-contact for home-bound patients

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BHCS Hospital Utilization Analysis for VPN-CHF Patients180 Day Pre and Post CHF Program Enrollment

Average Number of ED and IP Encounters per Patient(n=29 patients)

2.3

1.21.1 1.2

0.50.7

0.0

0.5

1.0

1.5

2.0

2.5

ED IP Total

Enco

unter

s per

Patie

nt

180 Day Pre Enrollment 180 Day Post Enrollment

36.4% Reduction 58.3% Reduction

47.8% Reduction

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BHCS Hospital Utilization Analysis for VPN-CHF Patients180 Day Pre and Post CHF Program Enrollment

Average ED and IP Direct Costs per Patient(n=29)

$8,695

$274

$8,969

$2,386 $2,579

$193$0

$2,000

$4,000

$6,000

$8,000

$10,000

ED IP Total

Dire

ct Co

sts pe

r Pati

ent

180 Day Pre Enrollment 180 Day Post Enrollment

29.6% Reduction

72.6% Reduction 71.2% Reduction

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Adapting Care Coordination:2. Community Diabetes Education (CoDE)

• Use of Community Health Workers to provide chronic disease education and self-management training to underserved diabetics within charitable health clinics across Dallas County

• Conduct one-on-one counseling with patients– CHW is bilingual/bi-cultural– Contextualizes diabetes curriculum & messages– Advocates for diabetics & families (meds, referrals, etc.)– Additional point-of-contact for patient/families

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Community Diabetes Education (CoDE):Clinical Outcomes

7.82

8.00 8.05 7.98 8.71

7.77 7.38

7.27

7.92

8.92

5.00

5.50

6.00

6.50

7.00

7.50

8.00

8.50

9.00

9.50

Baseline 3 Mos 6 Mos 9 Mos 12 Mos

Hb A

1C %

.

ControlGroup (CG)

ExperimentalGroup (EG)

(p=.53)

(p=.84) (p=.33) (p=.03)

(p=.043)

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Care Coordination-Next Steps:3. Ambulatory Care Coordination

• Supporting the move toward NCQA certification - Patient-Centered Medical Home (PCMH) Multi-disciplinary teams

• 2007 - The AAFP, AAP, ACP, and AOA publish the Joint Principles of the Patient-Centered Medical Home with 7 Core Features

• Ambulatory Care Coordination (HT-ACC) Using non-physician staff to navigate patient care Coordinating care/follow-up for patients (in-patient & out-patient) Addressing barriers, assessing progress and utilizing care paths for care

management Generating reminders for preventive care Implementing evidence-based guidelines for disease management

Sources: “Joint Principles of the Patient-Centered Medical Home” available at http://www.aafp.org/online/etc/medialib/aafp_org/documents/policy/fed/jointprinciplespcmh0207.Par.0001.File. tmp/022107medicalhome.pdf

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Summary

• Community Care Coordination and the Pathways model has been successfully adapted to provide a wide range of services to underserved patients– Navigation; clinical and social support; chronic disease

education• The model has produced:

– Improved clinical outcomes– Decrease in avoidable hospital utilization– Positive financial impact for hospitals

• The model will be applied in new efforts to achieve NCQA certification for PCMH