adding imaging services to the patient centered medical home
TRANSCRIPT
Adding Imaging Services to the Patient Centered Medical Home
Presented by:
Zara Marselian, CEO
John P. Lethin, Imaging Director
1
About La Maestra
o Mission: “To provide quality healthcare and
education, improve the overall well-being of the
family, bringing the underserved, ethnically diverse
communities into the mainstream of our society,
through a caring, effective, culturally and
linguistically competent manner, respecting the
dignity of all patients.”
First Clinic, opened 1990 LEED Gold Health Center, opened 2010 2
La Maestra Health Services
o Clinic formed in 1990 under La Maestra Amnesty
Center. The need for culturally competent healthcare
was identified by council representing over 12,000
students at the Center.
o 4 Medical & 5 Dental Centers in San Diego County
and 3 school-based medical/dental clinics
o Mental and Behavioral Health services onsite at main
clinic, high school clinic, and at other sites through
telemedicine.
o All services and programs have elements focusing on
education, case management and social services –
Interdisciplinary Approach
3
Annual Number of Patients
25,669
28,323
30,111
32,628
13,487
15,870
18,680
23,879
27,459
29,811
32,121
35,524
37,782
40,288
0
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
2002 2003 2004 2005 2006 2007 2008* 2009 2010 2011
Un
du
plica
ted
Pa
tie
nts
Public Housing
Patients
Total Patients
4
*Expanded
Grant in 2008
91.2% of Patients best served in a language other than English (2011)
Annual Number of Visits
112,898
124,383
150,598
159,487
39,881 41,420
56,192
82,492
88,948
102,843
122,564
138,070
165,872
174,430
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
200,000
2002 2003 2004 2005 2006 2007 2008* 2009 2010 2011
Vis
its
Public
Housing
Visits
Total Visits
*Expanded
Grant in 2008
5
Innovative Models at La Maestra
o Circle of Care
o Integrated Services
o Medically Trained Cultural Liaison Model
o Telemedicine
o School-Based and Mobile Health
o Imaging Services in an FQHC
6
Circle of Care
Residents of
Public Housing
- Outreach & Health Fairs (education/screening) at Housing Sites
- Eligibility & Enrollment Assistance
- Transportation
7
Well-Being & the Circle of Care
Network goes beyond the field of medicine, bringing greater
resources to our patients – Circle of Care Model
New Skills, Independence, Self-Esteem, Helping and Teaching
Others, Working in Healing Environments
o Food Pantry with nutrition education and obesity prevention
o Urban Community Garden
o Microcredit Program for Women & Microenterprise Assistance
o Job Training and Placement
Community Garden Zumba classes Food Pantry 8
Well-Being & the Circle of Care
o Social Services & Legal Advocacy
o Transitional Housing and help finding Affordable Housing
o “Culture and Healing through Art” Program
Microcredit
Participants
Transitional Housing
Job Trainees
Microcredit Meeting
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Community
Outreach Enabling Services
Primary Care Adult Health, Women’s Health,
Pediatric & Teen Health,
Senior Health
Dental/ Oral Health
Mental Health
Pharmacy
Optometry
Patient Education
Interpreter/
Translation Transportation
Social Services
Housing &
Community
Development
Mentoring
Ethnic CBOs
Healthcare
Training
Continuous Patient Follow-up and Case Management
Community
Development
Affordable
Housing
Counseling
& Linking
to Programs
Eligibility, Medi-Cal
& Healthy Families
Enrollment
Financial Literacy
Job Training &
Placement
Domestic
Violence
Referral
Behavior
Modification
Referrals
Childcare
Community Member / Patient
Clothing
& Food
Microenterprise
Assistance
Medically
Trained Cultural
Liaisons
Legal
Advocacy
Services
Laboratory
Integration of Programs
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Imaging
Telemedicine
Serving the Culturally Diverse Community o Most culturally diverse health center in California.
o Over 20 languages and dialects spoken by staff.
o 91% of patients prefer to communicate in a language other than
English
o Staff represents (is from) the cultures served, ensuring cultural and
linguistic competency.
o Medically Trained Cultural Liaisons provide valuable, ongoing
support and education to local residents and identify new needs.
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Languages Spoken by Staff
Acholi
Arabic
Burmese
Cantonese
Chaldean
English
French
Italian
Karen
Laotian
Luganda
Mandarin
Nuer
Polish
Russian
Sicilian
Sign Language
Somali
Spanish
Sudanese
Swahili
Tagalog
Thai
Vietnamese
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Medically Trained Cultural Liaisons & Promotoras
Mobile Outreach
Patient Support
Clinic Mammo Days & Onsite
Ultrasound
Provide Guidance
Partnerships
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Telemedicine o Telemedicine started in 2005 at main clinic
o Began providing Mental Health to satellites & rural sister health centers
o Continuing to expanded network of specialists to bring specialty care to
medical home
o By 2010, equipment installed at all satellites grants & collaborations
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School-Based and Mobile Health
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2012: Mobile Clinic
o 2 dental operatories and 1 medical exam room
o Bringing medical and dental services to at least
9,000 students and their families per year
o No construction cost of building on campus clinic
o Can also provide health screenings, mental health,
health education
o 2009: Opened Medical and Dental Clinic at Hoover High
o 2010: Opened Central Elementary Medical Clinic
o 2011: Opened Monroe Clark Middle Medical Clinic
o 2012: Will open Rosa Parks Elementary Medical Clinic
Adding Imaging Services
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Background
1992: Identified Patients’ and Community’s
Need for Breast Cancer Screening
Implemented Screening & Education in
Community
Challenges: Non-compliance, Case Management
o No Linguistic & Cultural Competency
outside La Maestra
o Transportation /Geography
o Self-pay patients
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1. Increase Access to Care
2. Increase Patient Compliance
3. Bring specialty care (Radiology) into the
community / medical home
4. Easier to offset self-pay patient costs
Why Add Imaging Services to an FQHC?
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o Enhances scope of services in medical home,
providing access to affordable, quality,
culturally competent care, with Built-in
Enabling and Outreach Services
o Education + screening + follow up / patient
navigation = better patient outcomes
Benefits for the FQHC
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o Additional revenue for the Health Center
o New funding streams
o More opportunities for grants to cover
uninsured care
Benefits for the FQHC
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o Reduces emergency room visits
o Lower surgery/specialist costs
o Reduces disability/unemployment
Relief to Healthcare System
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o Need / Interest in Community
o Survey community members, patients, staff
o In-house Data – patient tracking
o Available Services
o Inside and Outside Health Center
o Cost
o Distance from Medical Home and Patient Residence
o Linguistic & Cultural Competency
o Case Management
Feasability Analysis
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o Available Resources
o Expertise
o Within Organization and in Broader Network
o Funding Sources
o Start-up Assistance
o Low Interest Loans
o Reimbursements
o What are steps to add reimbursable services to your
scope?
Feasability Analysis
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Ultrasound:
o Few to no setup regulations
o Need ARDMS Sonographer to perform imaging
exams and a board certified radiologist.
Legal Requirements / Regulations
24
Mammography, DEXA and General X-Ray:
o require specific plans from the manufacturer
o space, weight load, lead shielding, electrical requirements
o radiation physicist report prior to construction
o Licensure of the equipment (State & Federal)
o MSQA Accreditation is required for Mammo
o Submit to the State and to FDA.
Legal Requirements / Regulations
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o Services
o Ultrasound, Mammography, Dexa Scan, X-Ray
o Mobile vs. Permanent
o Digital
o Teleradiology (PACS, IT, DR)
o Electronic Health Records
o Full Field Digital Mammography & Computer Aided
Detection
Equipment / Modality Options
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o Identify Local Partners: Teaching Hospitals
o Kaiser, V.A., Radiology Groups
o Identify organizations/companies to contribute to
planning and implementation processes:
o Manufacturers: facilitate acquisition of capital
equipment, installation and any necessary
accreditation.
o Teleradiologists
o Local Specialists
o Training programs for staff
Partners
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Ultrasound:
Case 1: A 30 year old male presented with left flank pain and blood in the urine
(hematuria). A renal ultrasound exam showed a 9 mm kidney stone in the left distal
ureter, creating obstruction of the left kidney (hydronephrosis). The patient was
transported to a urologist that same day, where lithotripsy was performed. The
patient was discharged and is doing well.
Avoided: Irreversible kidney damage due to long term renal obstruction.
Case 2: A 62 year old male was referred for an abdominal ultrasound for generalized
abdominal and back pain. This patient was getting ready to travel out of the country
and a La Maestra provider recommended the exam prior to travel. The ultrasound
was performed the same day, detecting a 5.2cm distal abdominal aortic aneurysm.
Detected before becoming symptomatic, where a rupture equals death, referred to
vascular surgery. Appropriate intervention and insertion of a transfemoral
intraluminal graft. Result: Saved life with a minor surgical procedure with minimal or
no hospitalization. A minimal recovery. Avoided extensive diagnostics that would
have been needed if patient had had aneurism rupture and ER had no idea of
problem.
Results: Individual Cases
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Case 3: A two week old male infant presented with projectile vomiting and dehydration,
and a pylorus ultrasound was performed the same day, demonstrating pyloric
stenosis. The infant was referred to Children's Hospital for corrective surgery and he
is now thriving.
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Results: Individual Cases
Implementation Stage
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Strategies for Implementation o If feasibility analysis indicates a need, then proceed to:
o Gathering Information – Collect data from:
o Hospitals
o Radiologists
o Medical Technologists
o Cultivating Networks / Building Collaborations
o Funding Opportunities
o Vendor Relations
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Strategies for Implementation o Phase In Services
o Builds Trust with Providers and Staff
o More Cost Efficient
o Cultivate networks with radiologists, medical imaging
technologists, hospitals, etc.
o Purchase equipment that allows for future expansion
o Stereotactic Biopsies
o 3-D Tomosynthesis
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Integrating Imaging into Existing Services
o Primary Care & Preventive Screening
o Gynecological Services
o Minor Procedures (Cryo & LEEP)
o Obstetric/Perinatal Care (Ultrasound)
o Family Planning & Counseling
o Comprehensive Perinatal Services Program
o Breast & Cervical Cancer Education/ Screening
o Education Classes: Nutrition & Weight Management, Management
of Hypertension, Diabetes, Cardiovascular Disease
Outreach
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2005: One stationary ultrasound unit at main site for OB patients
2006: Satellite patients travel to main site for ultrasound
2008: Realized need to add additional equipment.
-Established relations with vendors
-Provider interviews
-Vendor negotiations
Culminated in new acquisitions
Ultrasound at La Maestra
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2009: Purchased mobile ultrasound unit to serve OB
patients at satellite sites
2010: Added General Ultrasound using Teleradiology:
(Abdominal, Aorta, Renal,Thyroid, Breast, Pelvic, Endovaginal)
Required a new shift for additional 15 patients/week
Teleradiology - Interpretative report received in 24 hours
2012: Expanding Imaging Staff
95% Compliance Rate for in-house ultrasound referrals
Ultrasound at La Maestra
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Imaging Patients Served
0
500
1000
1500
2000
2500
3000
3500
4000
2005 2006 2007 2008 2009 2010 2011 2012
Estimated Imaging Patients per Year
Patients
36
o 3 days/week = 50 patients
o Internal Orientation & Marketing of New Services
o External Marketing
o New Funding Streams
o 8 hours/week Radiologist
2012: Added Mammography
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Before
1992 to March 2012
Breast & Cervical Cancer Education & Screening:
o “Mammo Day” – Mobile Imaging Service comes to Clinic
or patients are referred to Imaging Centers
o Clinic Staff does education, appointment follow-up, case
management, interpreting, transportation, etc.
o No reimbursement for staff time and enabling services
o Low compliance rates with Follow-up and Specialty
Referrals
Mammography at La Maestra
38
After
March 2012: Implementing Full Field Digital Mammography
Benefits of Mammography Center in Medical Home:
o Better Patient Care
o Compliance with Follow up
o Increased Quality Measures
o Specialty Care available in Medical Home
o Job Creation
o New Revenue Streams: Reimbursements, Grants, Contracts
o Cost Effectiveness (Staff time)
Mammography at La Maestra
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Mammography:
Microcalcifications were detected via full filed digital mammography.
Patient referred to breast surgeon to remove localized area of abnormal
tissue through lumpectomy. Sent to pathology to determine which
treatment is appropriate. Full field digital mammography improved
survivability and outcome.
Earlier detection meant lower stage of cancer which meant lumpectomy,
vs. a large invasive tumor with mastectomy, radiation and chemotherapy,
then breast reconstruction after time.
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Results: Individual Cases
DEXA = Dual-energy x-ray absorptiometry
With a DEXA machine you can:
o provide early diagnosis of osteoporosis
o implement timely pharmacological therapy
o educate about prevention of fractures to older adult patients
and their caregivers
2012: Added Bone Densitometry
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o Ultrasound guided Biopsy & Cyst Biopsy
o Stereotactic Biopsy
o 3-D Tomosynthesis
o X-Ray
o CT Services
Future Plans
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o Gain Internal Support
o Engage Staff
o Training
o Networking specifically around Imaging
o Initiate Accreditation
o Referral and Case Management Teams
o Provider Relations
o Promotoras /Health Educators
Keys to Success
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o Marketing
o Billing
o Additional Revenue Streams
o Additional Grant Opportunities
Keys to Success
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o Policies and Procedures
o QI and QC
o Peer Review
o Patient Surveys
o Provider Feedback
Compliance
45
Results from La Maestra Imaging Center:
400 Mammography patients seen
o About 15% had abnormal results
o 3 Breast Cancer Cases confirmed
o Assigned to Patient Navigator to help with follow-
up and treatment
Results: Saving Lives
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May 1 – 3, 2012
National Training Conference
Healthcare for Residents of Public Housing
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Organization: ___________________________________________
Tel:____________________ Email: _________________________
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