Transcript Applying the High Performance Health System Framework to a

High Performance Health
Systems Serving Vulnerable
Populations
Fernando A. Guerra, M.D., M.P.H.
Director of Health
San Antonio Metropolitan Health District
Objectives
• Review existing frameworks describing:
– The healthcare system
– The public health system
• Discuss the health challenges of
vulnerable populations
• Introduce a comprehensive framework for
a high performance health system and
implications for “safety net” providers
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The Health Care System
and High Performance
The Healthcare System
Tertiary
Medical Care
Secondary Medical Care
Primary Medical Care
Population-Based Public Health Services
Assessment, Policy Development, Assurance
Capacity to Deliver Public Health Services
Public Health System Infrastructure
Relationship-Centered Care; Pew-Fetzer Task Force
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Commission Framework for High
Performance
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The Commonwealth Fund
Keys to Healthcare System
Performance
• The Commission has identified the following
seven keys to high performance:
– Extend health insurance to all
– Pursue excellence in the provision of safe, effective, and efficient
care.
– Organize the care system to ensure coordinated and accessible
care for all.
– Increase transparency and reward quality and efficiency.
– Expand the use of information technology and exchange.
– Develop the health care workforce to foster patient-centered
primary care.
– Encourage leadership and collaboration among public and
private stakeholders.
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The Commonwealth Fund
Scorecard on the Health System
• Overall, the U.S. health care system scored
an average 66 out of a maximum 100 based
on 37 indicators of health outcomes
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Quality (71)
Access (67)
Efficiency (51)
Equity (71)
• Relative to the benchmarks, U.S.
performance averages near 50 for efficiency
and around 70 for other domains.
C. Schoen, K. Davis, S. K. H. How, and S. C. Schoenbaum, U.S. Health System
Performance: A National Scorecard, Health Affairs Web Exclusive, September 20, 2006
W457–w475
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The Pubic Health System
and High Performance
The Public Health System
• Public Health:
“What we as a society do collectively to assure
the conditions by which people can be healthy”.
• The Public Health System:
“Activities undertaken within the formal structure
of government and the associated parties of
private and voluntary organizations and
individuals”.
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The Future of Public Health, IOM, 1988
The Public Health System
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NPHPS User Guide, 2006
Public Sector “Safety Net”
Health System Model
Common Goal: Healthy People
and Communities
Public Hospital and
Healthcare System
Public Health Agency
• Assessment
• Assurance
• Policy Development
• Clinical Preventive Services
• Primary Care
• Specialty and Acute Care
Other Health
System Partners
Academic Institutions
Health Professional
Schools
• Private entities
•Federal and State agencies
•Non-Health focused
local public agencies
Performance Criteria:
-Quality
- Efficiency
- Equity/Accessibility
- Innovation
• Research
• Education
• Workforce Development
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The Ten Essential Services
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Public Health Efforts to Support
High Performance
• Turning Point Initiative - Performance
Management
• Mobilizing for Action through Planning and
Partnership (MAPP)
• RWJ’s Mulitstate Learning Collaborative
• ASTHO-NACCHO Exploring Accreditation
Workgroup
• NACCHO Operational Definition of a Local
Health Department
• Public Health Accreditation Board (PHAB)
• Certification of Public Health Professionals
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Identifying Vulnerable
Populations
Vulnerable Populations
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Uninsured and underinsured
Recent and/or undocumented immigrants
Persons of low Socio-economic status
Persons with limited English-proficiency
Persons with limited health literacy
Persons with physical and/or mental disabilities
The working poor – often do not qualify for assistance
Racial and ethnic minorities (color)
Teen parents
Others…
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Health Disparities
• HP2020 Overarching Goals:
– Achieve health equity, eliminate disparities, and
improve the health of all groups.
– Create social and physical environments that promote
good health for all.
• Despite goals clear disparities exist for racial
and ethnic minorities across the spectrum of
health concerns
• Persons in poverty, with low educational
attainment and low literacy have poor access to
services and worse health outcomes
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Projected Population of Bexar County
by Race and Ethnicity, 2000-2040
Population
1,600,000
1,400,000
1,200,000
1,000,000
800,000
600,000
400,000
200,000
0
2000
2005
2010
2015
2020
2025
2030
2035
2040
Year
Hispanic
NH White
African American
Source: U.S. Census and Texas State Data Center as per 2008
Other
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Age Distribution Bexar County
NH White
Hispanic
Female
Male
Female
African American
Male
Female
Age 80 to 84 yrs
Age 80 to 84 yrs
Age 80 to 84 yrs
Age 70 to 74 yrs
Age 70 to 74 yrs
Age 70 to 74 yrs
Age 60 to 64 yrs
Age 60 to 64 yrs
Age 60 to 64 yrs
Age 50 to 54 yrs
Age 50 to 54 yrs
Age 50 to 54 yrs
Age 40 to 44 yrs
Age 40 to 44 yrs
Age 40 to 44 yrs
Age 30 to 34 yrs
Age 30 to 34 yrs
Age 30 to 34 yrs
Age 20 to 24 yrs
Age 20 to 24 yrs
Age 20 to 24 yrs
Age 10 to 14 yrs
Age 10 to 14 yrs
Age 10 to 14 yrs
Age 0 to 4 yrs
Age 0 to 4 yrs
Age 0 to 4 yrs
50000 30000 10000 10000 30000 50000
50000 30000 10000 10000 30000 50000
Male
50000 30000 10000 10000 30000 50000
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Source: U.S. Census Bureau, 2008
Educational Attainment of Population Over
25 Years of Age, Bexar County
(Population 25 years and over)
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Bachelors degree or higher
Asian
African American
Hispanic
White Non Hispanic
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Age of Death Over 75 Years, Bexar County
80%
70%
60%
50%
40%
30%
20%
10%
0%
White Non Hispanic Females
African Am. Females
Hispanic males
2007 Health Profiles
Hispanic females
White Non Hispanic Males
African Am. Males
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Access to Care
• Texas leads the nation in number and
percentage of uninsured for both adults
and children
• In Bexar County:
– 24.6% of adults 18-64 uninsured
– 18.1% of children 0 -17 uninsured
– 306,340 unduplicated Medicaid clients
– 54% of births are covered by Medicaid
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2005 Texas Department of State Health Services
San Antonio’s “Ten Zip Codes”
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“Ten Zip Code” Demographics
Ten Zip Codes
Bexar County
(72 zip codes)
Population
421,561 (30%)
1,386,179 (100%)
Median Income
$27,075
$44,219
Below Federal Poverty
Level
104,458 (25%)
215,680 (16%)
Hispanic
347,102 (82%)
752,532 (54%)
Non-Hispanic White
55,474 (13%)
493,090 (36%)
African American
13,317 (3%)
94,131 (7%)
High School Graduates
or Higher Education1
240,290 (57%)
1,067,358 (77%)
Female Headed
Households
88,528 (21%)
207,929 (15%)
1) Among adults aged 25 and older. All data from 2000 U.S. Census and American Community Survey.
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Ten Zip Codes - 2008
Ten Zip
Codes
% of Bexar
County
Population
421,561
30%
Total Births
8,265
30.7%
Late Prenatal Care Births
2,627
36.6%
Birth within 24 Months of Previous
1,694
38.0%
Births To Mothers BMI >30
2,700
38.3%
Juvenile Probation
4,038
39.2%
Family Violence Reports
4,322
41.0%
Single Mother Births
5,154
41.2%
Medicaid Births
5,684
41.7%
Confirmed Child Abuse/Neglect Cases
2,460
43.8%
Births To Mothers Age <18
683
47.0%
Births to mothers < HS / GED
3,731
49.8%
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A High Performance
Health System Serving
Vulnerable Populations
The “Safety Net”
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Local Public Health Agencies
Public Hospital Systems and Clinics
Federally Qualified Health Centers
Local/State Mental Health Agencies
Other public sector, non-profit, faith based
or community service providers
– Homeless service programs
– Feeding ministries
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Safety Net Provider Challenges
• High rates of preventable chronic disease
• Widening health disparities
• Increased health care costs with level or decreased
funding
• High rate of uninsured
• Challenges establishing medical homes
• Health information for clinical and public health needs
remain in silos
• Quantity and quality of mental health services
• Access to dental health services
• Expanding role of providers in emergency response and
meeting the needs of displaced persons
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Need for an Integrated View
of the Health System
• Current challenges and resources require
cooperation to achieve goals
• Health is more than the absence of illness and
injury
• Public health and health care are
complementary and interdependent – both
sectors must achieve high performance
– Common mission and vision
– Distinct roles and strategies for achieving a healthy community
• Addressing the needs of vulnerable populations
requires cross-sector partnerships and
relationship-centered care
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Impact of Health Reform
• Access to care should improve but many may
still be left out
– How will the expansion of coverage affect traditional
Medicaid providers? What will be the demand for
“safety net” services in the future?
– How will areas with high levels of undocumented
residents fare with changes in access and funding?
• New level of focus on preventive health services
in both clinical and population based services
• Issues of healthcare cost are unresolved
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Priorities for “Safety Net” Providers
• Address issue of health care costs
• Assure access to a comprehensive and
well coordinated system of care
– Medical homes
– Interoperable health records
• Establish effective mechanisms to care for
undocumented persons
• Enhance coordination between the
healthcare and public health sectors
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Questions and Discussion
Fernando A. Guerra, MD, MPH
Director of Health
San Antonio Metro Health District
[email protected]