From the Health Commons to Health Extension (HEROs): An Academic - - PowerPoint PPT Presentation

From the Health Commons to Health Extension (HEROs):

An Academic Health Center Addresses the Social Determinants of Health

Society of Directors of Research in Medical Education

• Wed. June 17 • La Fonda

Santa Fe, NM

Arthur Kaufman, M.D.

Vice President for Community Health

• Prof. Dept. of Fam. and Community Medicine

akaufman@salud.unm.edu

Workforce Crisis

Looming National Health Workforce Crisis

• Decreased interest in primary care
• Decreased admission of rural students
• Low % ethnic minorities entering medicine
• Aging RN workforce
• Behavioral health, oral health inaccessible to many

• Fragmented system of

medical, behavioral, social services

• Poor access to basic services
• Maldistribution of health

professionals

• Research priorities often not

aligned with community’s priorities

Major Gaps/Challenges

Factors Associated with Low U.S. Health Care Ranking

• Weak primary care system
• High income, social disparities
• Inappropriate use of technology
• B. Starfield

Each additional primary care physician per 10,000 (about a 20% increase) is associated with a decrease in mortality of about 5%.

• B. Starfield

In England

Educational Innovation

Life Experience as Change Agent

• 1979

Change preclinical curriculum

• 1988

Change clinical curriculum

• 1992

Change residency education

• 1994

Interdisciplinary learning

• 1996

Change clinical practice

• 1998

Integrate public health and primary care

Education to Address Workforce Crisis: “Expansion of FM Residency”

• Increased number- from 6 to 36 in Albuquerque
• State funded 16 of these (free to work/learn in

community)

• Increased rotations in rural communities
• Locum tenens encouraged for all
• Established 3 rural residency sites in addition to

Albuquerque (Roswell, Las Cruces, Santa Fe) so total number of NM FM positions = 72

FM Residency Outcomes

50% Albuquerque FM grads to rural NM 80% of rural FM grads to rural NM 33% of FM grads who chose rural practices

worked with Native American communities

Educational Reform Must be Complemented by Service Reform

Predominance of chronic illness “Behavior” and “Culture” key factors in prevention,

management

SES important determinant of health, access Care increasingly delivered in interprofessional

teams, by non-MDs

Years of Productive Life Lost in NM

1st – Injuries (alcohol-related >50%) 2nd – Cancer (smoking, environment) 3rd – Homicide/suicide

Adverse Childhood Experiences

Correlated with Chronic Disease in Adults

Childhood Abuse

• Physical
• Emotional
• Sexual

Adults in Home

• Mother beaten
• Mental Illness
• Alcohol of substance abuse
• Having been a prisoner

Fellitti VJ, Anda RF, Nordenberg D, et al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. Am J Prev Medicine, Vol, 14, No. 4: 245-258

The Educational Payoff

EDUCATION ATTAINMENT

• AV. ANNUAL EARNINGS

High School Dropout $18,900 High School Graduate $25,900 Bachelor’s Degree $45,400 Master’s Degree $54,500 Professional Degree $99,300

SOURCE: BUREAU OF LABOR STATISTICS, DEPT. OF LABOR, 2002

Growing Need for New, Integrated Models of Care

“Status One” – top 5 % of care users consume 50%

• f resources

Social determinants of disease in high user subset

• 70% underlying cause of high ER use “behavioral”
• 70% of “behavioral” is alcohol and substance abuse

Intense case management requires collaboration

(medical, behavioral, social, community outreach)

Tips for Staying Healthy

Don’t be poor Don’t have poor parents Own a car Don’t work in a stressful, low paid manual job Don’t be unemployed Don’t live in damp, low quality housing

– Dave Gordon, 1999

Next UNM School of Medicine Curriculum Reform: Public Health Certificate

(17 credits) for all students matriculating in 2010

Service Models Relevant to Community Health

UNM Care Program Primary Care Dispatch Field Case Management 24 Hour Nurse Health Advice Line Health Commons

UNM Care Program for Medically Uninsured

Enroll ~14,000, ~40% with C.H.C. partner Assign to Primary Care Home Affordable Co-pays (based on means testing) Outcomes

increased prevention (paps, mammograms, etc) decreased hospitalizations (~$2 million saving) model for State Coverage Initiative

Kaufman A, Derksen D, McKernan S, et al. Managed Care for Uninsured Patients at an Academic Health Center: A Care Study. Academic Medicine, Vol. 75, No. 4 April 2000: 323-330.

Primary Care Dispatch: Finding a Medical Home

– 31% Reduction in return visits to ED

Murnik M, Randal F, Guevara M, et al. Web-based Primary Care Referral Program Associated with Reduced Emergency Department Utilization. Fam Med 2006; 38 (3): 185-9

Field Case Management: Sustainable Role, Funding for Community Health Workers (“promatoras”)

Managed Medicaid MCO profits reduced by

Medicaid high users

Need for case management, but “can’t find” this

group

Dept Fam & Comm Med received MCO contract to

hire, train Field Case Managers – given panel of high risk patients – managed “in the field”

Results: 62% reduction in cost; program expanded to

2 other MCOs, two rural regions; Co-care, mutual teaching with FM residents

Nurse Advice Line – Early Outcomes

~15,000 calls/month ED visits reduced (62% of planned ED visits

diverted: est. savings of $6 million/year)

Appts to primary care homes Broad support (state, counties, comm. hospitals,

practices)

Rural practice relief (esp. community health centers) Health Dept uses for “syndromic surveillance”

1-877-725-2552

“Health Commons”

Community stakeholders address intractable health

problems

One-stop-shopping (medicine, behavioral health, case

management, oral health, community health worker links with community)

Integration of medicine and public health Model interdisciplinary training site for health

professionals

Community engagement — e.g., pipeline

development, economic development

Kaufman A, Derksen D, Alfero C, et al. The Health Commons and Care of New Mexico’s Uninsured. Ann Fam Med, Vol. 4, Supplement 1, Sept/Oct 2006: 522-527

Health Commons models were created in two inner city neighborhoods (South Valley and Southeast Heights, both in Albuquerque and two in rural counties (Sandoval and Hidalgo).

Establishment of Office for Community Health

Appointed VP for Community Health Goal: “work with community partners to

achieve the greatest improvement in health of any state by 2020”

Programmatic efforts guided by extensive

community input, guidance

Universities & Community Engagement

“Most university-community partnerships are one-sided altruism. The University gives things to a needy community, compensated by warm feelings and a grant until it ends.” – Howell Baum “Shifting institutional leadership and grant-based funding often relegates community partnerships to boutique initiatives, paraded

• ut when the university needs to demonstrate its engagement

bona fides…Many community engagement offices are tucked away in outreach centers or isolated in a single school or college,

• utside the mainstream of the university’s priorities.”

– Mary Jane Brukardt

Comments from a Sampling of Community Health Leaders

• Important to overcome image:
• “University of ABQ,”
• “UNM only present while grant funds last”
• “UNM comes with its agenda, its priorities.”
• UNM needs to:
• Commit to long term partnerships, not just when grant present
• Build upon local wisdom, leaders, organizations, programs
• Create central office at UNM, single telephone number (like the

Physician Access Line)

• Have full-time presence in all communities like NMSU

Establish Health Extension Rural Offices (HEROs)

Place full-time in rural communities across the state Link community health priorities with UNM and

NMSU resources

Monitor effectiveness of university programs in

addressing community health needs

Partner with agricultural Cooperative Extension, with

• Dept. of Health, with County Health Planning

Councils

2007 Top Health Priorities from 31 County and 6 Tribal Councils

(compared with UNM HSC research priorities)

County Health Councils’

Priorities (in order)

Substance Abuse Teen Pregnancy Obesity Access to Care Violence Diabetes

• UNM HSC Research Priorities

(“Signature Programs”)

Cancer Cardiovascular and

Metabolic Diseases

Brain and Behavior Child Health Infectious Disease and

Immunity

Environmental Health

Example: Jemez Pueblo

Teleradiology [Tribe chose IHS] Credentialing Board Training Recruiting MDs Health Needs Assessment [Tribe chose Jemez Evaluator] Nurse Practitioners Nurse Manager Power Chart Outreach

HSC-linked Community Hospital- Academic Hubs

Hubs Propose d links

SAN JUAN SAN MIGUEL GUADALUPE CHAVEZ LEA DONA ANA GRANT TAOS SANTA FE

Sample County Health Report Card

Spin-Offs

Telepharmacy Food Pantries Training Agricultural Cooperative Extension

Agents (4-H, Home Economics, etc.)

BHAG: New Strategic Goal for the Health Sciences Center

“Working with our community partners, the University of New Mexico Health Sciences Center will help New Mexico make more progress in health than any other state by 2020.”

New Senate Bill: “Affordable Health Choices Act”

Sponsors: Kennedy’s Health Education, Labor & Pensions Committee (Bingaman, Harkin, Dodd, Mikulski, et al)

Section 399 “Primary Car Extension Program:

Integration of Primary Care with Health

Extensions

New cadre of Health Extension Agents Measures of Success: Community health as well as

health of enrollees in practice

Proposed support: $120 million/year x 6 years

“A new scientific truth does not triumph by cornering its opponents and making them see the light, but rather because its

• pponents eventually die and a new

generation grows up that is familiar with it.” – Max Planck, 1949