Homeless Health In In New Orleans: Do Student Clinics Connect - - PowerPoint PPT Presentation

Aaron Brug, Maren Gregersen, Georgie Green, Scott Mayer, Joseph Kanter MD MPH, Catherine Jones MD

Tulane University School of Medicine, New Orleans, LA

Homeless Health In In New Orleans:

Do Student Clinics Connect Patients with Long Term Care?

• Tulane University School of Medicine has 7+ free, student run clinics

serving the greater New Orleans area

▫ Clinics at 2 men’s emergency homeless shelters – weekly, preceptor model

 Opportunity to provide a variety of interventions:

 Point of care health screening (e.g. BP, DM, TB, HIV, HCV)  Counseling  OTCs  Prescriptions  Referrals to more sustainable complete, care

Background: Meeting patients where they are

• Federally qualified health

center (FQHC) providing primary healthcare services to adults in the city of New Orleans and surrounding parishes regardless of ability to pay for services.

• A potential medical home for

homeless patients

• A. Who are our patients?

▫ Are our anecdotal experiences an accurate representation of our patient population and the problems they face?

• B. Do they follow up at HCH when we refer them?

▫ Are they being seen once or establishing long-term care?

• C. What predicts a referral? What predicts a successful follow up

appointment?

▫ Can we harness that information to improve how we connect our patients with care?

Questions:

• TuPACT: Tulane University Patient Assessment & Care Tracking

▫ database started in 10/2016 to serves as a flexible architecture to constantly learn about our clinics

 Following each patient visit clinic volunteers collect:

 Demographics  Health risk factors  Key objective findings  Treatment plans: including places referred

 Survey via REDCAP: secure web application created at Vanderbilt University

 Geared towards providing data collection tool that met HIPAA compliance standards  Mobile compatible

• Tracked HCH patient follow up monthly: 90 day window

▫ 1 full year data (10/2016-10/2017)

• Analysis for predictive factors of referral and successful follow up

Methods:

• 207 patients* seen between

10/16/2016 and 10/15/2017

▫ *New Orleans Mission Clinic closed due to facility renovations (3/2017 to present)

 148 patients at Ozanam Inn; 59 patients at NOM

• Age: Range 22-74; Mean 51.7; StDev

11.64

• Gender: 92.6% Male
• Incarceration: 55.8%
• < GED or HS diploma: 61.4%

Results: A. Who are our patients?

1 1 2 72 121

20 40 60 80 100 120 140

Native Hawaiian or Pacific Islander Asian American Indian or Alaskan Native Other Caucasian African American

Race

3 4 11 15 17 19 23 28 35 38 51 74 99

20 40 60 80 100 120

HIV CAD Other Asthma Diabetes COPD HCV Alcohol abuse None Illicit Drug use Psychiatric Diagnosis Hypertension Smoking/Tobacco Use 4 15 27 27 29 78 20 40 60 80 100 VA Other Uninsured Unknown Medicare Medicaid

Results: B. . Do they follow up at HCH when we refer them?

56 151

Refered to HCH Not referred to HCH 27.05% of all patients were referred

12 44

Prior HCH Appt No Prior HCH Appt 21.43% of referred patients had been to HCH before

30 9 3 14

Never HCH Appt Prior w/o new Prior with New HCH Appt w/o prior 30.36% of referred patient’s followed up w/i 90d 25.00% of referred patients follow up w/o prior appt.

Results: B. . Are they establishing long term care?

1 2 3 4 5 6 7 8

1 2 3 4 5 Number of Patients Number of visits within 90 days

• Logistic regression model; backwards elimination
• Variables included in the model:

▫ Race: Black, White, Ethnicity (Hispanic vs Nonhispanic), Other ▫ Insurance status: Medicaid, Medicare, VA, unknown, other, uninsured ▫ Chief complaint: categorized into, pulmonary sx, ENT sx, neuro sx, MSK sx, skin sx, rash, abdominal sx, GU sx, women’s health, mental health, htn, diabetes, chest pain, intake, and other ▫ Whether or not the patient had multiple chief complaints per 1 visit (y/n) ▫ Medications refilled/prescribed on visit ▫ Chronic health conditions (COPD, asthma, HIV, HCV, diabetes, htn, cad, psychiatric condition) ▫ Smoking/Illicit drug use/Alcohol use

• Significance threshold p<0.05

Results: C. . What predicts a referral? What predicts a successful follow up appointment?

Results: C. . What predicts a referral?

Characteristic Odds Ratio Estimate (95% CI) p Mental health related chief complaint on first visit 4.50 (1.0 – 19.6) 0.0446

• Those with mental health related chief complaints were 4.50 times more likely

to get a referral to HCH than those with other types of chief complaints

• PMHx of mental health problems were a separate variable that did NOT

predict referral

• No other variables (race, substance abuse) significantly predicted a referral
• An indication that the clinics as a whole don’t have any pervasive biases?

N=193 (of 207)

Characteristic Odds Ratio Estimate (95% CI) p Mental health related chief complaint on first visit 26.31 (1.5 – 500.0) 0.0240 Medicaid 0.11 (0.01-- 0.9) 0.0410

Results: C. What predicts a successful follow up appointment in patients with no prior HCH appointment?

• Mental-health related chief complaints far more likely to follow-up at HCH than other chief

complaints

• Non-Medcaid patients are 9.47 times more likely to follow-up at HCH among all those who

received an HCH referral.

• Are these patients more likely to see a provider elsewhere? Their Medicaid assigned PCP?

N=55 (of 56)

• While the proportion could be greatly improved

▫ Homeless patients DO follow up with primary care ▫ Homeless patients DO establish longitudinal care at primary care provider  Recently started assessing transportation status  is there a potential transportation intervention?

• Medicaid patients were less likely to follow up with HCH

▫ Better tailor referrals given insurance status

• Mental health predicted both referral and follow up to HCH

▫ Are we missing mental health complaints in other patients? ▫ Supports increased mental health screening and advocacy

Conclusions:

• Health Care for the Homeless: Joseph Kanter MD MPH
• TuPACT Team: Maren Gregersen, Georgie Green, Scott Mayer,

Erika Chow, Frances Gill, Catherine Jones MD

• Tulane University School of Medicine for their support of the

clinics

Acknowledgements

Aaron Brug abrug@tulane.edu

Questions?