[PPT] - The Enabling Services Accountability Project Heidi Park, PhD The PowerPoint Presentation

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The Enabling Services Accountability Project

Heidi Park, PhD The New York Academy of Medicine Rosy Chang Weir, PhD The Association of Asian Pacific Community Health Organizations

Presented at the NACHC Annual Conference and Community Health Institute San Francisco, CA September 21, 2004

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Project Goals

Develop new database and data collection

protocol for enabling services at health centers

Describe the utilization of enabling

services by AAPIs at health centers

Assess health needs of enabling services

users

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$0 $200,000 $400,000 $600,000 $800,000 $1,000,000 $1,200,000 $1,400,000 $1,600,000

Total Cost Enabling Services

AAPCHO 00 AAPCHO 01 AAPCHO 02 AAPCHO 03 NATIONAL 00 NATIONAL 01 NATIONAL 02 NATIONAL 03

Average Financial Cost of Enabling Services

(Total cost after allocation of facility and administration)

00-03 Diff=$207,218 or 16% 00-03 Diff = $112,163 or 23%

Costs for Enabling Services Increased from 2000 to 2003 both at AAPCHO Health Centers and Nationally

Source: UDS

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Background

Enabling services are critical to access to

care for health center patients

Enabling services are not reimbursed and

are often underfunded

Need for better data on enabling services

and their impact on health

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Background – 2

Budgetary pressures and rising health

care costs

Racial/ethnic disparities in health National focus on quality of care

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Health Center Participants

Waianae, Hawaii Honolulu, Hawaii New York, New York Seattle, Washington

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AAPCHO Health Center Overview

2003 UDS

39% 56% 60% (minority) 42,463 12,376 FQHCs Average1 18% 50% 25% 25% 37% % uninsured 65% 67% 70% 77% 58% % at or below 100% FPL 77% 63% 87% 96% 72% % AAPI 107,156 32,571 35,614 124,940 52,960 # of medical encounters 23,612 7,665 9,589 24,777 12,764 # of medical users CHC #4 CHC #3 CHC #2 CHC #1 AAPCHO FQHCs

1 BPHC, National Rollup, 2004

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ESAP Definitions

Our categories: (modified from MGMA Report, 2000)

1. Case management-assessment
2. Case management-treatment & facilitation
3. Case management-referral
4. Eligibility Assistance/Financial Counseling
5. Health Education
6. Interpretation
7. Outreach Services
8. Transportation
9. Other

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Encounter Form

Sample encounter form With patient data fields

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Implementation varied by health center needs and existing procedures

Data Systems ES Structure Existing Processes

+ +

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Pilot Data Overview

(3 months)

23% 76% 2,638 1,558

ESAP

CHC # 4 CHC # 3 CHC # 2 CHC # 1

14% 33% * * 40% 20% 20% 17% 12% percent uninsured 80% 93% 82% 96% 90% 99% 97% percent AAPI 17,705 2,036 11,559 3,995 11,588 1,151 36,102 number of encounters 12,167 1,154 5,353 2,424 5,551 724 14,457 number of users

Total ESAP Total ESAP Total ESAP* Total **does not include uninsured who are covered by IHI *only includes ES provided by the social services department

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Demographic Data

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Age of ES Users

CH C 2 - Age

100 90 80 70 60 50 40 30 20 10 300 200 100

Std. D

ev = 23.53 Mean = 44 N = 2425.00

CH C 3 - Age

100 90 80 70 60 50 40 30 20 10 120 100 80 60 40 20

Std. D

ev = 22.07 Mean = 44 N = 1154.00

CH C 5 - Age

100 90 80 70 60 50 40 30 20 10 300 200 100

Std. D

ev = 20.63 Mean = 33 N = 1558.00

CH C 1 - Age

100 90 80 70 60 50 40 30 20 10 120 100 80 60 40 20

Std. D

ev = 21.09 Mean = 29 N = 724.00

CHC 1 CHC 2 CHC 3 CHC 4

Median=27 Median=47 Median=47 Median=29

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Race/Ethnicity of ES users

CHC 1 CHC 2 CHC 3 CHC 4

Eth n icity

O t h e r R a c e / E t h n i c i t y W h i t e O t h e r A s i a n V i e t n a m e s e C h i n e s e

C

u

n t

800 600 400 200

Eth n icity

O t h e r R a c e / E t h n i c i t y M i x e d

O

t h e r B l a c k / A f r i c a n

A

m e r i c H i s p a n i c / L a t i n

W

h i t e A m e r i c a n I n d i a n / A l a s O t h e r P a c i f i c I s l a n d S a m

a

n O t h e r A s i a n V i e t n a m e s e K

r

e a n J a p a n e s e F i l p i n

C

h i n e s e

C

u

n t

1600 1400 1200 1000 800 600 400 200

Eth n icity

O th e r R a c e / E th n ic ity M ix e d

O

th e r M ix e d

A

A P I B la c k / A fr ic a n

A

m e r ic H is p a n i c /L a tin

W

h i te A m e r ic a n I n d ia n /A la s O th e r P a c if ic Is la n d S a m

a

n G u a m a n ia n /C h a m a r ro N a t iv e H a w a iia n O th e r A s ia n V ie t n a m e s e K

r

e a n J a p a n e s e F ilp in

C

h in e s e

C

u

n t

1000 800 600 400 200

Eth n icity

O t h e r R a c e / E t h n i c i t y M i x e d

O

t h e r B l a c k / A f r i c a n

A

m e r i c H i s p a n i c / L a t i n

W

h i t e O t h e r P a c i f i c I s l a n d S a m

a

n N a t i v e H a w a i i a n O t h e r A s i a n V i e t n a m e s e K

r

e a n J a p a n e s e F i l p i n

C

h i n e s e

C

u

n t

400 300 200 100

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Primary language of ES users

CHC 1 CHC 2 CHC 3 CHC 4

Prim ary Lan gu age

O t h e r P r i m a r y L a n g u a V i e t n a m e s e T

n

g a n T h a i T a g a l

g

S p a n i s h S a m

a

n M a n d a r i n L a

t

i a n K

r

e a n K h m e r J a p a n e s e H m

n

g C a n t

n

e s e E n g l i s h

C

u

n t

1200 1000 800 600 400 200

Prim ary Lan gu age

O t h e r P r i m a r y L a n g u a V i s a y a n V i e t n a m e s e T

n

g a n T a g a l

g

S p a n i s h S a m

a

n M a n d a r i n L a

t

i a n K

r

e a n J a p a n e s e H m

n

g C a n t

n

e s e E n g l i s h

C

u

n t

300 200 100

Prim ary Lan gu age

O t h e r P r i m a r y L a n g u a T a g a l

g

S p a n i s h S a m

a

n M a n d a r i n K

r

e a n E n g l i s h

C

u

n t

2000 1500 1000 500

Prim ary Lan gu age

O t h e r P r i m a r y L a n g u a V i e t n a m e s e M a n d a r i n C a n t

n

e s e E n g l i s h

C

u

n t

400 300 200 100

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Insurance coverage of ES users

CHC 1 CHC 2 CHC 3 CHC 4

I n su ran ceCarrierCategory

O t h e r C a r r i e r S e l f

P

a y O t h e r P u b l i c M e d i c a r e M e d i c a i d

C

u

n t

600 500 400 300 200 100

I n su ran ceCarrierCategory

O t h e r C a r r i e r S e l f

P

a y P r i v a t e O t h e r P u b l i c M e d i c a r e M e d i c a i d

C

u

n t

1000 800 600 400 200

In su ran ceCarrierCategory

O t h e r C a r r i e r S e l f

P

a y P r i v a t e M e d i c a r e M e d i c a i d

C

u

n t

500 400 300 200 100

In su ranceCarrierCategory

S e l f

P

a y P r i v a t e O t h e r P u b l i c M e d i c a r e M e d i c a i d

C

u

n t

800 700 600 500 400 300 200 100

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Utilization Data

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Type of Services Provided

Enabling Service

Other Enabling Svcs Transportation Svcs Outreach Services Interpretation Svcs Health Ed/Supp Couns Financial Counseling Case Mgmt Referral Case Mgmt Treatm ent Case Mgmt Assessment

Number

4000 3000 2000 1000

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Service Use by Age Group

0% 20% 40% 60% 80% 100% less than 1 1 to 14 years 15 to 24 years 25 to 44 years 45 to 64 years 65 and

ver

Age Group

CM FC HE Int Out Trans

ther

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Average Length of Services

19.0 18.6 14.9 23.1 23.0 19.7 16.8 33.1 12.9 22.3 5 10 15 20 25 30 35

CM-a CM-t CM-r FC HE Int Out Trans Other All

Type of Service minutes

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Provider Type by Enabling Service

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Transportation Provider Health Educator Other Case Manager Interpreter Pharmacist Eligibility Worker Outreach Worker Administration/Clerk Nurse Community Health Worker ES Provider Medical Assistant

CM-a CM-t CM-r FC HE Interp Out Trans

ther

9 9 8 7 7 7 7 5 3 3 2 2 1

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Project Evaluation – Feedback

Enabling services staff were interested in

showing how their services impacted their patients’ health

Enabling services staff were willing to provide

information about their work

Enabling services staff were involved with

improving processes

Health centers faced many similar challenges

and benefits with the project

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Limitations of the Data

Health centers use different methods for

providing enabling services

Enabling services (ESAP) data reflects those

services captured through the protocols implemented at each health center

“Other enabling services” include those that link

patients with non-medically related services, such as housing, food, education

Services less than 10 minutes are not captured

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Health Needs Project: Preliminary Data

Do ES users have different characteristics from

non-ES users?

What are the health needs of ES users?

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Methodology

Setting

Three community health centers serving primarily AAPIs located in:

1. New York, NY
2. Seattle, WA
3. Waianae, HI

Population

1. Enabling Service Users (N=2656):
All patients who used at least one enabling service in 6/04
2. Non-Enabling Service Users (N=2190):
Random sample of patients who had a primary care visit in 6/04
Excluded patients who used enabling services during our data

collection period

Measures

Demographic: Gender, Age, Ethnicity, Insurance Primary diagnosis of all primary care visits from 6/1/02-6/30/04 *coded as Ambulatory Care Sensitive Conditions (Falik et al, 2001; Billings, et al. 1993)

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ES User Non-ES User Total Frequency Percent Frequency Percent Frequency Percent Total 2,656 100 2,190 100 4,846 100 Gender Female 1,809 68 1,255 57 3,064 63 Male 847 32 935 43 1,782 37 Ethnicity Chinese 1,150 43 779 36 1,929 40 Filipino 165 6 231 11 396 8 Korean 107 4 38 2 145 3 Vietnamese 307 12 307 14 614 13 Other Asian* 137 5 120 5 257 5 Native Hawaiian 469 18 318 15 787 16 Samoan 66 3 40 2 107 2 Other Pacific Islander 29 1 37 2 66 1 Total AAPI 2430 92 1870 86 4300 88 White 132 5 138 6 270 6 Other Race/Ethnicity** 92 3 180 8 272 6 Insurance Carrier Medicaid 1,004 38 976 45 1,980 41 Medicare 337 13 251 11 588 12 Other Public 505 19 272 12 777 16 Private 285 11 358 16 643 13 Self-Pay 525 20 326 15 851 18 Other Carrier 6 0.3 6 0.1 Age Younger than 1 72 3 137 6 209 4 1-4 154 6 195 9 349 7 5-14 174 7 298 14 472 10 15-24 390 15 240 11 630 13 25-44 687 26 488 22 1,175 24 45-64 687 26 501 23 1,188 25 Older than 64 492 19 331 15 823 17

*Other Asian Includes Japanese and Asian Indian **Other Race/Ethnicity includes American Indian/Alaska Native, Black, Hispanic/Latino, Mixed-AAPI, and Mixed-Other

Table 1. Patient Demographics – ES Users and Non-Users (Preliminary Data)

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ES User Frequency Percent Chronic Conditions Asthma 127 2 Epileptic Convulsions 17 0.3 Cellulitis 160 3 Diabetes 324 5 Congestive Heart Failure 71 1 Hypertension 108 2 Iron-Deficiency Anemia 12 0.2 Pulmonary Disease 174 3 Total 993 17 Acute Conditions Bacterial Pneumonia 3 0.1 Ear, Nose, & Throat Infections 667 11 Gastroenteritis, Dehydration 41 1 Hypoglycemia 7 0.1 Kidney/Urinary Infections 163 3 Pelvic Inflammatory Disease 3 0.1 Failure to Thrive 14 0.2 Tuberculosis 4 0.1 Immunization-related Events Total 902 15 Reproduction & Dev 917 15 Routine Care 874 15 Other 2,307 38 Total 5,993 100 Average number of conditions per user 1.5

Table 2. Chronic and Acute Ambulatory Care Sensitive Conditions – ES Users

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Management Decisions

to allocate resources effectively to appeal for more funding to improve services to target services

What can we do with the data? How can it be useful?

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Future Studies

How to use the data in research studies:

To look at enabling services in more detail:

Describe variation of services Determine the nature of need for services

To look at the contribution of enabling services

at health centers to quality care and reduction of health disparities

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The ESAP Team

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Thank you!

Our health center partners Bill Shanks, Hawaii Patient Accounting

Services

Linda Tran, AAPCHO Funded by: Agency for Healthcare Research and Quality and MetLife Foundation (HP), Office of Minority Health and the California Wellness Foundation (RCW)