Kenyatta Lee MD Medical Director Community Affair Department

Kenyatta Lee, MD Medical Director , Community Affair Department University of Florida/Shands Jacksonville

Disparities: Now You See Them, Soon You Won’t!

Objectives • Overview of Shands and the History of the Community Affairs Department. • The Perfect Storm • Exciting Time to be in Ambulatory medicine • The Bridge – EHR, Northside Virtual Healthcare Model (Virtual Community Disparity Network) • JUDI's unique Qualifications • The Plan • Priorities

Historical Overview Community Affairs Department, 1989 -Present • Elizabeth Means, VP established the department to address unmet medical needs in underserved communities • The initial goal was to provide health education, health promotion, and community outreach in targeted communities • Programs are primarily funded through grants, strategic partnerships, faith-based organizations and community support • The goal has expanded to provide free and reduced comprehensive health care to the medically underserved in the urban core.

The Perfect Storm…for health disparities • • • Population Gender Adolescents ages 10 -19 Adult ages 20 -64 Senior adults 65 and older Race Median family income Children below poverty level Percent of population below poverty Unemployment Uninsured • Leading health disparities health zone of the 6 health zones in Jacksonville and Duval County, Florida, in cancer, strokes, diabetes, HIV/AIDS, teen pregnancy, STD’s and infant mortality. - *(Parentheses denote figure for Duval County, Florida. ) 127, 512 (850, 251) 53% female (48. 7%) 15. 9% (14. 2%) 55. 8% (61%) 14. 5% (10. 7%) 83% African American (29%) $28, 307 ($44, 740) 38. 4% (15. 4%) 28% (11. 9%) 9. 9% (4. 8%) 45% (9%)

Community Affairs Department “Community Responsive Medicine” Medical Director Consultant Vice President JUDI Clinical Programs Free Script D-RAP REACH HY-LIP Community Programs Heal Thy People Shop Talk Healthy Start Sickle Cell CARE Little Miracles Renal Delta Care Hispanic Initiative Women’s Health Initiative Clinics Virtual Community Disparity Network Proposed Disparity Hybrid Traditiona l Health Fairs MRA HIV/AIDS Brown Bag PQRI Hep. C Anti-Coag Grant Writing Case Management Childhood Obesity Disease Mgmt. Case Mgmt. Durkeeville Brentwood Paxon Soutel Eastside Murray Hill C. B. Mc. Intosh Wellness C. B. Mc. Intosh Pediatric College Park Soutel Winn Dixie

Was formed to help reduce health disparities identified by the US center of Disease Control and prevention that adversely impact low socioeconomic individuals in Jacksonville and Duval county recently acknowledge by AMA as a major problem and concern for the nation.

Goals are: A. Promoting health care B. Educating the general public and medical community C. Exploring scientific and related charitable purposes D. Proposed Virtual Community Disparity Network

Issues on the Horizon that could have a devastating Impact on the Urban Core PQRI P 4 P MRA Healthcare Bubble

“Healthcare Bubble? ”

Who will be most affected? • Individuals a) Much like the housing BUBBLE those individuals on the lower end of the economic spectrum are the most likely to be affected (Urban Core – Jax Healthzone 1) b) Will access to care be affected? • • Health insurance Medications Physicians Providers – The Governments response to the BUBBLE seems volitional (EMR, EHRs, MRA and performance based reimbursement) and will become mandatory. Those institutions/physicians that are unable to adapt rapidly to the changing healthcare environment will be vulnerable.

“Healthcare Bubble? ” • When the “healthcare bubble” bursts, is it perhaps better to be Ford than GM? • It is JUDI's mission to develop mechanisms (Virtual Community Disparity Network) that allow us to position urban core patients and physicians to bridge the void and prepare for a worse case bubble scenario.

Chronic Disease Crisis “According to the Centers for Disease Control and Prevention (CDC), chronic diseases are responsible for” – seven out of every 10 deaths in the United States – 75 percent of the more than $2 trillion dollars spent each year on health care in the United States. ”

WHY Chronic Disease Crisis? 1) Provider disconnect: a. Apprehension by PCP to see patient more than once a month and specialist more than 2 times per year. b. Fear of presumed perception of churning by payor and patient c. Hesitancy to treat if not at goal and will attribute diseases not to goal to patient issues (non-compliance) d. Provider hesitancy to adopt electronic medical records which is key to managing and addressing medical disparities (Journal Watch-Aug. 08). Benefit does not justify expense. 2) Patient disconnect: a. Lack of trust that disease is life threatening or is of eminent cause of morbidity b. Lack of funds c. Presumed system (provider) is churning for financial gain

Proposed Models of Chronic Disease Care • Proposed models: Chronic Care Model (CCM), Future of Family Medicine (FFM), Medical Home Model (MHM). • Regardless of what you ultimately call this (CCM, FFM or MHM) a new model of chronic care must emerge. • Regardless of the model it will take 2 -3 years for a system to mature and for us to begin to see improvement.

Pay for Performance (P 4 P) Implications for the Urban Core • Pros – Improved systems Virtual Community Disparity Network – The light will be focused on disparities • Cons – Medical Darwinism – Margins are tight – Barely Funded Mandate (presently reward does not justify the expense).

PQRI and MRA Physician Quality Reporting Initiative (PQRI) • On December 20, 2006, President Bush signed the Tax Relief and Health Care Act of 2006 (TRHCA). • Division B, Title I, Section 101 of the TRHCA authorizes a financial incentive for eligible professionals to participate in a voluntary quality reporting program. • Schedule and report on a designated set of quality measures… may earn a bonus payment of 1. 5% of their charges during that period, subject to a cap.

PQRI and MRA • Medicare Risk Adjustment (MRA) is the payment methodology mandated by the Balanced Budget Act of 1997. • It is used by the Centers for Medicare & Medicaid Services (CMS) to improve payment accuracy to Medicare Advantage (MA) organizations.

PQRI and MRA • CMS makes funding and other program decisions based upon the accuracy of the information that MA organizations supply to CMS. Risk adjustment helps to improve the accuracy of that information. • Consider installing an electronic medical records (EMR) system. • Talk to CMS about medical coding training for your office staff. • Check Web sources for medical coding assistance.

"Americans can always be counted on to do the right thing (Virtual Community Disparity Network). . . after they have exhausted all other possibilities. ” [Winston Churchill]

The Bridge – Virtual Community Disparity Network • Community Affairs Department will use its leverage to assist physicians in the transition to incorporate performance based medicine and the MRA initiative. • We believe that it is essential that we maintain the diversity of providers in the urban core. • That we determine our own destiny and not be dependent on others. Virtual Community Disparity Network

What's the plan? Disparity centers which through the Virtual Community Disparity Network offers: • • • No charge to patients regardless of ability to pay Disease Management Chronic Disease Registries for the providers Community Programs PQRI registries to all participating providers that can be submitted for improved reimbursements Ø Confidentiality bound by the IRB and HIPPA from sharing using information in a way different from that then that outlined • • • MRA support and advice Provide computer access E Prescribe Access to free scripts Infrastructure to adjust to the dynamic market place Levels the playing field for America’s Urban Core vs. more affluent areas

• What uniquely qualifies JUDI for this responsibility? • Lets talk: – Community Programs – Clinical Programs – Clinics

Community Programs • • Shop talk • Little Miracles • Healthy Start • Ryan White • Sickle Cell • Brown Bag Luncheon • Women’s Health Initiative Hep. C Screening Hispanic Initiative Health Fairs Heal Thy People Case Management Childhood Obesity

Program: Shop Talk • Shop Talk: The Touch of Life is a program dedicated to increasing breast cancer awareness and promoting optimal breast health for women in Duval and surrounding counties. • Health educators go into beauty salons, with learning materials and videos, to teach self-exam techniques • 2, 689 customers reached in 2008 • Self Testicular and Self Breast Examination Education • Quarterly Breast & Cervical Cancer Luncheons

Program: Healthy Start/Little Miracles • Healthy Start Program was started at Shands Jacksonville in November 2001. • Little Miracles began in October 2000 by Shands Jacksonville in an effort to make a difference in the alarming increase in infant mortality in Duval County. 2008 Statistics • Healthy Start Face to Face Encounters – 10, 368 • Little Miracles Enrollments - 5, 212 • Little Miracles Deliveries - 3, 160

Program: Ryan White Title I • This program was implemented March 1999 funded by Federal HRSA grant focus to decrease, navigate and educate the large volume of persons living with HIV/AIDS that were utilizing the ER as their primary care into medical clinics that specialized in HIV/AIDS. 2008 Statistics • Over 1, 600 patients were served

Program: Sickle Cell Community Partnership and Public Support • Sickle Cell program expanded to include adolescent, adult and traits. • Sickle Cell Disease and Trait Seminar 2007 – 103 participants • Sickle Cell Walk-a-Thon 2008 – 310 participants • Sickle Cell Health Symposium and reception 2008 – 286 participants • 116 customers were reached in 2008 with education

Program: Brown Bag Luncheon Background • Developed in response to the overwhelming need to increase compliance and decrease morbidity secondary to medications • Targets seniors many of whom take on average of 5 medications daily • Seniors meet daily at more than 20 local sites • Meets monthly 2008 Statistics • 199 customers were served

Program: Hep. C Screening Goal: – Provide health education and public information (HCV) for 2, 000 or more individuals in Jacksonville, Duval County – To complete HCV testing for 500 or more ILA, Inc members • Aug. 2007, Shands Jacksonville Eastside Family Medicine Center initiated the Hepatitis C project with the International Longshoremen Association (ILA) Inc • The project was funded by Roche Pharmaceuticals, Inc. • 2008 screened 171 customers from the ILA population

Program: Hispanic Initiative • Health fairs at Hispanic Churches • Third Sundays • Serving the Hispanic populations of Duval County – *2006 total Hispanic population 57, 765 (6%) – *Anticipated growth rate for 2010 - 76, 894 • 703 customers were reached in 2008 with education and health screening * Florida Statistical Outlook – 2007; Bureau of Economic and Business Research University of Florida, Gainesville, FL.

Program: Health Fairs • Free health screenings provided to all participants • Screening for: • High Blood Pressure • Diabetes • High cholesterol • Disease specific education handouts • 2008 Back to School Rally and Health Fair Statistics: • 1, 000+ total participants • 2, 200 backpacks filled with school supplies given out • 508 Physicals • 214 Immunizations for children • 101 Adult Health screenings • 8, 630 customers reached with education/health screening P. Riley, RN

Program: Heal. Thy People § Heal Thy People Health Sunday rotates churches every 3 rd & 4 th Sunday for health education by a physician and health screening makes great fellowship. § Other churches are involved in Saturday health fairs § Quarterly newsletters chock full of information go out to participating churches § The initiative builds trust, removes barriers, educates and collaborates with pastors and other community stakeholders § More than 1, 361 customers were reached in 2008 with education and health screening

Program: Case Management § Began May 2005 § Bi-annual review of ER encounters for the uninsured to identify those that make the ER their primary care home and redirect them to a more appropriate setting (Eastside, Brentwood or Disparity Clinic). § Number of Patients Converted from Uninsured to Insured 2005 - 2008 Eastside and Brentwood Combined – 4, 378 § There are 4, 330 patients in the program of which there were 83 new patients January 2009 *NOTE: After eliminating out of county, there is an 80% success rate of in county conversions. § Number of Patients with funding sources found: 2007 2008 City Contract 512 389 Medicare 17 27 Medicaid 193 131 Commercial 66 41

Program: Childhood Obesity • Scientific common sense approach to Childhood metabolic obesity • Recently acknowledged by ACP (American College of Pediatrics). They have recognized that Metabolic Syndrome is a major cause of Childhood Obesity • Reducing Childhood Obesity through early identification of DM, Hy-Lip, Thyroid disease and dietary consult • Labs being reviewed for Metabolic Syndrome i. e. Lipid Profile, Glucose, Hypertension and Thyroid.

Clinical Programs • D-RAP • Pharmacy/Anti-Coag • REACH • Free Scripts • HY-LIP • Renal • CARE • Delta Care

DIABETES RAPID ACCESS PROGRAM THE DISEASE MANAGEMENT PROTOTYPE

Disparity Program: D-RAP • Historically started with A 1 c > 9. 0 since the inception of the program all diabetics are in the D-RAP program • Educated concerning diabetes and lifestyles changes • Assessed as to whether or not they are taking medication or can afford medication/co-pay • We use long acting insulin and generics. • The patient is an active participant in the program • Patients are assessed each visit through PQRI and outliers are followed-up by the nurses in disease management

Disparity Program: D-RAP Results: • Program began in June 2006 with study group of 300, average A 1 c - 11. 0 • 11 months into the program average A 1 c - 8. 5 at which time all diabetics enrolled • 265 letters sent for month of January 2009 • Seeing a fast growing population of UF non. Commonwealth patients

D-RAP Start long acting insulin A 1 C >= 8. 0/ glucose>200 mg/dl fasting Follow-up every 2 -3 days A 1 c checked every 3 mnths Short acting insulin before meals NC w/multiple injections add Januvia increase Lantus Continue f/u Metformin (start at 500 mg – qd (max)/Education No Add Symlin/Januvia Short acting insulin (? Covered) BMI >= 40 Waist circumference Female >= 35 Male >= 40 Review lifestyle changes Review barriers Cost an issue Life Style Changes A 1 c <= 8. 0/ fasting < 150 Yes Follow-up every 2 -3 days Freescript pgm. Taken meds as ordered A 1 c checked every 3 mnths A 1 c <= 7. 0/fasting < 110 glucose <150 fasting Yes No Edu. No yes Continue to f/u add Januvia ( ? Covered) BMI = 40 Waist cir. female >= 35 Male >= 40 Not covered consider insulin

Diabetes Spreadsheet

Disparity Program: D-RAP *NHANES III A 1 c Avg. – 7. 7

National A 1 c Average – 7. 7

Review Evaluate And Control Hypertension

Disparity Program: REACH • Disparity Centers used for monitoring and modification of treatment • Medication assistance provided • Pharmacist routinely review medication protocol • Disease specific education • Patients contacted via letter/phone • Registry – > 7, 000 for quarterly evaluation by Physicians Results • • 400 letters sent for the month of January 2009 City Contract patients - 1, 477 FCA patients - 370 Humana patients - 1, 173

REACH Pharmacist Systolic > 140 Diastolic > 90 Life Style Changes/ Review barriers and labs HCTZ ACE Calcium Channel Blocker ARB Alpha Blocker/ Beta Blocker Tekturna/Other Renal

Hypertension Spreadsheet

HYper. LIPidemia

Disparity Program: HY-LIP Background: • Recognized as a significant risk for morbidity and mortality • Decreasing risk of heart attack and stroke by lowering LDLs Methods: • Monitor all labs for elevated lipids and triglycerides • To include women of child bearing age with LDL > 100 • Guidelines based on NCEP/ATP III

HY-LIP Trig > 200 LDL > 100 Yes Life Style Changes/ Review barriers and labs No Female of child bearing age LDL > 100 Questeran LDL > 100 Endocrinologist Yes No Zocor Trig > 200 Lipitor Tricore Zetia Endocrinologist

Disparity Program: HY-LIP

HY-LIP Spreadsheet

COPD/Asthma and Respiratory Enhancement

Disparity Program: CARE METHODS: § To assist patients to achieve and maintain optimal lung function with effective control of COPD/Asthma based on 2007 GOLD and GINA guidelines § To decrease mortality and morbidity associated with COPD/Asthma § To Education patients regarding COPD/asthma § To assure appropriate, safe, and cost-effective treatment strategies are provided to patients RESULTS: § Currently 251 patients enrolled in CARE Program

CARE Baseline Asthma COPD PCP Clinical Spirometry/PFTs/ Assessment/Diagnosis Classification of Severity Initiate Treatment A. B. C. A. ICS/LABA LTRA SABA B. C. D. E. Monitor Response Patient Education Document encounter /results in Allscripts & forward to PCP Abbreviation Key: ICS/LABA: inhaled corticosteroid/long acting beta-2 agonist LTRA: leukotriene receptor antagonist SABA: short acting beta 2 agonist LA AM/AC RB: long acting amtimuscarinic/anticholinergic receptor blocker Nebulizer Tx; repeat Spirometry ICS/LABA LTRA SABA LA AM/AC RB Patient Education

Disparity Program: Anti-Coagulant Clinic Pharmacy • Pharmacy clinic at Soutel Wellness Clinic on Thursdays • Patients INR done at Disparity Clinics • No co-pay • Follow-up visit at Soutel Wellness with Pharmacist • Letter sent for patient to be seen at Soutel Wellness • Number of Patients Seen in the Coumadin Clinic - 209

FREE SCRIPTS

FREE SCRIPTS • • Part of JUDI Disparity Clinic System: No Cost Access to Medical Care Part of JUDI Disease Management: No Cost Screening and Medication Management Patient given No Cost/free generic or negotiated brand medications Takes pressure off patient concerning financial priorities “Do I buy meds, gas or food? ” food? Gains patient trust Increases patient compliance Decreases ER and Hospital encounters

Program: Free Script Results: • To date, greater than 10, 000 prescriptions have been filled. • Patients in program – 418 Future Initiative: • Negotiation to expand the Free Script program with Winn-Dixie/ILA (done)

Data Management Registry Specialist • PQRI Initiative • MRA Initiative • Health Maintenance Notification

Communication to Patient Addressing Areas of Disparities • Letters are mailed on a continuous basis for patient to come in and follow-up on labs and PCP visits • Patient on registry are assessed quarterly through the registry program • Forms go to Registry Specialist to enter data into the registries • 2, 492 letters were sent for the month of January 2009 for Health Maintenance • Approximately 710 letters sent to patients concerning abnormal labs for the month of January 2009

Diabetes PQRI Form

Allscripts Note SHANDS JACKSONVILLE 655 W. 8 TH STREET JACKSONVILLE, FLORIDA 32209 Chief Complaint • Patient is here for BP check-up, glucose check-up. PCP is Dr. Reluctant. Vital Signs Recorded by bmarcus on 09 Sep 2008 03: 29 PM BP: 158/100, LUE, Sitting, HR: 76 b/min, Height: 68 in, Weight: 240 lb, BMI: 36. 5 kg/m 2. Assessment • Benign essential hypertension (401. 1); on HCTZ- 25 mg • Diabetes mellitus (250. 00); A 1 c– 3/08– 11. 0 due 6/08 Accu-Check Fasting: 230 mg/dl denies hypoglycemia Fasting whole blood sugar glucose reference range: 60 -99 mg/d. L Notes Are you having trouble getting your medications? No Are you taking your medications daily? Yes Have you been to the ER? No Have you had any low blood sugars? No When is your next scheduled visit with your provider? appointment next week with PCP

Coun/Edu Patient is made aware of the importance of monitoring Hgb. A 1 c every three months, having a yearly dilated eye exam, checking feet regularly for damage to the skin, monitoring cholesterol, seeing an endocrinologist yearly and maintaining a diet consistent with diabetes care. discussed results of A 1 C, to return for labs Teaching re: Hypertension, accurate monitoring includes daily BP check by viable tester, nurse, health care provider, fire department to be taken same time each day. Documentation card to patient. Agrees to return in one week for re-evaluation. Plan Decrease salt intake Check blood sugar twice a day at different times regularly and bring log to next appointment. Discussed with patient how to take medication prescribed. Reviewed medications, bottle dated within 30 days Patient: MRN: APPLE TEST 13650730 Encouraged patient on medication compliance. Return in 3 days. F/U with PCP at appointment next week denies dizziness or headache. Instructed pt to go to ER or call PCP if he should start having symptoms consider adding ACE consider increasing Lantus to 25 units nightly Signature Signed By: Bobbie Marcus ; 09/09/2008 3: 58 PM EST.

Other Providers # of Patients Diabetes 66 88 DCHD – 2 VA CLINIC – 6 Hypertension 74 115 DCHD – 1 VA CLINIC – 6 VOLS IN MEDS – 2 Hyperlipidemia 6 6 Program Provider not specified (# of patients)

Clinics • Improved Access – Strategically located throughout the Urban Core – Flexible hours of operation – Same day Walk-ins • Disparity clinics have access to Electronic Medical Record System (Allscripts) (Virtual Community Disparity Network – proposed) • Disparity clinics have access to the Shands Hospital’s Electronic Medical Record System (Portal) • All clinics have access to Case Management • Participating clinics have access to our Registry Specialist. • Office MAs send PQRI forms to clinic for registry and actions. • Hispanic based system available.

JUDI-affiliated clinics and programs reflect the major causes of morbidity and mortality in Jacksonville, in both purpose and location. Disparity Traditional Hybrid Winn Dixie (Coming Soon) Soutel Wellness Durkeeville Soutel Shands Eastside College Park Brentwood Commonwealth C. B. Mc. Intosh Murray Hill

Hybrid Clinics Eastside Brentwood C. B. Mc. Intosh • Provides care for both uninsured and insured patients. • Decrease inappropriate utilization of ER as source or primary care. – Hospital discharges – ER discharges • Pediatric patients • Total encounters for FY 08 – 12, 528

Eastside § Opened: September 2003 § Location: 1155 East 21 st Street § Services: § Adult Medicine § Pediatrics § Obstetrics and Gynecology § Providers: 2 § FY 08 § Patient visits – 8, 439 § Special programs: § Case Management § Free Script § HIV Clinic § ER/hospital discharge - safety net

Brentwood § Opened: June 2007 § Location: 3465 Village Center Drive § Services: Adult Medicine § Providers: 1 § FY 08 § Patient visits 3, 333 § Special programs: § Case Management § Free Script

C. B. Mc. Intosh Pediatric Center • Sickle Cell Services – Patient visits FY/08 - 756 – Pediatric Services – Adolescent Services – Transition Program – New Sickle Cell Trait Initiative • Pediatric Service – 5/07 – Center for uninsured

Paxon • Located in zip code 32254 • FY 08 Patient visits - 16, 287 Soutel Plaza • Located in zip code 32208 • FY 08 Patient visits – 6, 485 Traditional Clinics College Park • Located in zip code 32209 • FY 08 Patient visits - 5, 612 Murray Hill • Located in zip code 32205 • FY 08 Patient visits – 12, 820 Total encounters for FY 08 – 41, 204

THE NUMBER OF WALK-INS FROM THE COMMONWEALTH GROUP.

Registry Impacting ER Utilization • Query of the non-emergent uninsured encounters from the Shands ER population • 4, 075 Patients sent letter offering a Community Affairs Clinic as an alternative • Number of Uninsured Patients Sent from Shands ER and patients discharged from hospital between 2005 - May 2008 to Eastside and Brentwood were a combined total of - 1, 654

ER impact on an annual basis with an average cost per visit saved.

What makes the Disparity Clinics different? Payment source/Staffing/HER – Disparity - no payment required – Staffing - Pharmacist/Registry Specialist/Nurse/MA – Virtual Community Disparity Network - proposed

Disparity Clinics Services: § No cost (funded and Un-funded) § § Screening (HTN, Diabetes, Hyperlipidemia) Monitoring Education Treatment Programs: § Disease Management § Pharmacy Initiative Statistics: § Soutel patient visits FY 08 – 5, 992 § Durkeeville patient visits FY 08 – 4, 336 § NEW – CB Mc. Intosh/Winn Dixie Soutel Durkeeville CB Mc. Intosh

Number of ER self-pay cases.

Questions and Discussion