The Palmetto Project: Putting Innovative Ideas to Work in South Carolina-Steve Skardon

The Palmetto Project Putting Innovative Ideas to Work in South Carolina Steve Skardon, Executive Director

South Carolina Immunization Partnership
Communicare
AccessNET Provider Collaborative &
Patient Navigator Network

South Carolina Immunization Partnership February 1993 – May 1994
Objective
Make S.C a national leader in childhood immunization
Partners
S.C. Department of Health & Human Services
Palmetto Project
Alliance for South Carolina’s Children
Blue Cross Blue Shield of SC
S.C. Press Association
Rotary & Lions Clubs

South Carolina Immunization Partnership (continued)
Methods
Political campaign techniques identify, educate, & motivate parents
Community partnerships among business and civic leaders create
local strategies in 13 public health districts
Broadcast and print media partners in each health district
Outcomes
Increased immunization rates statewide from 53% to 90%
Ranked by CDC as 1 st in the nation in 1994

Communicare 1993 – present
Objective
Improve access and coordination of health care services for the
uninsured and underinsured
Partners
S.C. Medical Association
S.C. Hospital Association
S.C. Pharmacy Association
Six National Pharmaceutical Companies
Smith Kline Beecham Labs

Communicare (continued )
Methods
Care coordinator at statewide toll-free call center arranges for…
free visit for any uninsured caller to one of 2,000 providers
free pharmaceuticals from formulary of six participating drug companies,
overnight stays at one of 30 participating hospitals
Outcomes
53% of 8,000 clients provided medical home
Central fill pharmacy provides 1000 free prescriptions daily at
an estimated value of more than $70 million annually (Welvista)
Faith-based Initiative in African American health reduces disparity
in cardiovascular mortality among males by 50%. (Heart & Soul)

AccessNET Provider Collaborative & Patient Navigator Network 2005 – present
Objective
Improve health care outcomes and reduce cost of care for the uninsured with chronic disease through enhanced provider coordination and patient-centered navigation
Partners
Medical University of South Carolina (Women’s Health Initiative)
Medical University of South Carolina (Children’s Hospital)
Two Federally Qualified Community Health Centers
Three Local Free Clinics
Charleston Dorchester Mental Health Association
SC Department of Health & Environmental Control
SC Office of Research & Statistics

AccessNET (continued)
Methods
Providers standardize records into single data management system (AIMS), implement procedures for patient referral & medical follow up, & refer patients to health education and disease management programs
Navigators assess needs of new patients, address barriers to care, develop plan for care including referral to primary & specialty care and pharmacy assistance,
Outreach specialists implement health education and disease prevention programming in at-risk communities, conduct ongoing screening, monitoring, life style modification, $ disease self-management for navigated patients

AccessNET (continued)
Outcomes
100% of 2,000 clients provided medical home and access to patient navigation services
AIMS system becomes statewide platform for statewide medical records locator and health information exchange for 4.4 million South Carolinians
Cost of care for navigated patients declines by 27%
A 66 percent reduction in emergency room utilization by navigated patients with diabetes
An 83 percent reduction in ER utilization by navigated patients with cardiovascular disease

Lessons Learned
Clearly perceived need & limited objective
Opportunity
Plan
Needs assessment of every collaborating partner
Management of Collaborative: Democratic versus direction from lead partner?
Signs of early success

Y’all com beck, y’hare?

“ To every person there comes in life that special moment when one is tapped on the shoulder and offered the chance to do one very special thing. What a tragedy if that moment finds you unprepared or unqualified for the work which would be your finest hour.”
“
Winston Churchill

Where are we headed? (and who’s doing the driving?)

Regional Networks of Care
We can’t solve problems by using the same kind of thinking we used when we created them.”
Albert Einstein

Regional Networks of Care Population 703,505 Nearly 45% of population is uninsured or does not have sufficient coverage to meet its needs.

Continuum of Care
Provider collaborative reduces administrative duplication
& streamlines access to primary, diagnostic, & specialty care
Access & Care Coordination
New navigator network increases access & care coordination
Education & Prevention
149 Heart & Soul sites provide outreach & ongoing health education
Data Collection & Management
Providers create single data management system

Medical Outcomes & Patient Centered Care

Outcomes research seeks to understand the end results of particular health care practices and interventions. These include effects that people experience and care about, such as change in the ability to function. For individuals with chronic conditions, end results include quality of life as well as mortality. By linking the care people get to the outcomes they experience, outcomes research has become the key to developing better ways to monitor and improve the quality of care.
Agency for Healthcare Research and Quality

Patient centered care is that which is based on a partnership among practitioners, patients, & their families to ensure that decisions respect patient wants, needs, and preferences and that patients have the required education & support to make decisions and participate in their own care .
Institute of Medicine

Data Management & Electronic Records

Disabilities & Special Needs Vocational Rehabilitation Law Enforcement Health Department Education Outpatient Surgeries State Employee Health Services Emergency Room Visits Hospitalizations Environmental Conditions Home Health Care Medicaid Services Social Services Public Safety Mental Health Juvenile Justice Free Clinic Visits Alcohol & Drug Services Child Care Community Health Centers Medicare Disease Registries Elder Services & Assessments Probation, Pardon & Parole Corrections* Legal/Safety Services Social Services Claims Systems All Payer Health Care Databases Behavioral Health Health Department Education Other State Support Agencies Disease Registries LEGEND SC Integrated Data System

Web-based database system designed and implemented by the SC Office of Research and Statistics (ORS),
System integrations and coordination utilizes the state’s HIPAA compliant secure Data Warehouse and Client Information System.
Accessible to all collaborative members for information storage and retrieval, referral of clients, and meeting reporting requirements.
PNs use the AIMS individual client records as basic client information---scheduled appointments, language, pharmacy and transportation needs are viewed up to date, in real time.
Database allows for maintaining information about the client; tracking and maintaining client appointments, assessments, and referrals; recording information about community outreach activities and health education.

Communications

Communications
Last year 98,000 patients died as a result of medical errors.
According to the American Hospital Association, the leading cause of those errors was inadequate communication among providers.
o

Communications
Evidence-based practices are specific clinical guidelines that help bridge the gaps between what researchers find to be effective treatment and what is implemented at the practice level. Their use is growing in all areas of health care in an effort to reduce errors and improve health.
According to the Institute of Medicine, only 50%-60% of medical treatments are evidence-based .

Communications

New Programming under PNDP New H&S Health Education & Prevention Sites New Health Collaborative Service Delivery Sites

Health Conditions Targeted
Diabetes
SC is 2 nd in the nation
Hypertension/CVD
SC is 3 rd in the nation for high blood pressure
Stroke
SC is 2 nd highest in the nation for stroke mortality
Obesity
SC is 3 rd in the nation for obesity

Disparities in Cardiovascular Disease
African Americans had a higher prevalence rate (15.4%) than Caucasians (8.4%).
African Americans were more likely to report a diagnosis of high blood pressure (36.4%) than Caucasians (29.5%).
African American men in SC are likely to die from CVD 10 years before white men. Most will not reach 65 .

Palmetto Project
What does it take to provide health care to the nearly 45% of South Carolinians without private health insurance?
Continuum of Care
Access & Care Coordination
Health Education & Disease Prevention
Data Collection & Management

Target Counties Population 703,505 Nearly 45% of population are uninsured or do not have sufficient coverage to meet their needs.

Disparities in Stroke
Mortality from stroke among African Americans is 24% higher than the national average.
African Americans are 40 percent more likely to die from stroke than Caucasians.
Identifiable and treatable risk factors for CVD and stroke nearly twice those of whites
One in three African Americans has high blood pressure
One in two is overweight
Two in three are physically inactive.

Disparities in Diabetes
I n 2005, estimated 280,000 state residents had been diagnosed with diabetes, and another 140,000 have diabetes but do not know it
African Americans had a higher prevalence rate for diabetes (15.4%) than Caucasians (8.4%).
Mortality rates for diabetes were three times higher for non-whites as for whit es
ER visits for diabetes were almost seven times higher among African Americans than among whites.
In Dorchester County, diabetes resulted in more than three times as many ER visits for blacks than whites.

How Patients are Identified
Referrals by collaborative partners
Outreach & screening
Community
Target Capacity under PNDP
3,000 navigated clients by August 2010

What are the interventions?
Outreach to health disparities populations
Prevention and early detection
Education, screening, monitoring, life style modification
Referral to primary care
Referral for diagnostic and specialty care
Medication assistance
Reduction of Barriers
Self-management goal setting
Facilitate involvement with community organizations
Coordinate with relevant insurance/other coverage

PNDP Navigated Patients
PN Actions by Patient Condition
Diabetes = 53
Ophthalmology scheduling = 21
Foot care scheduling = 4
Hypertension = 186
Cardiology scheduling = 22
Cancer screening and treatment referrals = 41
Women’s services/OB/GYN scheduling = 90
Pediatrics = 266
Dental or oral health scheduling = 10
Mental health referrals = 11
Other specialty care scheduling = 148
Arthritis (8) Neurology (12) Pulmonology (6)
GI (78) Orthopedic (10) ENT (14)
Dermatology (20)
Non-Disease Specific PN Activities
Health coverage assistance = 28
Medication/PAP assistance = 68
(ECCO PAP = 298)

SC Data Warehouse
Builds off of existing legacy systems from state agencies and private sector
Creates a Unique ID (not related to any other number)
Identifiers are pulled off of the statistical data. Use only the statistical data
Data is always “owned” by originating agency. Permissions required to use and/or link
Using Data in the Data Warehouse Agencies & Other Entities can:
Evaluate their programs
Look at Outcomes
Understand better how their programs interact with other agency & other entity programs
Study Health, Human Service, Education, and Law Enforcement Issues
Analyze Statistical – Aggregate Information
Access Analytic Data Cubes
Partner in the Development of Customized Software Applications

The Client Information System Web-based HIPAA compliant secure Client Information System tracks SC public sector clients and services across multiple agencies .
For Treatment and Operations
Designed to provide a 12-month rolling history of the client’s services.
Includes management and summary reports.
Medicaid clients served by the Dept. of Health and Human Services operational.
Discussions with two other state agencies
Legal teams involved
End product will allow the tracking of SC public sector clients across multiple agencies to ensure better coordination and management.

AIMS
Web-based database system designed and implemented by the SC Budget and Control Board’s Office of Research and Statistics (ORS),
System integrations and coordination utilizes the state’s HIPAA compliant secure Data Warehouse and Client Information System.
Accessible to all collaborative members for information storage and retrieval, referral of clients, and meeting reporting requirements.
PNs use the AIMS individual client records as basic client information---scheduled appointments, language, pharmacy and transportation needs are viewed up to date, in real time.
Database allows for maintaining information about the client; tracking and maintaining client appointments, assessments, and referrals; recording information about community outreach activities and health education.

AccessNET RHIO HeadStart
State Data Warehouse used to establish a Record Locator Service (RLS) for the region as well as longitudinal record for over 4 million residents of the state. Specifically, the data includes
all Medicaid (including pharmacy and physician office visits)
State Health Plan claims
UB-92 inpatient, ambulatory surgery and ED claims
In summary, a secure “bus” to connect to.
As such, this warehouse will provide a nearly comprehensive record of all providers who have served a given patient or client since 1996
Diagnoses
Procedures
Prescription History

The Palmetto Project: Putting Innovative Ideas to Work in South Carolina-Steve Skardon

by Health & Medicine Policy Research Group on Sep 24, 2009

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The Palmetto Project: Putting Innovative Ideas to Work in South Carolina-Steve Skardon — Presentation Transcript