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

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

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

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

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)

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

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

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

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

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

“ 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

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.

Regional Networks of Care 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

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

Regional Networks of Care Medical Outcomes & Patient Centered Care

Regional Networks of Care

Medical Outcomes & Patient Centered Care

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

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

Medical Outcomes & Patient Centered Care 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

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

Regional Networks of Care Medical Outcomes & Patient Centered Care Data Management & Electronic Records

Regional Networks of Care

Medical Outcomes & Patient Centered Care

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

Data Management & Electronic Records 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.

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.

Regional Networks of Care Medical Outcomes & Patient Centered Care Data Management & Electronic Records Communications

Regional Networks of Care

Medical Outcomes & Patient Centered Care

Data Management & Electronic Records

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

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.

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 .

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 .

Regional Networks of Care Medical Outcomes & Patient Centered Care Data Management & Electronic Records Communications

Regional Networks of Care

Medical Outcomes & Patient Centered Care

Data Management & Electronic Records

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

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 .

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

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.

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.

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

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

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)

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

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.

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.

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

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