Rishi Manchanda MD MPH
Founder, HealthBegins
Author, The Upstream Doctors
The question your doctor
is not asking you &
how...
“Where do you live?
Tell me about it.”
“p.s. Where do you work, eat and play?”
What would your health look
like if doctors’ offices routinely
asked about and could help
address problems where you
live,...
Photo taken with permission
Mrs. M
Photo taken with permission
Mrs. M had a chronic
headache. After exhausting
primary care options, she
visited 3 Emergency ...
Photo taken with permission
After 3 ER visits, a clinic noted
that Mrs. M lived in an area
endemic for unhealthy housing.
...
The Social Determinants of Health
– The conditions in which people are born, grow,
live, work and age, including the healt...
At the Intersection of Health Care
and the Social Determinants of Health,
the Current Standard of Care
Isn’t Good Enough
Schroeder S. N Engl J Med 2007;357:1221-1228
Contribution
of Social
Factors to
Premature
Mortality
What’s the big deal abo...
The sickest, costliest patients
often have unmet needs
in social & built environment
• Cohen, S. The Concentration of Heal...
Addressing Social Factors
improves care
Addressing social factors
lowers costs
Glimpses
of this better standard
of care are out there
But 4 out of 5 physicians still
feel under-equipped to
address their patients’
social needs.
-RWJF “Health Care’s Blind Si...
Smart medicine starts upstream
Stories of
Upstreamists
A new conceptual
model for the
health care
workforce in the
context of the
Affordable Care
Act
A new model for the
healthcare workforce
By 2020,
24,000
260,000
450,000
Population-
level Impact
Our Work:
Improve Care
Train & Equip Upstreamists
Our Goal:
2.5K Upstreamists by 2015
25K Upstreamists by 2020
Propietary/ Confidential
Courtesy: Community Scholars 2012, Ben Palmquist
Housing and Health
Housing is linked to:
– Asthma
– Allergies
– Lung Cancer
– Injuries
– Mental Health
– Brain Development...
Housing Hazards
• Biological agents
– allergens, mold
• Toxics
– lead, secondhand smoke, carbon
monoxide, radon, asbestos,...
Can health care transformation help more clinics
help improve conditions where we live?
Community-Centered
Health Home
Com...
Medicaid Health Homes
A “Medical Neighborhood”
• One of the coordinated care models that states can
pursue with funding fr...
Medicaid Health Home
• Includes:
– Comprehensive care management
– Care coordination
– Health promotion
– Comprehensive tr...
States with
Medicaid Health Homes
1115 Waivers: A chance for housing
under ACA?
• Under section 1115 of the Social Security Act, the
federal government can ...
Minnesota example: Reform 2020
• Reform 2020 is an initiative to reform Medical Assistance (MA)
Minnesota’s Medicaid progr...
TO LEARN MORE
HealthBegins.org
Read the Upstream
Doctors
http://www.ted.com/pages/tedbooks
_library#RishiManchanda
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Rishi Manchanda, Health Begins

  1. 1. Rishi Manchanda MD MPH Founder, HealthBegins Author, The Upstream Doctors The question your doctor is not asking you & how everyone, including you, could save money and live healthier lives if she did
  2. 2. “Where do you live? Tell me about it.” “p.s. Where do you work, eat and play?”
  3. 3. What would your health look like if doctors’ offices routinely asked about and could help address problems where you live, work, eat, and play?
  4. 4. Photo taken with permission Mrs. M
  5. 5. Photo taken with permission Mrs. M had a chronic headache. After exhausting primary care options, she visited 3 Emergency Rooms (ER) in 1 month, but still had neither a diagnosis nor a treatment plan. Overall, she had: 2 CAT scans of her head 1 Lumbar puncture Blood tests Pain medicines Out-of-pocket charges Missed work Lost income And she was still sick. Good Care?
  6. 6. Photo taken with permission After 3 ER visits, a clinic noted that Mrs. M lived in an area endemic for unhealthy housing. A medical assistant screened her for housing risks. Mrs. M lived in a damp, moldy home. With that key social data, the MD correctly diagnosed her in 12 minutes with a housing-related illness. He treated her with meds and a healthy housing program. Mrs. M & her home got better. Better Care
  7. 7. The Social Determinants of Health – The conditions in which people are born, grow, live, work and age, including the health system. • These conditions are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy. – Major contributor to health inequities • “Health inequities are unfair and avoidable differences in health status seen within and between countries often over generations.”
  8. 8. At the Intersection of Health Care and the Social Determinants of Health, the Current Standard of Care Isn’t Good Enough
  9. 9. Schroeder S. N Engl J Med 2007;357:1221-1228 Contribution of Social Factors to Premature Mortality What’s the big deal about housing & other ‘social determinants’?
  10. 10. The sickest, costliest patients often have unmet needs in social & built environment • Cohen, S. The Concentration of Health Care Expenditures and Related Expenses for Costly Medical Conditions, 2009. Statistical Brief #359. February 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st359/stat359.shtml In 2009, 5% of the population accounted for nearly 50% of overall US health care spending Propietary/ Confidential
  11. 11. Addressing Social Factors improves care
  12. 12. Addressing social factors lowers costs
  13. 13. Glimpses of this better standard of care are out there
  14. 14. But 4 out of 5 physicians still feel under-equipped to address their patients’ social needs. -RWJF “Health Care’s Blind Side” Dec 2011 Propietary/ Confidential
  15. 15. Smart medicine starts upstream
  16. 16. Stories of Upstreamists A new conceptual model for the health care workforce in the context of the Affordable Care Act
  17. 17. A new model for the healthcare workforce By 2020, 24,000 260,000 450,000 Population- level Impact
  18. 18. Our Work: Improve Care Train & Equip Upstreamists Our Goal: 2.5K Upstreamists by 2015 25K Upstreamists by 2020
  19. 19. Propietary/ Confidential Courtesy: Community Scholars 2012, Ben Palmquist
  20. 20. Housing and Health Housing is linked to: – Asthma – Allergies – Lung Cancer – Injuries – Mental Health – Brain Development – Respiratory Infections Courtesy: Dr. Jim Krieger, Seattle Public Health
  21. 21. Housing Hazards • Biological agents – allergens, mold • Toxics – lead, secondhand smoke, carbon monoxide, radon, asbestos, VOCs, etc. • Temperature extremes • Injury hazards • Crowding • Conditions: – Ventilation – Energy efficiency – Structural integrity – Sanitation and plumbing – Siting – Building materials Courtesy: Dr. Jim Krieger, Seattle Public Health
  22. 22. Can health care transformation help more clinics help improve conditions where we live? Community-Centered Health Home Community-Centered Health Home • Coordinate with policymakers and community stakeholders to address social and environmental conditions Medical Neighborhood • Coordinate care for patients and populations with clinical and community “neighbors” • Potential role for ACOs Medical Neighborhood PCMH Ambulatory ICU • Integrate and coordinate care for high- need, +/- high-utilizer patients with clinical and community partners AICU PCMH • Coordinate care for patients and clinic population, primarily within clinical system R. Manchanda MD
  23. 23. Medicaid Health Homes A “Medical Neighborhood” • One of the coordinated care models that states can pursue with funding from the Affordable Care Act • For patients with: – mental health condition, – substance use disorder, – asthma, – diabetes, – heart disease, AND/OR – body mass index over 25 (overweight) http://familiesusa2.org/assets/pdfs/health-system-reform/Health-Homes-in-Medicaid.pdf
  24. 24. Medicaid Health Home • Includes: – Comprehensive care management – Care coordination – Health promotion – Comprehensive transitional care – Individual and family support services • Must coordinate with behavioral health providers • Required to help enrollees obtain non-medical supports and services, such as: • public benefits, housing, transportation, legal services, and social support services. http://www.medicaid.gov/State-Resource-Center/Medicaid-State-Technical-Assistance/Health-Homes-Technical- Assistance/Approved-Health-Home-State-Plan-Amendments.html http://familiesusa2.org/assets/pdfs/health-system-reform/Health-Homes-in-Medicaid.pdf Propietary/ Confidential Not found in most PCMH
  25. 25. States with Medicaid Health Homes
  26. 26. 1115 Waivers: A chance for housing under ACA? • Under section 1115 of the Social Security Act, the federal government can allow states to develop comprehensive demonstration, experimental projects that modify (waive) federal Medicaid and State Children’s Health Insurance Program (SCHIP) requirements related to benefits, cost-sharing and eligible populations. • Any new waivers must be “budget neutral” to the federal government. • Several states have combined coverage expansions with a new managed care delivery system and used the anticipated managed care savings to offset the cost of the coverage expansion.
  27. 27. Minnesota example: Reform 2020 • Reform 2020 is an initiative to reform Medical Assistance (MA) Minnesota’s Medicaid program. • On Nov. 21, 2012, DHS resubmitted the Reform 2020 waiver proposal to the Centers for Medicare and Medicaid Services (CMS). This proposal would have made the following housing stabilization services as eligible for Medicaid reimbursement up to $600 for each member per month: – Service coordination – Outreach/InReach – Tenancy Support Services – Community Living Assistance • The target population included: (a) Medicaid recipient who were receiving General Assistance and homeless; and (b) Medicaid recipients who were eligible of Group Residential Housing.
  28. 28. TO LEARN MORE HealthBegins.org Read the Upstream Doctors http://www.ted.com/pages/tedbooks _library#RishiManchanda

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