Sheryl L. Garland, M.H.A. Vice President, Community Outreach VCU Health System November 28, 2005 Role of Academic Medical Centers In Safety Net Health.

Sheryl L. Garland, M.H.A.Vice President, Community Outreach

VCU Health SystemNovember 28, 2005

Role of Academic Medical CentersIn Safety Net Health Care Delivery Systems

Slide 2Slide 2

Outline

Overview of Healthcare Safety Net

Role of the Academic Medical Center

Partnership Opportunities

OB Dilemma in the Greater Richmond Area

Slide 3Slide 3

In March 2000, the Institute of Medicine released a study entitled “America’s Health CareSafety Net: Intact but Endangered” that defined

A Safety Net as:

“Those providers that organize and deliver a significant level of health care and other

health-related services to uninsured, Medicaid and other vulnerable patients.”

Institute of Medicine, America’s Health Care SafetyNet: Intact but Endangered (Washington, D.C:National Academy Press, 2000) p.21.

Slide 4Slide 4

Safety Net Health Systems Have Two Distinguishing Characteristics:

They maintain an “open door”, usually offering access to both inpatient and outpatient services to uninsured or under-insured patients

They represent a significant proportion of the preventive, acute and chronic health care services delivered to uninsured, Medicaid and other vulnerable populations in their region

“America’s Health Care Safety Net: Intact, but Endangered”, Institute of Medicine Report, 2000

10

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The nation’s health care safety net for low income and uninsured has grown somewhat stronger….The safety net varies from community to community and can include various configurations of public and private hospitals, community health centers (CHC’s), local health departments, free and school-based clinics and physician charity care .

Laurie E. Felland, Kyle Kinner, John F. Hoadley, “The Health Care Safety Net: Money Matters but Savvy Leadership Counts”, Issue Brief No. 66, August 2003, p.1.

Slide 6Slide 6

Strategies Used to Strengthen Safety Nets

• Develop strong partnerships• Create managed care programs for the

uninsured • Construct prescription formularies• Develop disease case management and

care coordination programs• Increase enrollment in Medicaid and

SCHIP programs (FAMIS)• Capture all public and private funding

sources• Develop low cost health insurance

options for working poor

Slide 7Slide 7

Outline

Overview of Healthcare Safety Net

Role of the Academic Medical Center

Partnership Opportunities

OB Dilemma in the Greater Richmond Area

Slide 8Slide 8

The Commonwealth of Virginia

• Population is approximately 7.1 million people

• Approximately 30% of Virginians are below 200% of the FPL

• Nearly 2/3 of the counties are designated as full or partially medically underserved areas

• An estimated 12-15% of the population lacks basic health insurance

“An Opportunity for Unprecedented Growth”, Virginia Primary Care Association, Sept. 2002

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Slide 9Slide 9

Virginia’s Indigent Care Program

• Established in the late 1970’s to provide coverage to the uninsured

• Virginia’s Medicaid program only covers those who are pregnant, under 18, aged, blind or disabled

• Indigent Care Program marries federal DSH dollars and State General funds (50/50 match)

• Eligibility criteria:- Reside in the Commonwealth - U.S. Citizen- At or below 200% FPL- Meet asset test criteria

Slide 10Slide 10

VCU Health System

• Part of Virginia Commonwealth University’s Medical Center

• Formerly known as MCV Hospitals and Physicians

• Located in downtown Richmond, Virginia• 779 Bed Teaching Hospital• Level I Trauma Center• Over 31,000 admissions• Estimated 80,000 ED visits• Over 500,000 Outpatient visits• Approximately 600 housestaff• Over 700 full time faculty in the School of Medicine

Slide 11Slide 11

VCU Health System

20002000Percentage of Entire Percentage of Entire Charity Care for the Charity Care for the

CommonwealthCommonwealth

VHI Definition of Charity Care: Charity Care represents (unreimbursed) charges to individuals at 100% of the federal non-farm poverty level

Sources: VHI 2000 Hospital Financial Data Report, VCUHS Financial Services, VCUHS Strategy & Marketing

34.2%34.2%

16.5%16.5%

UVA6.0%6.0%

6.2%6.2%

7.0%7.0%

Carillion

Sentara

Inova

Leading Providers of Charity Care

Slide 12Slide 12

Indigent Care Cost in Dollars

47,270,000 to 47,300,0002,000,001 to 15,000,000

700,001 to 2,000,000150,001 to 700,00010,001 to 150,0005,001 to 10,000

0 to 5,000

VCU Health System Indigent Care Distribution

FY03 Budget $107.3M in Indigent Cost

Slide 13Slide 13

The total population of the Richmond Metro area exceeds 850,000

“Examining Access to Health Care in the Greater Richmond Area”, Presentation at the RACE for Health 2003, Stephen Horan, Ph.D., Community Health Resource Center 26

Slide 14Slide 14

More than 186,000 have incomes below 2x poverty (22%)

“Examining Access to Health Care in the Greater Richmond Area”, Presentation at the RACE for Health 2003, Stephen Horan, Ph.D., Community Health Resource Center 27

Slide 15Slide 15

More than 48,000 (estimated) are below 2x poverty and uninsured

“Examining Access to Health Care in the Greater Richmond Area”, Presentation at the RACE

for Health 2003, Stephen Horan, Ph.D., Community Health Resource Center 28

Slide 16Slide 16

Healthy with unmet needs

Healthywithepisodicneeds

Chronically ill

The Ecology of Safety Net Care

Acutehospitalization

Catastrophicevent

Presentation: Governor’s Covering the Uninsured Conference, Dr. Sheldon M. Retchin, 2003 29

Slide 17Slide 17

With the increasing pressures to identify funds and reduce the cost

of caring for the uninsured and the underinsured,

the VCU Health System has developed innovative strategies to

continue to provide servicesto these populations

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Pieces of the Puzzle

• VCUHS purchased Medicaid HMO in the mid 1990’s

• In 1999, a work group explored idea of using managed care principles to coordinate care for the uninsured

• Virginia Coordinated Care for the Uninsured (VCC) program

launched in November, 2000

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Goals of the VCC Program

• Utilize managed care principles to support a defined population

• Support a centralized/automated Financial Screening process

• Establish Primary Care Physician (PCP) centered care

• Partner with Community Primary Care Physicians and Specialty Physicians

• Reduce the average cost per unit of service

• Improve the health status of the population

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Slide 20Slide 20

Number of Uninsured Patients Qualifying for the Indigent Care Program at the VCU Health System

Number of “Indigent” Patients

FY 200038.781

19.619 14.814 10.0562.576 0.977 0.885 0.321 4.805

Tot

al

Ful

l Ind

igC

ateg

ory

1

VC

C E

ligib

le

Ric

hmon

d

Hen

rico

Che

ster

field

Tri-

City

Are

a

Han

over

Oth

er A

reas

01020304050

Thousands

Slide 21Slide 21

The VCC Service Area

C a r o l i n e

H a n o v e r

H e n r i c o

R ic h m o n d C i t y

C o lo n ia l H e ig h t sH o p e w e l l

P e t e r s b u r g

C h e s t e r f i e l d

G o o c h l a n d

P o w h a t a n

A m e l i a

D in w i d d i eP r i n c e G e o r g e

C h a r l e s C i t y

N e w K e n t

K i n g W i l l i a m

33

Slide 22Slide 22

VCC Program

• VCC is NOT an insurance program• VCUHS partnered with Primary Care

Physicians in the Greater Richmond and Tri-Cities Communities, as well as the academic medical center

• Enrollment for first year was 11,000• All ancillary and diagnostic services

provided at VCUHS and BSR-Richmond Community Hospital

• All inpatient admissions referred to the VCUHS and BSR-Richmond Community Hospital

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Slide 23Slide 23

Program Components

• Primary and Specialty Care visits

• Medications• Well Child Visits• Ancillary and

Diagnostic Services

• Family Planning• Outpatient

Services• Inpatient Services

• VCC does NOT cover:– Home Health

Care– Dental Services– Elective

Services such as cosmetic surgery or sterilizations

35

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VCC Patient Utilization Issues

• Utilization of the Emergency Room for non-acute services remained high

• VCC population had a lower average inpatient acuity than other patients

• 50% of the population enrolled in VCC remained with the program for 12 months or less

36

Slide 25Slide 25

Emergency Room Visits for Uninsured: Reason for Visit

2 7 %

1 7 %4 %8 %

1 8 %

2 %2 %

2 2 %

N o t E m e r g e n c y P r i m a r y C a r e E m e r g e n c y / A v o i d a b l e

E m e r g e n c y / N o t A v o i d a b l e In j u r y P s y c h

A l c o h o l / D r u g U n c l a s s i f i e d

Visits = 30,273

FY2002

48% of visits could have been avoided

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Emergency Room VCUHS Visits for the Uninsured

Diagnosis Visits %Chest Pain 1,001 3.9%Abdominal Pain 1,346 4.9%Sprains and Strains 1,567 7.1%Back Problems 1,127 3.7%Upper Respiratory Infections 1,131 3.7%Urinary Tract Infections 765 2.5%Headaches/Migraines 822 2.7%Dental Services 1,095 3.6%Total ED Visits = 30,191

39

Slide 27Slide 27

Nurse

Case ManagersCare Coordinators

Outreach Workers

Jenkins Foundation Care Coordination Model

*Community = Community physicians who serve uninsured patients, community-based Safety Net Providers and local agencies

Jenkins Care Coordination Program

LEGENDStand. Op. Procedures

Information System

Communications System

Safety NetProviders

Human ServicesAgencies

Community Physicians

Community*

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V C C E D U t i l i z a t i o n

7 7 3 57 7 9 88 1 6 0

9 9 5 6

0

2 0 0 0

4 0 0 0

6 0 0 0

8 0 0 0

1 0 0 0 0

1 2 0 0 0

F Y 0 1 F Y 0 2 F Y 0 3 F Y 0 4

Vis

its

41

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0 %

1 0 %

2 0 %

3 0 %

4 0 %

5 0 %

6 0 %

7 0 %

8 0 %

9 0 %

1 0 0 %

F is c a l Y e a r

C l a s s i f i c a t i o n o f E D V i s i t s f o r V C C P a t i e n t s

F l a g s O n l y 1 .6 % 1 .7 % 2 .3 % 2 .3 %

E D C a r e N e e d e d - N o t P r e v e n ta b l e /A v o i d a b l e

1 8 .2 % 1 9 .0 % 2 0 .5 % 2 0 .4 %

E D C a r e N e e d e d - P r e v e n ta b l e / A v o i d a b l e 5 .0 % 5 .7 % 6 .2 % 6 .3 %

E m e r g e n t - P r i m a r y C a r e P r e v e n ta b l e 3 0 .7 % 3 4 .8 % 3 6 .6 % 3 5 .0 %

N o n E m e r g e n t 4 4 .5 % 3 8 .7 % 3 7 .6 % 3 6 .2 %

F Y 0 1 F Y 0 2 F Y 0 3 F Y 0 4

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Bon Secours - Richmond Community Hospital Partnership

• Richmond Community Hospital (RCH) is a 100-bed community Disproportionate Share Hospital (DSH) that has excess capacity

• In January 2004, partnership developed to provide inpatient, diagnostic, ancillary and emergency services for the VCC patients

• Goal is to reduce the overall cost of caring for the VCC population by providing care in a lower cost setting

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VCC Today

• Enrollment in FY05 was approximately 17,000 patients

• 31 Community Physicians and 9 Safety Net Providers participate

• Community partnerships are driving costs down (primary care visits dropped from $180 to $90/visit)

• In the process of requesting CMS approval to utilize DSH funds to support the Bon Secours – Richmond Community Hospital affiliation

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Outline

Overview of Healthcare Safety Net

Role of the Academic Medical Center

Partnership Opportunities

OB Dilemma in the Greater Richmond Area

Slide 33Slide 33

Other Innovative Partnerships

• Richmond Enhancing Access to Community Healthcare (REACH) initiatives

• Healthy Community Access Program (CAP) grant

• The Healing Place – Social Detoxification Unit

• Richmond City Department of Public Health - Hayes E. Willis Health Center

• Collaboration with CrossOver Health Ministries to provide continuity of care for undocumented pregnant women

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Slide 34Slide 34

Collaboration with REACH

• REACH stands for Richmond Enhancing Access to Community Healthcare

• REACH is a non-profit organization that serves as a catalyst for community Safety Net providers to enhance access to health care services for the uninsured and underinsured in the Greater Richmond Metro area

Slide 35Slide 35

• Developed a coalition with 9 Safety Net provider organizations • Primary goal is to identify mechanisms to

improve access to health care for the uninsured and underinsured in the region

• Enrollment of undocumented pregnant patients

into Emergency Medicaid• Collaborating with area providers to develop

a low cost pharmaceutical model for uninsured

• Researching models to improve access to behavioral health services

44

Slide 36Slide 36

Healthy Community Access Program (HCAP)

• With VCU as the fiscal intermediary, REACH has been awarded over $2.5 million from HRSA

• Funding has been utilized to develop a web-based program (MOREAccess)to assist Safety Net providers in financially screening patients to determine

eligibility for programs such as Medicaid or FAMIS

47

Slide 37Slide 37

HCA

VCUHSBon

Secours

Community Physicians

CrossOverMinistries

Daily Planet

CraigHealth Center

Vernon J. HarrisHealth Center

Free Fan Clinic

RCDPH

Greater Richmond Safety Net Health Care Providers

45

Slide 38Slide 38

HCA VCUHS Bon Secours

Community Physicians

CrossOverMinistries

Daily Planet

CraigHealth Center

Vernon J. HarrisHealth Center

Free Fan Clinic RCDPH

Vision: Safety Net Health Care Delivery System

AcutePatients

AcutePatients

FundingSupport Funding

Support

Primary Care Access

Acute Care Providers

52

Slide 39Slide 39

The Healing Place Social Detoxification Unit

• Partnership established a 6-bed detoxification unit for patients who were seen in the VCUHS ER

• Provided an alternative treatment program for those with a primary diagnosis of alcohol or substance abuse problems

• A total of 428 patients were cared for over a 12 month period

• For a subset of 165 clients, there was a reduction of 182 ED visits and 16 fewer inpatient admissions for a cost savings of approx. $150,000

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Slide 40Slide 40

Hayes E. Willis Health Center

• Began as a collaboration between Richmond City Department of Public Health and VCUHS in 1993

• Goal was to integrate traditional Public Health services into a primary care setting in South Richmond

• Grew out of SJR 179 study that found there was adequate primary care capacity, but an unequal distribution of services

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Hayes E. Willis Health Center

• Community-based health center in South Richmond that offers Family Medicine, Women’s Health and Pediatric services

• Center also provides screening and treatment for STD’s

• Houses the Arthur Ashe Early Intervention Program

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Slide 42Slide 42

Hayes Willis Center Plays a Major Role

• Approximately 4,000 patients with 15,000 annual visits

• Approximately 45% of the patients have no insurance; another 34% are Medicaid recipients

• 10% of patients are Hispanic• In the process of researching

federally qualified health center status

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Slide 43Slide 43

Outline

Overview of Healthcare Safety Net

Role of the Academic Medical Center

Partnership Opportunities

OB Dilemma in the Greater Richmond Area

Slide 44Slide 44

The OB Dilemma

Slide 45Slide 45

2002 Birth Data for Richmond Metro Area

• Approximately 12,200 births• Approximately 890 were classified

as “Self Pay”• It is “guestimated” that

approximately 400 of these mothers did not qualify for Medicaid (“Self Pay”)

• Over 37% of the “Self Pay” births were for mothers classified as HispanicHoran, Stephen, Ph.D., 2002 Birth Profile for Metro Richmond, February 3, 2004

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Of the 890 Self Pay Mothers

• Over 36% reported receiving “late” prenatal care (after the 1st trimester)

• Approximately 13% delivered infants with Low Birth Rates (as compared to 7.9% for patients with private insurance)

• Over 17% were under the age of 20

Horan, Stephen, Ph.D., 2002 Birth Profile for Metro Richmond, February 3, 2004

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Results of 2003 Immigrant Health Needs Assessment for the Greater

Richmond Area

• The greatest health needs for Hispanic and Asian women were OB/Gyn services and preventative care

• Between 2000 and 2001, there was a 25% increase in births for Hispanic women

• Approximately 20% of all Hispanic births experienced complications during the same time period

Immigrant Health Needs Assessment for the Greater Richmond Area, August 2003

Slide 48Slide 48

VCU Health System Issues

• Cost for uncompensated care for OB patients in 2003 was approximately $1 million• Over 200 births in 2003 were to mothers with no Social Security

Number• Over 65% of the mothers with no SSN

were Hispanic • Patients who were not U.S. Citizens did

not qualify for the Commonwealth’s Indigent Care program

Slide 49Slide 49

REACH Members Identified Issues

• Difficulty making appointments for prenatal care at area health departments

• No “free clinics” or FQHC’s in the region offering service

• Accessing care at VCUHS was problematic

Slide 50Slide 50

The Community Responds

• Cross Over Ministry initiated the Healthy Homes Campaign: Health Care and Education for Mothers, Babies and Families in 2003

• REACH convened the Access to Perinatal Care Task Force in 2004

• VCU Health System began developing programs specifically to support the Hispanic OB population in 2004

• Virginia Premier Health Plan offered transportation to VCUHS L&D tours for Healthy Homes patients in 2004

• Virginia League for Planned Parenthood began development of a Prenatal clinic for Hispanic women in 2005

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REACH Perinatal Care Model

ACCESS POINTSHealth departmentSafety net providersPlanned ParenthoodEmergency departmentPrivate practicesCommunity

Initial Screening & RISK ASSESSMEENT

(Coordinating Agency)

Medicaid Eligible(Refer to Private Practice)

Non-Medicaid Eligible

Due to income or citizenship(Refer to Passport Program)

Perinatal Passport ProgramRisk AssessmentClinical, perinatal servicesMedicineLaboratoriesInpatient care (non-delivery)Care coordination/case managementSpecialty careInterpretationTransportationEmergency careHealth educationFamily planningSocial Service referralsTransfer of records to delivery siteAssistance with Medicaid applications

High RiskAssigned Care CoordinatorAssigned OB

Low RiskAssigned Care CoordinatorAssigned OB

Delivery Site Identified (Records Transferred Pre-Delivery)

MomFamily support (e.g., Healthy Start)Family planningHealth educationPrimary care home

BABYFAMIS/FAMIS PlusPediatrician

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I-95

I-195

I-64

Petersburg

Colonial Heights

Richmond

Hanover

I-85

I-295

Henrico

Chesterfield

2000 Uninsured and <200% Poverty (Estimated)

2,890 to 5,090 (8)1,100 to 2,890 (6)

680 to 1,100 (15)340 to 680 (8)70 to 340 (9)

Estimated uninsured below 2x poverty by zip code2000 Census

Slide 53Slide 53

Perinatal Access Program

• In 2004, the Perinatal Access Program was piloted with Cross Over Ministry, REACH and VCU Health System as partners

• Cross Over Ministry developed case management to enhance services for Hispanic women

• Volunteer physicians, including faculty from the VCU Department of OB/Gyn provided prenatal care and ultrasounds

• REACH Community Health Advocates assisted patients with Emergency Medicaid applications

• VCUHS agreed to provide OB services• Lab Corp provided free prenatal labs

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Outcomes

• 367 women have enrolled in CrossOver’s Healthy Homes campaign since its inception

• Over 200 moms delivered babies at the VCUHS

• Over 70% of the mothers had their deliveries covered by Emergency Medicaid

• REACH received a March of Dimes grant to provide prenatal education classes in Spanish

• VCUHS provides IS link to CrossOver to access patient discharge summaries

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Moving Forward

• Perinatal Access Partnership for Non-Medicaid Eligible Women received Honorable Mention by the National Association of Public Hospitals and Health Systems for its 2005 Community and Patient Safety Award

• Virginia League for Planned Parenthood has implemented a prenatal program for Hispanic women utilizing the same model

• VCU Center of Excellence in Women’s Health is researching opportunities to apply for national grants to support this partnership

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Conclusion

• The role the Academic Medical Center plays is critical in a Safety Net System due to the resources (financial, human, clinical) available

• Communities in Virginia continue to create opportunities to enhance access to care for the Uninsured

• Providers in the Greater Richmond Metro area are partnering to develop a Safety Net Health Care Delivery System

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“University-based urban academic medical centers….

function most effectively and for the greater good when their care is a complement to,

and not a substitute for, community health care providers.”

Hill, Laurence and Madara, James, “Role of the Urban Academic Medical Center in US Health Care”,Journal of the American Medical Association, November 2, 2005 – Vol 294, No. 17, p.2219.