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High Performance Health Systems Serving Vulnerable Populations. Fernando A. Guerra, M.D., M.P.H. Director of Health San Antonio Metropolitan Health District. Objectives. Review existing frameworks describing: The healthcare system The public health system - PowerPoint PPT Presentation
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High Performance Health Systems Serving Vulnerable
Populations
Fernando A. Guerra, M.D., M.P.H.
Director of Health
San Antonio Metropolitan Health District
2
Objectives
• Review existing frameworks describing:– The healthcare system– The public health system
• Discuss the health challenges of vulnerable populations
• Introduce a comprehensive framework for a high performance health system and implications for “safety net” providers
The Health Care System and High Performance
Tertiary Medical Care
Secondary Medical Care
Primary Medical Care
Population-Based Public Health Services
Assessment, Policy Development, Assurance
Public Health System Infrastructure
Capacity to Deliver Public Health Services
Incr
easi
ng Cost
s
4Relationship-Centered Care; Pew-Fetzer Task Force
The Healthcare System
5
Commission Framework for High Performance
The Commonwealth Fund
6
Keys to Healthcare System Performance
• The Commission has identified the following seven keys to high performance: – Extend health insurance to all – Pursue excellence in the provision of safe, effective, and efficient
care. – Organize the care system to ensure coordinated and accessible
care for all. – Increase transparency and reward quality and efficiency. – Expand the use of information technology and exchange. – Develop the health care workforce to foster patient-centered
primary care. – Encourage leadership and collaboration among public and
private stakeholders.
The Commonwealth Fund
7
Scorecard on the Health System
• Overall, the U.S. health care system scored an average 66 out of a maximum 100 based on 37 indicators of health outcomes – Quality (71)– Access (67)– Efficiency (51)– Equity (71)
• Relative to the benchmarks, U.S. performance averages near 50 for efficiency and around 70 for other domains.
C. Schoen, K. Davis, S. K. H. How, and S. C. Schoenbaum, U.S. Health System Performance: A National Scorecard, Health Affairs Web Exclusive, September 20, 2006 W457–w475
The Pubic Health System and High Performance
9
The Public Health System
• Public Health:
“What we as a society do collectively to assure the conditions by which people can be healthy”.
• The Public Health System:
“Activities undertaken within the formal structure of government and the associated parties of private and voluntary organizations and individuals”.
The Future of Public Health, IOM, 1988
10
The Public Health System
NPHPS User Guide, 2006
11
Public Sector “Safety Net” Health System Model
Common Goal: Healthy People and Communities
Performance Criteria:-Quality
- Efficiency- Equity/Accessibility
- Innovation
Public Hospital and Healthcare System
• Clinical Preventive Services• Primary Care
• Specialty and Acute Care
Academic InstitutionsHealth Professional
Schools• Research• Education
• Workforce Development
Public Health Agency• Assessment• Assurance
• Policy Development
Other Health System Partners
• Private entities•Federal and State agencies
•Non-Health focused local public agencies
12
The Ten Essential Services
13
Public Health Efforts to Support High Performance
• Turning Point Initiative - Performance Management
• Mobilizing for Action through Planning and Partnership (MAPP)
• RWJ’s Mulitstate Learning Collaborative• ASTHO-NACCHO Exploring Accreditation
Workgroup• NACCHO Operational Definition of a Local Health
Department• Public Health Accreditation Board (PHAB)• Certification of Public Health Professionals
Identifying Vulnerable Populations
15
Vulnerable Populations
• Uninsured and underinsured • Recent and/or undocumented immigrants• Persons of low Socio-economic status• Persons with limited English-proficiency• Persons with limited health literacy• Persons with physical and/or mental disabilities • The working poor – often do not qualify for assistance• Racial and ethnic minorities (color)• Teen parents• Others…
16
Health Disparities
• HP2020 Overarching Goals: – Achieve health equity, eliminate disparities, and
improve the health of all groups. – Create social and physical environments that promote
good health for all.
• Despite goals clear disparities exist for racial and ethnic minorities across the spectrum of health concerns
• Persons in poverty, with low educational attainment and low literacy have poor access to services and worse health outcomes
17
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1,600,000
2000 2005 2010 2015 2020 2025 2030 2035 2040
Hispanic NH White African American Other
Projected Population of Bexar County by Race and Ethnicity, 2000-2040
Source: U.S. Census and Texas State Data Center as per 2008
Year
Population
18
Age Distribution Bexar County Hispanic NH White
Source: U.S. Census Bureau, 2008
MaleFemale
African AmericanMaleFemale MaleFemale
50000 30000 10000 10000 30000 50000
Age 0 to 4 yrs
Age 10 to 14 yrs
Age 20 to 24 yrs
Age 30 to 34 yrs
Age 40 to 44 yrs
Age 50 to 54 yrs
Age 60 to 64 yrs
Age 70 to 74 yrs
Age 80 to 84 yrs
50000 30000 10000 10000 30000 50000
Age 0 to 4 yrs
Age 10 to 14 yrs
Age 20 to 24 yrs
Age 30 to 34 yrs
Age 40 to 44 yrs
Age 50 to 54 yrs
Age 60 to 64 yrs
Age 70 to 74 yrs
Age 80 to 84 yrs
50000 30000 10000 10000 30000 50000
Age 0 to 4 yrs
Age 10 to 14 yrs
Age 20 to 24 yrs
Age 30 to 34 yrs
Age 40 to 44 yrs
Age 50 to 54 yrs
Age 60 to 64 yrs
Age 70 to 74 yrs
Age 80 to 84 yrs
19
Educational Attainment of Population Over 25 Years of Age, Bexar County
(Population 25 years and over)(Population 25 years and over)
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Bachelors degree or higher
Asian African American Hispanic White Non Hispanic 19
20
Age of Death Over 75 Years, Bexar County
0%
10%
20%
30%
40%
50%
60%
70%
80%
White Non Hispanic Females Hispanic femalesAfrican Am. Females White Non Hispanic MalesHispanic males African Am. Males
202007 Health Profiles
21
Access to Care
• Texas leads the nation in number and percentage of uninsured for both adults and children
• In Bexar County:– 24.6% of adults 18-64 uninsured– 18.1% of children 0 -17 uninsured– 306,340 unduplicated Medicaid clients– 54% of births are covered by Medicaid
2005 Texas Department of State Health Services
22
San Antonio’s “Ten Zip Codes”
23
“Ten Zip Code” Demographics
Ten Zip Codes Bexar County
(72 zip codes)
Population 421,561 (30%) 1,386,179 (100%)
Median Income $27,075 $44,219
Below Federal Poverty Level
104,458 (25%) 215,680 (16%)
Hispanic 347,102 (82%) 752,532 (54%)
Non-Hispanic White 55,474 (13%) 493,090 (36%)
African American 13,317 (3%) 94,131 (7%)
High School Graduates or Higher Education1
240,290 (57%) 1,067,358 (77%)
Female Headed Households
88,528 (21%) 207,929 (15%)
1) Among adults aged 25 and older. All data from 2000 U.S. Census and American Community Survey.
24
Ten Zip Codes - 2008
Ten Zip Codes
% of Bexar County
Population 421,561 30%
Total Births 8,265 30.7%
Late Prenatal Care Births 2,627 36.6%
Birth within 24 Months of Previous 1,694 38.0%
Births To Mothers BMI >30 2,700 38.3%
Juvenile Probation 4,038 39.2%
Family Violence Reports 4,322 41.0%
Single Mother Births 5,154 41.2%
Medicaid Births 5,684 41.7%
Confirmed Child Abuse/Neglect Cases 2,460 43.8%
Births To Mothers Age <18 683 47.0%
Births to mothers < HS / GED 3,731 49.8%
A High Performance Health System Serving Vulnerable Populations
26
The “Safety Net”
• Local Public Health Agencies
• Public Hospital Systems and Clinics
• Federally Qualified Health Centers
• Local/State Mental Health Agencies
• Other public sector, non-profit, faith based or community service providers – Homeless service programs– Feeding ministries
27
Safety Net Provider Challenges
• High rates of preventable chronic disease• Widening health disparities• Increased health care costs with level or decreased
funding• High rate of uninsured• Challenges establishing medical homes• Health information for clinical and public health needs
remain in silos• Quantity and quality of mental health services• Access to dental health services• Expanding role of providers in emergency response and
meeting the needs of displaced persons
28
Need for an Integrated View of the Health System
• Current challenges and resources require cooperation to achieve goals
• Health is more than the absence of illness and injury
• Public health and health care are complementary and interdependent – both sectors must achieve high performance– Common mission and vision– Distinct roles and strategies for achieving a healthy community
• Addressing the needs of vulnerable populations requires cross-sector partnerships and relationship-centered care
29
Impact of Health Reform
• Access to care should improve but many may still be left out– How will the expansion of coverage affect traditional
Medicaid providers? What will be the demand for “safety net” services in the future?
– How will areas with high levels of undocumented residents fare with changes in access and funding?
• New level of focus on preventive health services in both clinical and population based services
• Issues of healthcare cost are unresolved
30
Priorities for “Safety Net” Providers
• Address issue of health care costs• Assure access to a comprehensive and
well coordinated system of care– Medical homes– Interoperable health records
• Establish effective mechanisms to care for undocumented persons
• Enhance coordination between the healthcare and public health sectors
Questions and Discussion
Fernando A. Guerra, MD, MPHDirector of Health
San Antonio Metro Health [email protected]