3rd Annual Quality Conference (2012)

Resolving Socioeconomic Stressors for Stronger, Healthier Women

“We have to understand that by not addressing these socioeconomic issues, we’re going to spend more money on our health and suffer worse morbidity and mortality. By not paying for it now, we’re paying for it later in terms of lost health and lives.” Tracey Cohen, MD, Neighborhood Health Plan of RI

Research shows that the social circumstances in which we are born, live and work – our jobs, schools, built space, transportation, even the quality of civic life – get under the skin, influencing our behaviors, access to resources, chronic stress levels and ultimately increasing or decreasing our chances for health.

Racial and ethnic health inequities don’t just reflect income. More African American, Native American, Latino and Pacific Islanders are in poor or fair health than whites at practically every income level.

“Recognizing this, RI payors are driving delivery system change by creating, providing, or paying for services which are designed to bridge socioeconomic barriers.” Renee Rulin, MD, MPH, RI, Medical Director, Medicaid/United Health Care

“Right now we’re in a period of total disruption of the healthcare system. The Affordable Care Act will be disruptive, but the biggest disruption will come from the shift to electronic medical records, which will completely flip how healthcare is delivered, and how our socioeconomic stressors are resolved.

“Primary care provider systems and practices will be increasingly encouraged by payors to offer a more holistic range of services, so private practices look more like community health centers and a fuller range of socioeconomic stressors can be managed from one place.

“We will see health insurance carriers responding to what health consumers want as opposed to what employers want and as opposed to what providers offer. As a new consumer based healthcare system evolves, there is an immediate opportunity to be part of the conversation about what plans and payment models consumers want to have and what provider services are most effective.” Christine Fergueson, Director, RI Health Insurance Exchange

“Now is the time to engage (in developing criteria for these new models of payment),” as Christy Ferguson said, “I want you to come to me and say ‘this is what I want.’ ”

Good to Know

“Many people in RI are underserved because of RI’s role as a safe haven for immigrants and undocumented folks. We need more data in order to formulate new policies to better serve this population.” Mary Reich Cooper, MD, JD Co Chair, Women’s Health Council

Defining Measures

Starting in 1990, keynote speaker Michelle Berlin, MD, MPH, began to partner with the National Women’s Law Center (NWLC) and NIH to look at creating data collection on women’s health disparities and inequities, so that better policies could be promoted. She helped to define 26 health status indicators that are now used nationally and state-by-state to evaluate the status of women’s healthcare delivery. Divided into four categories, the units of measure are collected in every state across a consistent continuum of socioeconomic indicators that assess:

1. Women’s access to health care services

2. Addressing both wellness and prevention

3. Key health conditions, diseases and causes of death

4. Living in a healthy community

The results show that, as a country, our national grade has been unsatisfactory.

Click here for slides showing where RI meets the grade and where we need to improve. Michelle Berlin, MD, MPH, Oregon Health & Science University

Why Women Are More at Risk in RI

Rhode Island’s cost of living is 2.5 times above the poverty level. Assistance from RI Works is 65% below the federal poverty level, and 44,000 women are without health coverage.

Poor RI women are no longer on the policy agenda to increase their benefits because there is such a lack of respect among legislators for the single mother population. The ACA will provide more insurance to all Rhode Islanders including women through the new Health Benefits Exchange. We must make sure it is affordable. Linda Katz, JD, Executive Director, Economic Progress Institute

A high percentage of new mothers, especially with premature babies, have significant social and environmental stressors. They suffer from a combination of depression, domestic violence and substance abuse. Rates of mental health issues in mothers have gone up 64% as home situations continue to worsen.Betty Vohr, MD, Women And Infants Hospital

Health Payment Reform’s Triple Aim

  1. Improve the patient experience
  2. Improve health of the population
  3. Reduce per capita cost of health

RI Medicaid is evolving from fee for service payment to value-purchasing with managed care organizations. The new goal is to pay for what is important to the patient, and to wrap a better delivery system around member practices. Renee Rulin, MD, MPH

Blue Cross Blue Shield of RI is supporting the Patient Centered Medical Home model, encouraging the development of a care team within practices and having staff work to the top of their licensure. Andrea Galgay, MBA

Neighborhood Health Plan of RI focuses on care across the socioeconomic spectrum because “the ROI is better when the whole person is considered.”Tracey Cohen, MD

Roadmaps to Innovative Care

Providence Community Health Centers We “crosswalk them.” Working with underserved populations, the Health Center decreases the barriers to care and helps patients understand their own disease process combined with their mental health issues. Patients develop their own multi-part plan and then are helped to get to the right resource when they need it.  Angela Reda, RN, Providence Community Health Centers

Health Leads goal is a healthcare system that addresses all of the patient’s basic resource needs as a standard part of quality care. Health Leads physicians, currently at Hasbro, write prescriptions for food, childcare, employment, job training, housing, and then walk patients over to the volunteer teams who follow the patient until their needs are met. Health Leads offers systemic deep integration of a practical solution for resolving socioeconomic determinants to health. Sonia Sarkar, MPH, Health Leads

Patient Centered Medical Home programs develop a patient care team within medical practices where all staff work to the top of their licensure and the whole patient is treated. The focus is on proactive care, like planning to complete tests and labs prior to patient visit with PCP. Patient engagement is the key. Andrea Galgay, MBA, Blue Cross & Blue Shield Of RI

Partnering with Parents Complex social environments contribute to the greatest risk of infant rehospitalizations. We’ve shown that increased parental support and education reduces infant rehospitalizations by 60% and since the average cost of rehospitalization is $22,000, this kind of intervention can have a significant impact on health care costs. Betty Vohr, MD, Women & Infants Hospital

In Your Practice

Many private practices don’t have the facilities to partner with Medical Home models or access to all the stakeholders needed to care for vulnerable families.

Right now, payors like Blue Cross Blue Shield, United Health Care, RI Neighborhood Health and developers of the new Health Insurance Exchange are actively seeking ways to wrap a better health care package around your practice. Let them know what you and your patients want.

Suggestions for improving access to care and a more holistic approach can include:

  • Opening morning and evening after hours and on weekends to improve access for working parents and single mothers.
  • More proactive service, like arranging to have lab tests completed prior to the PCP visit.
  • Empowering a care team to offer more comprehensive care, because the results are significantly better when the whole person is considered.
  • Most local insurers will now pay for adding Nurse Case Managers and Peer Navigators who connect all the dots for patients and pay attention to how they are living.
  • Provide home visits
  • Provide a training curriculum before taking child home; manage infant’s early care; give a new mother lots of assurance.
  • Connect families with resources in the community, include housing and other environmental issues; add a Family/Parent Resource Counselor.
  • Treat the whole family. Take a whole team approach.
  • Provide contraceptive counseling to help women make better choices; one key question to ask at every patient encounter: “Do you want to become pregnant in the next year?”

Conference Survey Summary shows what percentage of conference attendees belong to each healthcare provider category.

The Affordable Care Act: A Quick Guide for Physicians  explains ACA’s key provisions that impact physicians and patients.

Socioeconomic Stressors Workshop (2013)

 Solutions to Socioeconomic Stressors

“Public policies sustain socioeconomic stressors. We create risk through our policies, and we have the power to change these policies.”

In the 2013 Women’s Health Council Survey on Socioeconomic Stressors, we asked our members “What are the biggest socioeconomic gaps that impede your vulnerable population from accessing health care?”137 doctors, nurses and social workers completed the survey. Topping the list of their responses by a significant margin were Incomeand Unemployment, followed in ranking by Transportation, Education, Housing, Language and Food Insecurity.

In our April workshop, we learned that poverty is associated with higher risk for many diseases. Poor housing affects both physical and mental health; and a lower education predicts poorer health outcomes as well as a shorter life expectancy. Presenters and panelists came together from the provider, payor and policy maker sectors to describe the needs they see and the innovative solutions they are implementing as care providers across many dimensions in Rhode Island.

Perhaps the most important plea was “How do we all work together and avoid redundancy? We still have the habit of being in a silo; we need to find a better way to coordinate care across the state.”  Lauren Morton,  Blue Cross Blue Shield of RI.  Barriers to women’s mental health continue, as it is very hard to find short-term care for women who are dual diagnosed and homeless, and also struggle with mental health issues. Psychiatry has to be at the table.

Good to Know

Two districts in Providence are part of a pilot program from Evidence2Success, which is a new strategic process to improve outcomes for all children by improving risk and protection factors at the community level.  “Addressing just one risk can impact many outcomes, so we look for the most effective evidence-based solutions and help to implement them.” Justin Milner, Evidence2Success

“This program brings public health right into the educational system, with outcomes for kids that improve their education as well as emotional well-being, behaviors, positive relationships and physical health.  What is really new is the mechanism for measurement and level of granularity we can get to in the most difficult areas where kids need to be buffered the most.” Carrie Bridges, Providence Public School System

RI has a history of successful public health efforts in reducing exposure and anti-tobacco messaging and is now far below national averages as a result. So there is a commitment in this state to redirect funds towards programs that are proven to be the most effective in reducing risk and improving protective factors for youth.

Roadmaps to Innovative Care

Here’s a look at what panelists from this workshop are saying and doing to improve access to coordinated health care for their patient populations.

Suzanne McLaughlin, MD at RI Hospital, talked about the host of challenges patients face before they get to the hospital; there is not enough opportunity to provide preventive care. Patients don’t have the reserves to sort out all the things they need, including behavioral health, nutrition and absence from work. She wants better parity of physical and mental health, both in provision and coverage. She is focused on promoting wellness from the first contact with a patient, saying “A healthy you is going to be a better mom, worker, and partner.”

Primary care for its homeless population has changed dramatically. From an outreach mobile van 7 years ago, now all primary care and internal medicine has been located inside the Crossroads building. Facing lack of transportation, it is difficult for the homeless population to find them. She recommends bringing more nurse care management into Community Health Centers.

Bernadette McDowell is a school nurse instructor and recommends increasing the number of school nurses who are responsible for student health for 6-8 hours every school day. Because of problems getting health insurance or access to primary care, the school nurse is often the only person they see. She recommends electronic medical records be made accessible to school nurses so student care is less fragmented.

Michelle Lupoli serves the Medicaid population via Neighborhood Health Care.

To better manage this vulnerable population, she hires community outreach workers to visit members homes and better understand their needs and conditions. Lack of transportation is a major barrier for members, so she hires pharmacists who do home visits. She also focuses on co-location of services at community health centers; and provides help with translations and childcare. She seconded the request for electronic medical records.

Nancy Harrison from United Healthcare also serves the Medicaid population and faces the same challenges the hospitals face in getting patients to engage in their own health care. She looks for new ways to deliver care to people who have long term health challenges, including behavioral health case managers or field managers, to do behind the scenes work that coordinates care for members on the street. She wants to give people hope that they can in fact navigate the healthcare system.

Lauren Morton described the Blue Cross Blue Shield of RI’s own Patient Centered Medical Home program, which focuses on using a nurse care manager to build trust between patient and provider and walk the patient through to the provider services. She is promoting electronic medical records to help patients get the most out of the system they can. Lauren asked how everyone might work together in a better way and avoid creating redundancy in the system. “We still have the habit of being in silos,” she cautioned. “ We need to understand all care management across the state, and find a better way to coordinate this care statewide.”

In Your Practice

Iris Tong, MD, described the new Women’s Medicine Collaborative (WMC) as a practice of integrated services, with multidisciplinary programs. The 11 specialties included are primary care, obstetric medicine, gastroenterology, behavioral medicine, plus clinical services and specialists, plus lifestyle medicine like yoga and massage.

The WMC goal is to inspire women to achieve health in mind, body and spirit. So the first shared vision for every staff member is to care for them self first, to respect each other’s work and to share common goals.  Staff and providers are encouraged to attend the Lunch and Learn sessions, join walking groups and take one of the Collaborative’s yoga or meditation classes.

This kind of intensive co-location makes a difference in providing coordinated integrated care. A checkout person can coordinate the next steps in patient care, on the spot, at checkout.

The nurses serve as case managers and coordinate care after ER, provide home care and facilitate referrals.

In the provider workspace, the Assistant and provider work side by side, so they know each other’s practices and preferences.

A patient navigator addresses the social needs of patients.

In this model of collaborative care, the various disciplines work together in real time to create and provide a team-activated plan of care.

Another new model of care recently introduced is the concept of “shared medical visits”, where multiple patients join in one room for a shared 90-minute medical visit with their doctor. Initially skeptical, providers have found that patients enjoy the sense of community and support that results. This is particularly effective with diabetes prevention, physical activity, nutrition improvement and stress reduction. Patients respond well to hearing about other people’s experiences, what they struggled with and how they have succeeded.

The next step for WMC is to build in the quality measures that will provide recognition that this model of co-located integrated care does in fact yield better healthcare results for patients, especially because it encourages proactive involvement in preventive care.

Survey Charts show survey responses from this year’s conference participants.

Additional Info on Survey Respondents

Resources Poster details opportunities and resources for women in RI.

Slides from the Socioeconomic Stressors Workshop (2013)

Report Cards from the Socioeconomic Stressors Workshop (2013)

2012 Women’s Health Report Card (side 1) socioeconomic determinants of health (side 1)

2012 Women’s Health Report Card (side 2) socioeconomic determinants of health (side 2)

Report Cards from the 3rd Annual Quality Conference (2012)

2012 Women’s Report Card: Socioeconomic Determinants of Health.

Pocket Cards from the Socioeconomic Stressors Workshop (2013)

Resolving Socioeconomic Stressors: When providers recommend healthcare practices like exercise and safe behaviors, they make assumptions that their patients live in safe neighborhoods, are not in abusive relationships, have stable employment and can read the instructions on their medications. This card provides resources for a wide range of socioeconomic assistance

Affordable Care Act: Patient opportunities, including specific benefits for women that lower costs, improves care, improves access and helps families afford good insurance.

Affordable Care Act Timeline: This timeline from 2010 to 2014 shows when key provisions become effective that give more healthcare control back to doctors and their patients.

Resources for Addressing Socioeconomic Stressors

Resolving Socioeconomic Stressors Poster: This 11 inch x 17 inch poster is packed with Rhode Island Resources for patients with stressors related to socioeconomic issues.

Food Insecurity: A screening designed to identify food insecurity in a family as a whole.