“Public policies sustain socioeconomic stressors. We create risk through our policies, and we have the power to change these policies.”
ANA NOVAIS, RI DEPARTMENT OF PUBLIC HEALTH
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.
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.
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.”
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.
Resources Poster details opportunities and resources for women in RI.