Community Partnership for Patient Activation Santa Cruz Experience Wells Shoemaker MD September 29, 2008

3 Messages, Thinking Flogging the “usual suspects,” the delivery system, will help for diabetes and heart disease… and we will keep it up…but only help a little bit. (HEDIS is a narrow view.) 2. Public Health thinking and customized, broad community initiatives are essential. 3. Patient activation is the key to the garden… and we can turn it

Bumper Sticker Wisdom Think Globally Think Globally Act Locally Act Locally …and…Get all the help you can! …and…Get all the help you can!

DIABETES PYRAMID Late Complications Patients with Diagnosed diabetes Undiagnosed and “Pre diabetes” Obese, Sedentary Children

Primary Care Workforce Crisis New entrants now << 50% of 1995 New entrants now << 50% of 1995 New kids can’t buy houses here New kids can’t buy houses here Leaving CA—hassles, regulations, no “life.” …and seeking niches if they stay. Leaving CA—hassles, regulations, no “life.” …and seeking niches if they stay. Overwhelmed with “WYODI’s”—impossible Overwhelmed with “WYODI’s”—impossible Disaffected, to say it politely Disaffected, to say it politely Think FTE’s, not “heads”—they’re getting gray, part time; we’re in deep trouble Think FTE’s, not “heads”—they’re getting gray, part time; we’re in deep trouble

What can be done? What can be done? Expand capacity of each doctor—practice redesign, teams, community supports, information systems, outreach Expand capacity of each doctor—practice redesign, teams, community supports, information systems, outreach Respond to reimbursement disparity, including novel payment for chronic care Respond to reimbursement disparity, including novel payment for chronic care Improve job satisfaction and personal life balance—delete stupid time waste Improve job satisfaction and personal life balance—delete stupid time waste

Think Local: Santa Cruz County Small county with natural geographic boundaries. Mix: urban, residential, ag Small county with natural geographic boundaries. Mix: urban, residential, ag Population 260,000, fairly stable Population 260,000, fairly stable Microcosm of Pacific Coast demographics, with ethnic clusters Microcosm of Pacific Coast demographics, with ethnic clusters University & Junior College University & Junior College Liberal politics Liberal politics Both collaboration and friction Both collaboration and friction Severe PCP recruitment handicaps Severe PCP recruitment handicaps

Two Grass Roots Collaboratives Health Improvement Partnership— Executives of all health “Usual Suspects” Health Improvement Partnership— Executives of all health “Usual Suspects” Regional Diabetes Collaborative—”Worker Bees” in diabetes care, education, advocacy Regional Diabetes Collaborative—”Worker Bees” in diabetes care, education, advocacy –Diabetes Health Center

Patient engagement resources Diabetes Health Center—non-profit, local, ethnically attuned, community engaged… and struggling for nickels and dimes Diabetes Health Center—non-profit, local, ethnically attuned, community engaged… and struggling for nickels and dimes Hospital based programs “pt education” Hospital based programs “pt education” Group & clinic-based programs Group & clinic-based programs Entrepreneurial programs “if you got the money, honey, I got the time” Entrepreneurial programs “if you got the money, honey, I got the time”

What can Plans do to help? Participate in regional collaboratives Participate in regional collaboratives Seek and pay for local patient activation services that work Seek and pay for local patient activation services that work Flexibility in criteria for vendors Flexibility in criteria for vendors Protect these in limited benefit products Protect these in limited benefit products Openness to novel chronic care reimbursement strategies Openness to novel chronic care reimbursement strategies

Santa Cruz background Following slides for background—not likely time for presentation 9/29 Following slides for background—not likely time for presentation 9/29

Health Improvement Partnership Executive representation, monthly meetings: Public Health Dept & HSA Public Health Dept & HSA 3 hospitals 3 hospitals 2 private sector medical groups 2 private sector medical groups The Alliance—Medi-Cal managed care The Alliance—Medi-Cal managed care Hospital staffs & Medical Society Hospital staffs & Medical Society ERs ERs 3 Community Foundations 3 Community Foundations Cabrillo Junior College Cabrillo Junior College

HIP: Cross-Cutting Targets Healthy Kids launch Healthy Kids launch ER Frequent Users Program ER Frequent Users Program Diabetes Program support Diabetes Program support Students & health professions Students & health professions Electronic connectivity Electronic connectivity Area 99 injustice Area 99 injustice Community forums & “United Nations” Community forums & “United Nations” Grant magnet Grant magnet

Regional Diabetes Collaborative Santa Cruz, Monterey, San Benito Counties Santa Cruz, Monterey, San Benito Counties 800,000 people total 800,000 people total 7% diabetes prevalence  50, % diabetes prevalence  50,000 + “Worker bee” professionals from “Worker bee” professionals from –Public health, medical groups, Comm Clinics, Alliance –Hospitals (7) diabetes education staff –Diabetes Health Center—non profit, ethnic ++ –Advocacy organizations & Seniors –CA Diabetes Program –Cal State Monterey Bay, Cabrillo, UCSC

Three Thrusts of RDC 1. Clinical Care Improvement 2. Patient education…morph to self- management support, culturally appropriate, community focused 3. Public information and Policy And liaison with related organizations, i.e. Pediatric Obesity, CCCN And liaison with related organizations, i.e. Pediatric Obesity, CCCN

RDC Activities Quarterly general meetings—best practices, education, networking Quarterly general meetings—best practices, education, networking Annual conference Annual conference Health fairs Health fairs Multiple local engagements Multiple local engagements Lawmaker outreach Lawmaker outreach Public information & speakers Public information & speakers AHRQ grant conduit AHRQ grant conduit Amplifier of messages Amplifier of messages

Highlights HIP adopted diabetes formal goal 2003 HIP adopted diabetes formal goal 2003 IOM Presentation 2004 IOM Presentation 2004 AHRQ grant Registry project AHRQ grant Registry project Annual tri-county diabetes forum with “hot” speakers, lots of pub, political push Annual tri-county diabetes forum with “hot” speakers, lots of pub, political push Expansion, solidification of RDC Expansion, solidification of RDC Coordination with others Coordination with others Still playing catch-up Still playing catch-up

Take Home Local resources potentially powerful Local resources potentially powerful Can reach further than “medical” alone Can reach further than “medical” alone Bake sale economics to start Bake sale economics to start Grant funding appealing but can be disruptive Grant funding appealing but can be disruptive High degree of customization needed High degree of customization needed Leadership cultivation required Leadership cultivation required Costs real $ to launch and maintain Costs real $ to launch and maintain Easy to fall back to silo thinking Easy to fall back to silo thinking