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 Increasing Costs 4 Relationship-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 Institutions Health 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 Projected Population of Bexar County by Race and Ethnicity, 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 American MaleFemaleMaleFemale

19 Educational Attainment of Population Over 25 Years of Age, Bexar County (Population 25 years and over) 19

20 Age of Death Over 75 Years, Bexar County 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 uninsured –18.1% of children 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 CodesBexar 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%) Hispanic347,102 (82%)752,532 (54%) Non-Hispanic White55,474 (13%)493,090 (36%) African American13,317 (3%) 94,131 (7%) High School Graduates or Higher Education 1 240,290 (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 Ten Zip Codes % of Bexar County Population421,56130% Total Births8, % Late Prenatal Care Births2, % Birth within 24 Months of Previous1, % Births To Mothers BMI >302, % Juvenile Probation4, % Family Violence Reports4, % Single Mother Births5, % Medicaid Births5, % Confirmed Child Abuse/Neglect Cases2, % Births To Mothers Age < % Births to mothers < HS / GED3, %

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, MPH Director of Health San Antonio Metro Health District