Together.Today.Tomorrow. 21 st Century Model of Primary Care for Chronic Diseases Jane Allen Calhoun, Director, Clinical Services Anna Lyn Whitt, Executive Assistant to CEO

Delta State University - John Hilpert, Chairman MS Valley State University – Donna Oliver Univ. of MS Medical Center - James Keeton Mississippi State University - Melissa Mixon Delta Council - Bill Kennedy Community Members – Bruce Brumfield Representative Willie Bailey Cass Pennington Board of Directors

DHA Overview Access Access Increase access and availability of care Education Education Offer health education programs Research Research Conduct and apply health research

Access, Education & Research

Service Area

Mississippi Mississippi’s National Ranking  % obese adults 1 48 th % diabetes 2 1 st Number of adults who smoke cigarettes 42 nd Asthma-related disease among school age students 50 th Teen pregnancy Highest Infant mortality49 th DeltaMSUS Infant mortality per 1, Adult Obesity Adult Diabetes Level 1 Literacy or Below Unknown Physicians per 10,

Vital Stats Physician Patient Load by County = 5 or less physicians residing in county = no physicians in county publications/healthmaps/primcarephys.pdf MSDH State Health Plan 2007 Within recommended patient load (1,429 patients PCP) Up to double recommended patient load 2x to 4x recommended patient load More than 4x recommended patient load No PCP in County Map 1: Patients per Primary Care Physician, 2002

The Destructive Cycle of The Destructive Cycle of Health Disparities in the Delta

When Good Health Drives the Economy of the Region

What are we doing to address this? Mathematica  External evaluation  GAP analysis Project Portfolio Shift from small, narrow research projects to broader, infrastructure building projects that are likely to have near-term effect on improving healthcare knowledge, access or quality. Source: Social-ecological model from CDC.

Partners

Additional Collaborators Delta Area Health Education Center (AHEC) Mathematica Policy Research Inc. Oak Ridge National Laboratories Hamilton Eye Institute Vanderbilt University University of Chicago Northwestern University

Delta Health Initiative Highlights

Addressing Solutions Today Investments in Technology Streamline Rural Programs Enhance Rural Infrastructure

Investments in Technology Consistent use of best practices regardless of clinic location

Electronic Health Records EHRs Benefit Our Communities ~329,000 Patients in Delta Database 13 site locations - DRMC Patient education for chronic disease self-management Improved medication management Improved tracking of long-term outcomes Reduction of health disparities

Expanding Infrastructure Rural TeleStroke VISICU—Telemedicine for Intensive Care—University of MS Medical Center TelePsychiatry Program—University of MS Medical Center Vision Screening

21 st Century Primary Care Model T ransforming primary care practices in rural health clinics and free clinics in target counties Measuring impact on access to care, treatment outcomes, & provider and patient satisfaction

21 st Century Model of Primary Care ∙ Utilizing the TransforMED Patient- Centered Model to better serve the needs of both patients and practices

21 st Century Model of Primary Care ∙ The model encourages ∙ Clinician-patient communication: trust, respect, shared decision- making ∙ Patient engagement ∙ Provider/patient partnership ∙ Culturally sensitive care ∙ Continuous relationship ∙ Whole person care

21 st Century Model of Primary Care Goal 1: Improved health outcomes for people with diabetes and hypertension Goal 2: Increased access to goal Goal 3: Increased community awareness Goal 4: Evaluate the effectiveness of the process and the outcomes of a PCMH model in the Delta and its impact on overall health outcomes

21 st Century Primary Care Model Applying PCMH principles to the traditional chronic care model Enhancing access to a clinical team Adopting new technologies Improving quality, equity, and efficiency

Successful Communities Workforce Development Literacy Early Childhood Interventions Appropriate Healthcare Successful Communities

Together. Today. Tomorrow.