1. 1 AHRQ Annual Conference Progress of a Learning Network: Working to Reduce Disparities by Improving Access to Care Bethesda, Maryland September 14, 2009 Jim Walton, DO, MBA Baylor Health Care System – Dallas, TX

2. 2 Baylor Health Care System Overview Baylor Health Care System (BHCS) – Dallas-Ft. Worth metropolitan area of N. Texas – 15 owned, leased, or affiliated hospitals and 6 short-stay hospitals – Affiliated physician organization, Health Texas Provider Network, has 450+ physicians in 110+ practices in the region – Baylor’s flagship hospital, Baylor University Medical Center, is a 1000-bed inner city hospital with Level 1 trauma designation

3. 3 Addressing Disparities: BHCS Office of Health Equity The BHCS Office of Health Equity – Responsible for the identification, measurement, and elimination of health disparities within the Baylor Health Care System and the communities it serves Health Care Access –Insuring Equal Access to Care & Decreasing Unnecessary Utilization Health Care Delivery –Insuring Equal Quality of Care & Decreasing Adverse Events Health Care Outcomes –Improving Health Outcomes & Decreasing Mortality and Morbidity BHCS Equity Triangle Equity in Healthcare Health Care Access Health Care Delivery Health Care Outcomes

4. 4 Disparities in DFW: Limited Access to Health Care The Problem: Approximately 23.6% of the population in the Dallas-Ft. Worth metropolitan area are without health insurance coverage. Translates to 1.3 million individuals with limited access to care 1. That number increases when you consider the number of Medicare and Medicaid patients struggling to access care. BHCS facilities bear much of the burden of uncompensated care in our community. 1 Parkland Health & Hospital System, 2006 Estimates

5. 5 Office of Health Equity: Health Care Access Goals Primary Objective : By increasing access to needed health services in community and home-based settings, underserved patients will experience less health disparities and require less frequent utilization of hospital services (ED and admissions), resulting in decreased uncompensated care for BHCS facilities. Health Care Access Strategies: 1.Facilitate access to medical services (Medical Home, Ancillary, and Specialty Care) 2.Facilitate access to affordable prescription medications 3.Care coordination to overcome barriers (i.e. low SES, language, health literacy)

6. 6 Care Coordination & Pathways: An Adaptive Model Leveraging Baylor’s infrastructure – Physicians Adjunctive support - Community Health Workers Pathways model – Care protocols to ensure connection with and delivery of evidence-based care BHCS has adapted the CCC model over the past eight years to improve: – Access to primary care – Health outcomes – Financial savings – Innovation in care delivery

7. 7 Care Coordination-First Steps: Community Health Navigation A collaboration with Project Access Dallas: – A network of volunteer providers across Dallas Co. organized to provide care to uninsured working poor Community Health Navigation was created to help patients overcome barriers to care: – Translation, Transportation, Medication assistance – Health Education to improve patient knowledge and behaviors – Coordination of referrals within the PAD program

8. 8 Adapting Care Coordination: 1. BHCS Vulnerable Patient Network A unique “house-calls” program utilizing a multi- disciplinary team to provide home-based primary care services to underserved patients with complex medical and social conditions – Neuro-trauma and Heart Failure Specially-trained CHW supports the care team with physicians and nurse practitioners: – CHW’s have medical assistant training – Utilize clinical and social “Equity care-path” tools – Serve as a single point-of-contact for home-bound patients

9. 9 36.4% Reduction 58.3% Reduction 47.8% Reduction

10. 10 29.6% Reduction 72.6% Reduction 71.2% Reduction

11. 11 Adapting Care Coordination: 2. Community Diabetes Education (CoDE) Use of Community Health Workers to provide chronic disease education and self-management training to underserved diabetics within charitable health clinics across Dallas County Conduct one-on-one counseling with patients – CHW is bilingual/bi-cultural – Contextualizes diabetes curriculum & messages – Advocates for diabetics & families (meds, referrals, etc.) – Additional point-of-contact for patient/families

12. 12 Community Diabetes Education (CoDE): Clinical Outcomes

13. 13 Care Coordination-Next Steps: 3. Ambulatory Care Coordination Supporting the move toward NCQA certification - Patient- Centered Medical Home (PCMH)  Multi-disciplinary teams 2007 - The AAFP, AAP, ACP, and AOA publish the Joint Principles of the Patient-Centered Medical Home with 7 Core Features Ambulatory Care Coordination (HT-ACC)  Using non-physician staff to navigate patient care  Coordinating care/follow-up for patients (in-patient & out-patient)  Addressing barriers, assessing progress and utilizing care paths for care management  Generating reminders for preventive care  Implementing evidence-based guidelines for disease management Sources: “Joint Principles of the Patient-Centered Medical Home” available at http://www.aafp.org/online/etc/medialib/aafp_org/documents/policy/fed/jointprinciplespcmh0207.Par.0001.File. tmp/022107medicalhome.pdf http://www.aafp.org/online/etc/medialib/aafp_org/documents/policy/fed/jointprinciplespcmh0207.Par.0001.File

14. 14 Summary Community Care Coordination and the Pathways model has been successfully adapted to provide a wide range of services to underserved patients – Navigation; clinical and social support; chronic disease education The model has produced: – Improved clinical outcomes – Decrease in avoidable hospital utilization – Positive financial impact for hospitals The model will be applied in new efforts to achieve NCQA certification for PCMH