From the Health Commons to Health Extension (HEROs): An Academic Health Center Addresses the Social Determinants of Health Society of Directors of Research in Medical Education Wed. June 17 • La Fonda Santa Fe, NM Arthur Kaufman, M.D. Vice President for Community Health Prof. Dept. of Fam. and Community Medicine akaufman@salud.unm.edu
Workforce Crisis � Looming National Health Workforce Crisis • Decreased interest in primary care • Decreased admission of rural students • Low % ethnic minorities entering medicine • Aging RN workforce • Behavioral health, oral health inaccessible to many
Major Gaps/Challenges Fragmented system of • medical, behavioral, social services Poor access to basic services • Maldistribution of health • professionals Research priorities often not • aligned with community’s priorities
Factors Associated with Low U.S. Health Care Ranking • Weak primary care system • High income, social disparities • Inappropriate use of technology B. Starfield
In England Each additional primary care physician per 10,000 (about a 20% increase) is associated with a decrease in mortality of about 5%. B. Starfield
Educational Innovation Life Experience as Change Agent • 1979 Change preclinical curriculum • 1988 Change clinical curriculum • 1992 Change residency education • 1994 Interdisciplinary learning • 1996 Change clinical practice • 1998 Integrate public health and primary care
Education to Address Workforce Crisis: “Expansion of FM Residency” • Increased number- from 6 to 36 in Albuquerque • State funded 16 of these (free to work/learn in community) • Increased rotations in rural communities • Locum tenens encouraged for all • Established 3 rural residency sites in addition to Albuquerque (Roswell, Las Cruces, Santa Fe) so total number of NM FM positions = 72
FM Residency Outcomes � 50% Albuquerque FM grads to rural NM � 80% of rural FM grads to rural NM � 33% of FM grads who chose rural practices worked with Native American communities
Educational Reform Must be Complemented by Service Reform � Predominance of chronic illness � “Behavior” and “Culture” key factors in prevention, management � SES important determinant of health, access � Care increasingly delivered in interprofessional teams, by non-MDs
Years of Productive Life Lost in NM 1 st – Injuries (alcohol-related >50%) 2 nd – Cancer (smoking, environment) 3 rd – Homicide/suicide
Adverse Childhood Experiences Correlated with Chronic Disease in Adults Childhood Abuse Physical • Emotional • Sexual • Adults in Home Mother beaten • Mental Illness • Alcohol of substance abuse • Having been a prisoner • Fellitti VJ, Anda RF, Nordenberg D, et al. Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. Am J Prev Medicine, Vol, 14, No. 4: 245-258
The Educational Payoff EDUCATION ATTAINMENT AV. ANNUAL EARNINGS High School Dropout $18,900 High School Graduate $25,900 Bachelor’s Degree $45,400 Master’s Degree $54,500 Professional Degree $99,300 SOURCE: BUREAU OF LABOR STATISTICS, DEPT. OF LABOR, 2002
Growing Need for New, Integrated Models of Care � “Status One” – top 5 % of care users consume 50% of resources � Social determinants of disease in high user subset • 70% underlying cause of high ER use “behavioral” • 70% of “behavioral” is alcohol and substance abuse � Intense case management requires collaboration (medical, behavioral, social, community outreach)
Tips for Staying Healthy � Don’t be poor � Don’t have poor parents � Own a car � Don’t work in a stressful, low paid manual job � Don’t be unemployed � Don’t live in damp, low quality housing – Dave Gordon, 1999
Next UNM School of Medicine Curriculum Reform: Public Health Certificate (17 credits) for all students matriculating in 2010
Service Models Relevant to Community Health � UNM Care Program � Primary Care Dispatch � Field Case Management � 24 Hour Nurse Health Advice Line � Health Commons
UNM Care Program for Medically Uninsured � Enroll ~14,000, ~40% with C.H.C. partner � Assign to Primary Care Home � Affordable Co-pays (based on means testing) � Outcomes � increased prevention (paps, mammograms, etc) � decreased hospitalizations (~$2 million saving) � model for State Coverage Initiative Kaufman A, Derksen D, McKernan S, et al. Managed Care for Uninsured Patients at an Academic Health Center: A Care Study. Academic Medicine, Vol. 75, No. 4 April 2000: 323-330.
Primary Care Dispatch: Finding a Medical Home – 31% Reduction in return visits to ED Murnik M, Randal F, Guevara M, et al. Web-based Primary Care Referral Program Associated with Reduced Emergency Department Utilization. Fam Med 2006; 38 (3): 185-9
Field Case Management: Sustainable Role, Funding for Community Health Workers (“promatoras”) � Managed Medicaid MCO profits reduced by Medicaid high users � Need for case management, but “can’t find” this group � Dept Fam & Comm Med received MCO contract to hire, train Field Case Managers – given panel of high risk patients – managed “in the field” � Results: 62% reduction in cost; program expanded to 2 other MCOs, two rural regions; Co-care, mutual teaching with FM residents
Nurse Advice Line – Early Outcomes � ~15,000 calls/month � ED visits reduced (62% of planned ED visits diverted: est. savings of $6 million/year) � Appts to primary care homes � Broad support (state, counties, comm. hospitals, practices) � Rural practice relief (esp. community health centers) � Health Dept uses for “syndromic surveillance” 1-877-725-2552
“Health Commons” � Community stakeholders address intractable health problems � One-stop-shopping (medicine, behavioral health, case management, oral health, community health worker links with community) � Integration of medicine and public health � Model interdisciplinary training site for health professionals � Community engagement — e.g., pipeline development, economic development Kaufman A, Derksen D, Alfero C, et al. The Health Commons and Care of New Mexico’s Uninsured. Ann Fam Med, Vol. 4, Supplement 1, Sept/Oct 2006: 522-527
Health Commons models were created in two inner city neighborhoods (South Valley and Southeast Heights, both in Albuquerque and two in rural counties (Sandoval and Hidalgo).
Establishment of Office for Community Health � Appointed VP for Community Health � Goal: “work with community partners to achieve the greatest improvement in health of any state by 2020” � Programmatic efforts guided by extensive community input, guidance
Universities & Community Engagement “Most university-community partnerships are one-sided altruism. The University gives things to a needy community, compensated by warm feelings and a grant until it ends.” – Howell Baum “Shifting institutional leadership and grant-based funding often relegates community partnerships to boutique initiatives, paraded out when the university needs to demonstrate its engagement bona fides…Many community engagement offices are tucked away in outreach centers or isolated in a single school or college, outside the mainstream of the university’s priorities.” – Mary Jane Brukardt
Comments from a Sampling of Community Health Leaders Important to overcome image: � “University of ABQ,” • “UNM only present while grant funds last” • “UNM comes with its agenda, its priorities.” • UNM needs to: � Commit to long term partnerships, not just when grant present • Build upon local wisdom, leaders, organizations, programs • Create central office at UNM, single telephone number (like the • Physician Access Line) Have full-time presence in all communities like NMSU •
Establish Health Extension Rural Offices (HEROs) � Place full-time in rural communities across the state � Link community health priorities with UNM and NMSU resources � Monitor effectiveness of university programs in addressing community health needs � Partner with agricultural Cooperative Extension, with Dept. of Health, with County Health Planning Councils
2007 Top Health Priorities from 31 County and 6 Tribal Councils (compared with UNM HSC research priorities) � County Health Councils’ UNM HSC Research Priorities � Priorities (in order) (“Signature Programs”) � Substance Abuse � Cancer � Teen Pregnancy � Cardiovascular and Metabolic Diseases � Obesity � Brain and Behavior � Access to Care � Child Health � Violence � Infectious Disease and � Diabetes Immunity � Environmental Health
Example: Jemez Pueblo � Teleradiology [Tribe chose IHS] � Credentialing � Board Training � Recruiting MDs � Health Needs Assessment [Tribe chose Jemez Evaluator] � Nurse Practitioners � Nurse Manager � Power Chart Outreach
HSC-linked Community Hospital- Academic Hubs TAOS SAN JUAN Hubs SAN MIGUEL SANTA Propose FE GUADALUPE d links CHAVEZ GRANT LEA DONA ANA
Sample County Health Report Card
Spin-Offs � Telepharmacy � Food Pantries � Training Agricultural Cooperative Extension Agents (4-H, Home Economics, etc.)
Recommend
More recommend
