Homeless Health In In New Orleans: Do Student Clinics Connect - PowerPoint PPT Presentation

Homeless Health In In New Orleans: Do Student Clinics Connect Patients with Long Term Care? Aaron Brug, Maren Gregersen, Georgie Green, Scott Mayer, Joseph Kanter MD MPH, Catherine Jones MD Tulane University School of Medicine, New Orleans, LA

Background: Meeting patients where they are • Tulane University School of Medicine has 7+ free, student run clinics serving the greater New Orleans area ▫ Clinics at 2 men’s emergency homeless shelters – weekly, preceptor model  Opportunity to provide a variety of interventions:  Point of care health screening (e.g. BP, DM, TB, HIV, HCV)  Counseling  OTCs  Prescriptions  Referrals to more sustainable complete, care

• Federally qualified health center (FQHC) providing primary healthcare services to adults in the city of New Orleans and surrounding parishes regardless of ability to pay for services. • A potential medical home for homeless patients

Questions: A. Who are our patients? ▫ Are our anecdotal experiences an accurate representation of our patient population and the problems they face? B. Do they follow up at HCH when we refer them? ▫ Are they being seen once or establishing long-term care? C. What predicts a referral? What predicts a successful follow up appointment? ▫ Can we harness that information to improve how we connect our patients with care?

Methods: • TuPACT: T ulane University P atient A ssessment & C are T racking ▫ database started in 10/2016 to serves as a flexible architecture to constantly learn about our clinics  Following each patient visit clinic volunteers collect:  Demographics  Health risk factors  Key objective findings  Treatment plans: including places referred  Survey via REDCAP: secure web application created at Vanderbilt University  Geared towards providing data collection tool that met HIPAA compliance standards  Mobile compatible • Tracked HCH patient follow up monthly: 90 day window ▫ 1 full year data (10/2016-10/2017) • Analysis for predictive factors of referral and successful follow up

Results: A. Who are our patients? Race • 207 patients* seen between African American 121 10/16/2016 and 10/15/2017 ▫ *New Orleans Mission Clinic closed due to Caucasian 72 facility renovations (3/2017 to present)  148 patients at Ozanam Inn; 59 Other 2 patients at NOM American Indian or • Age: Range 22-74; Mean 51.7; StDev 1 Alaskan Native 11.64 Asian 1 • Gender: 92.6% Male Native Hawaiian or • Incarceration: 55.8% 0 Pacific Islander • < GED or HS diploma: 61.4% 0 20 40 60 80 100 120 140

Smoking/Tobacco Use 99 Medicaid 78 Hypertension 74 Psychiatric Diagnosis 51 Medicare 29 Illicit Drug use 38 None 35 Unknown 27 Alcohol abuse 28 HCV 23 Uninsured 27 COPD 19 Diabetes 17 Other 15 Asthma 15 Other 11 VA 4 CAD 4 HIV 3 0 20 40 60 80 100 0 20 40 60 80 100 120

Results: B. . Do they follow up at HCH when we refer them? 12 14 56 3 30 151 44 9 Never HCH Appt Refered to HCH Prior w/o new Prior HCH Appt Not referred to HCH No Prior HCH Appt Prior with New HCH Appt w/o prior 30.36% of referred patient’s followed up w/ i 90d 21.43% of referred patients had 27.05% of all patients were referred 25.00% of referred patients follow up w/o prior been to HCH before appt.

Results: B. . Are they establishing long term care? 8 7 6 Number of Patients 5 4 3 2 1 0 1 2 3 4 5 Number of visits within 90 days

Results: C. . What predicts a referral? What predicts a successful follow up appointment? • Logistic regression model; backwards elimination • Variables included in the model: ▫ Race: Black, White, Ethnicity (Hispanic vs Nonhispanic), Other ▫ Insurance status: Medicaid, Medicare, VA, unknown, other, uninsured ▫ Chief complaint: categorized into, pulmonary sx, ENT sx, neuro sx, MSK sx, skin sx, rash, abdominal sx, GU sx , women’s health, mental health, htn, diabetes, chest pain, intake, and other ▫ Whether or not the patient had multiple chief complaints per 1 visit (y/n) ▫ Medications refilled/prescribed on visit ▫ Chronic health conditions (COPD, asthma, HIV, HCV, diabetes, htn, cad, psychiatric condition) ▫ Smoking/Illicit drug use/Alcohol use • Significance threshold p<0.05

Results: C. . What predicts a referral? N=193 (of 207) Characteristic Odds Ratio Estimate (95% CI) p Mental health related chief 4.50 (1.0 – 19.6) 0.0446 complaint on first visit • Those with mental health related chief complaints were 4.50 times more likely to get a referral to HCH than those with other types of chief complaints • PMHx of mental health problems were a separate variable that did NOT predict referral • No other variables (race, substance abuse) significantly predicted a referral • An indication that the clinics as a whole don’t have any pervasive biases?

Results: C. What predicts a successful follow up appointment in patients with no prior HCH appointment? N=55 (of 56) Characteristic Odds Ratio Estimate (95% CI) p Mental health related chief complaint on first 26.31 (1.5 – 500.0) 0.0240 visit Medicaid 0.11 (0.01-- 0.9) 0.0410 • Mental-health related chief complaints far more likely to follow-up at HCH than other chief complaints • Non-Medcaid patients are 9.47 times more likely to follow-up at HCH among all those who received an HCH referral. • Are these patients more likely to see a provider elsewhere? Their Medicaid assigned PCP?

Conclusions: • While the proportion could be greatly improved ▫ Homeless patients DO follow up with primary care ▫ Homeless patients DO establish longitudinal care at primary care provider  Recently started assessing transportation status  is there a potential transportation intervention? • Medicaid patients were less likely to follow up with HCH ▫ Better tailor referrals given insurance status • Mental health predicted both referral and follow up to HCH ▫ Are we missing mental health complaints in other patients? ▫ Supports increased mental health screening and advocacy

Acknowledgements • Health Care for the Homeless: Joseph Kanter MD MPH • TuPACT Team: Maren Gregersen, Georgie Green, Scott Mayer, Erika Chow, Frances Gill, Catherine Jones MD • Tulane University School of Medicine for their support of the clinics

Questions? Aaron Brug abrug@tulane.edu