Together.Today. Tomorrow.

21st Century Model of Primary Care for Chronic Diseases

Jane Allen Calhoun, Director, Clinical ServicesAnna Lyn Whitt, Executive Assistant to CEO

Delta State University - John Hilpert, Chairman

MS Valley State University – Donna OliverUniv. of MS Medical Center - James

KeetonMississippi State University - Melissa

MixonDelta Council - Bill KennedyCommunity Members – Bruce BrumfieldRepresentative Willie BaileyCass Pennington

Board of DirectorsBoard of Directors

DHA Overview

AccessAccess Increase access and availability of care

EducationEducation Offer health education programs

ResearchResearch Conduct and apply health research

Access, Education & Research

Service Area

Mississippi

Mississippi’s National Ranking

% obese adults1 48th

% diabetes2 1st

Number of adults who

smoke cigarettes 42nd

Asthma-related disease

among school age students 50th

Teen pregnancy Highest

Infant mortality49th

Delta

MS US

Infant mortality per 1,000 13.2 11.4 6.9

Adult Obesity 34.4 30.9 24.4

Adult Diabetes 11.5 10.8 7.5

Level 1 Literacy or Below Unknown 30.0 14.0

Physicians per 10,000 1.1 1.8 3.00

Vital Stats

Physician Patient Loadby County

= 5 or less physicians residing in county

= no physicians in county

http://www.healthpolicy.msstate.edu/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 When Good Health Drives the Economy of the RegionEconomy of the Region

What are we doing to address this?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

DHA TouchWorks Cluster

UMC TouchWorks Cluster

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

21st Century Primary Care Model

• Transforming 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

21st Century Model of Primary Care

∙ Utilizing the TransforMED Patient-Centered Model to better serve the needs of both patients and practices

21st 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

21st 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

21st 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.