The Palmetto Project: Putting Innovative Ideas to Work in South Carolina-Steve Skardon

The Palmetto The Palmetto ProjectProject

Putting Innovative Ideas Putting Innovative Ideas to Work in South Carolinato Work in South Carolina

Steve Skardon, Executive Director

South Carolina Immunization Partnership

Communicare

AccessNET Provider Collaborative & Patient Navigator Network

South Carolina Immunization PartnershipFebruary 1993 – May 1994

ObjectiveMake S.C a national leader in childhood immunization

PartnersS.C. Department of Health & Human ServicesPalmetto ProjectAlliance for South Carolina’s ChildrenBlue Cross Blue Shield of SCS.C. Press AssociationRotary & Lions Clubs

South Carolina Immunization Partnership(continued)

Methods

Political campaign techniques identify, educate, & motivate parents

Community partnerships among business and civic leaders create local strategies in 13 public health districts

Broadcast and print media partners in each health district

Outcomes

Increased immunization rates statewide from 53% to 90%

Ranked by CDC as 1st in the nation in 1994

Communicare 1993 – present

ObjectiveImprove access and coordination of health care services for the uninsured and underinsured

PartnersS.C. Medical AssociationS.C. Hospital AssociationS.C. Pharmacy AssociationSix National Pharmaceutical CompaniesSmith Kline Beecham Labs

Communicare (continued)

Methods

Care coordinator at statewide toll-free call center arranges for…

free visit for any uninsured caller to one of 2,000 providers

free pharmaceuticals from formulary of six participating drug companies,

overnight stays at one of 30 participating hospitals

Outcomes

53% of 8,000 clients provided medical home

Central fill pharmacy provides 1000 free prescriptions daily at an estimated value of more than $70 million annually (Welvista)

Faith-based Initiative in African American health reduces disparity in cardiovascular mortality among males by 50%. (Heart & Soul)

AccessNET Provider Collaborative & Patient Navigator Network 2005 – present

ObjectiveImprove health care outcomes and reduce cost of care for the uninsured with chronic disease through enhanced provider coordination and patient-centered navigation

PartnersMedical University of South Carolina (Women’s Health Initiative)Medical University of South Carolina (Children’s Hospital)Two Federally Qualified Community Health CentersThree Local Free ClinicsCharleston Dorchester Mental Health AssociationSC Department of Health & Environmental ControlSC Office of Research & Statistics

AccessNET(continued)

Methods

Providers standardize records into single data management system (AIMS), implement procedures for patient referral & medical follow up, & refer patients to health education and disease management programs

Navigators assess needs of new patients, address barriers to care, develop plan for care including referral to primary & specialty care and pharmacy assistance,

Outreach specialists implement health education and disease prevention programming in at-risk communities, conduct ongoing screening, monitoring, life style modification, $ disease self-screening, monitoring, life style modification, $ disease self-management for navigated patientsmanagement for navigated patients

AccessNET(continued)

Outcomes

100% of 2,000 clients provided medical home and access to patient navigation services

AIMS system becomes statewide platform for statewide medical records locator and health information exchange for 4.4 million South Carolinians

Cost of care for navigated patients declines by 27%

A 66 percent reduction in emergency room utilization by navigated patients with diabetes

An 83 percent reduction in ER utilization by navigated patients with cardiovascular disease

Lessons Learned

Clearly perceived need & limited objective

Opportunity

Plan

Needs assessment of every collaborating partner

Management of Collaborative: Democratic versus direction from lead partner?

Signs of early success

Y’all com beck, y’hare?Y’all com beck, y’hare?

“To every person there comes in life that special moment when one is tapped on the shoulder and offered the chance to do one very special thing. What a tragedy if that

moment finds you unprepared or unqualified for the work which would be

your finest hour.”“

Winston Churchill

Where are we headed?(and who’s doing the driving?)

Regional Networks of Care

We can’t solve problems by using the same kind of thinking we used when we created

them.”

Albert Einstein

Regional Networks of CareRegional Networks of Care

Population Population

703,505703,505

Nearly 45% of population is uninsured

or does not have sufficient coverage

to meet its needs.


Continuum of CareProvider collaborative reduces administrative duplication

& streamlines access to primary, diagnostic, & specialty care

Access & Care CoordinationNew navigator network increases access & care coordination

Education & Prevention149 Heart & Soul sites provide outreach & ongoing health

education

Data Collection & ManagementProviders create single data management system


Medical Outcomes & Patient Centered Care


Outcomes research seeks to understand the end results of particular health care practices and interventions. These include effects that people experience and care about, such as change in the ability to function. For individuals with chronic conditions, end results include quality of life as well as mortality. By linking the care people get to the outcomes they experience, outcomes research has become the key to developing better ways to monitor and improve the quality of care.

Agency for Healthcare Research and Quality


Patient centered care is that which is based on a partnership among practitioners, patients, & their families to ensure that decisions respect patient wants, needs, and preferences and that patients have the required education & support to make decisions and participate in their own care.

Institute of Medicine



Data Management & Electronic Records

Disabilities & Special Needs

Vocational Rehabilitation Law Enforcement

Health Department

Education

Outpatient Surgeries

State Employee Health Services

Emergency Room Visits

Hospitalizations

Environmental Conditions

Home Health Care

Medicaid Services

Social Services

Public Safety

Mental Health

Juvenile Justice

Free Clinic Visits

Alcohol & Drug Services

Child Care

Community Health Centers

Medicare

Disease Registries

Elder Services & Assessments

SC

Integrated

Data

System

Probation, Pardon & Parole

Corrections*

Legal/Safety Services

Social Services

Claims Systems

All Payer Health Care Databases

Behavioral Health

Health Department

Education

Other State Support Agencies

Disease Registries

LEGEND

Data Management & Electronic RecordsData Management & Electronic Records

Web-based database system designed and implemented by Web-based database system designed and implemented by the SC Office of Research and Statistics (ORS),the SC Office of Research and Statistics (ORS),

System integrations and coordination utilizes the state’s System integrations and coordination utilizes the state’s HIPAA compliant secure Data Warehouse and Client HIPAA compliant secure Data Warehouse and Client Information System. Information System.

Accessible to all collaborative members for information Accessible to all collaborative members for information storage and retrieval, referral of clients, and meeting storage and retrieval, referral of clients, and meeting reporting requirements. reporting requirements.

PNs use the AIMS individual client records as basic client PNs use the AIMS individual client records as basic client information---scheduled appointments, language, pharmacy information---scheduled appointments, language, pharmacy and transportation needs are viewed up to date, in real time. and transportation needs are viewed up to date, in real time.

Database allows for maintaining information about the client; Database allows for maintaining information about the client; tracking and maintaining client appointments, assessments, tracking and maintaining client appointments, assessments, and referrals; recording information about community and referrals; recording information about community outreach activities and health education.outreach activities and health education.




Communications

Communications

Last year 98,000 patients died as a result of medical errors.

According to the American Hospital Association, the leading cause of those errors was inadequate communication

among providers.

o

Communications

Evidence-based practices are specific clinical guidelines that help bridge the gaps between what researchers find to be effective treatment and what is implemented at the practice level. Their use is growing in all areas of health care in an effort to reduce errors and improve health.

According to the Institute of Medicine, only 50%-

60% of medical treatments are evidence-based.




Communications

New Programming under PNDP

New H&S Health

Education & Prevention

Sites

New Health Collaborativ

e Service Delivery

Sites

Health Conditions TargetedHealth Conditions Targeted

DiabetesDiabetesSC is 2SC is 2ndnd in the nation in the nation

Hypertension/CVDHypertension/CVDSC is 3SC is 3rdrd in the nation for high blood in the nation for high blood pressurepressure

StrokeStrokeSC is 2SC is 2ndnd highest in the nation for highest in the nation for stroke mortalitystroke mortality

Obesity Obesity SC is 3SC is 3rdrd in the nation for obesity in the nation for obesity

Disparities in Disparities in Cardiovascular DiseaseCardiovascular Disease

African Americans had a higher African Americans had a higher prevalence rate (15.4%) than prevalence rate (15.4%) than Caucasians (8.4%).Caucasians (8.4%).

African Americans were more likely to African Americans were more likely to report a diagnosis of high blood report a diagnosis of high blood pressure (36.4%) than Caucasians pressure (36.4%) than Caucasians (29.5%).(29.5%).

African American men in SC are likely African American men in SC are likely to die from CVD 10 years before white to die from CVD 10 years before white men. Most will not reach 65men. Most will not reach 65..

Palmetto Project

What does it take to provide health What does it take to provide health care to the nearly 45% of South care to the nearly 45% of South

Carolinians without private health Carolinians without private health insurance?insurance?

Continuum of CareContinuum of Care Access & Care CoordinationAccess & Care Coordination Health Education & Disease Health Education & Disease

PreventionPrevention Data Collection & ManagementData Collection & Management

Target CountiesTarget Counties

Population Population 703,505 703,505

Nearly 45% of population

are uninsured or do not have

sufficient coverage to meet

their needs.

Disparities in StrokeDisparities in Stroke Mortality from stroke among African Mortality from stroke among African

Americans is 24% higher than the national Americans is 24% higher than the national average.average.

African Americans are 40 percent more African Americans are 40 percent more likely to die from stroke than Caucasians.likely to die from stroke than Caucasians.

Identifiable and treatable risk factors for Identifiable and treatable risk factors for CVD and stroke nearly twice those of whitesCVD and stroke nearly twice those of whites

One in three African Americans has high blood One in three African Americans has high blood pressure pressure

One in two is overweightOne in two is overweight Two in three are physically inactive.Two in three are physically inactive.

Disparities in Diabetes

IIn 2005, estimated 280,000 state residents had n 2005, estimated 280,000 state residents had been diagnosed with diabetes, and another been diagnosed with diabetes, and another 140,000 have diabetes but do not know it 140,000 have diabetes but do not know it

African Americans had a higher prevalence African Americans had a higher prevalence rate for diabetes (15.4%) than Caucasians rate for diabetes (15.4%) than Caucasians (8.4%).(8.4%).

Mortality rates for diabetes were three times Mortality rates for diabetes were three times higher for non-whites as for whithigher for non-whites as for whiteses

ER visits for diabetes were almost seven ER visits for diabetes were almost seven times higher among African Americans than times higher among African Americans than among whites.among whites.

In Dorchester County, diabetes resulted in more In Dorchester County, diabetes resulted in more than three times as many ER visits for blacks than than three times as many ER visits for blacks than whites.whites.

How Patients are IdentifiedHow Patients are Identified

Referrals by collaborative partnersReferrals by collaborative partners

Outreach & screeningOutreach & screening

CommunityCommunity

Target Capacity under PNDPTarget Capacity under PNDP

3,000 navigated clients by August 3,000 navigated clients by August 20102010

What are the What are the interventions?interventions?

Outreach to health disparities populationsOutreach to health disparities populations Prevention and early detectionPrevention and early detection

Education, screening, monitoring, life style Education, screening, monitoring, life style modificationmodification

Referral to primary careReferral to primary care Referral for diagnostic and specialty careReferral for diagnostic and specialty care Medication assistanceMedication assistance Reduction of BarriersReduction of Barriers Self-management goal settingSelf-management goal setting Facilitate involvement with community Facilitate involvement with community

organizationsorganizations Coordinate with relevant insurance/other Coordinate with relevant insurance/other

coveragecoverage

PNDP Navigated PatientsPNDP Navigated PatientsPN Actions by Patient ConditionPN Actions by Patient Condition Diabetes = 53Diabetes = 53 Ophthalmology scheduling = 21Ophthalmology scheduling = 21 Foot care scheduling = 4Foot care scheduling = 4 Hypertension = 186Hypertension = 186 Cardiology scheduling = 22Cardiology scheduling = 22 Cancer screening and treatment referrals Cancer screening and treatment referrals

= 41= 41 Women’s services/OB/GYN scheduling = Women’s services/OB/GYN scheduling =

9090 Pediatrics = 266Pediatrics = 266 Dental or oral health scheduling = 10Dental or oral health scheduling = 10 Mental health referrals = 11Mental health referrals = 11 Other specialty care scheduling = 148Other specialty care scheduling = 148

Arthritis (8) Neurology (12) Arthritis (8) Neurology (12) Pulmonology (6) Pulmonology (6)

GI (78)GI (78) Orthopedic (10) ENT (14) Orthopedic (10) ENT (14)

Dermatology (20)Dermatology (20)

Non-Disease Non-Disease Specific PN Specific PN ActivitiesActivities

Health coverage Health coverage assistance = 28assistance = 28

Medication/PAP Medication/PAP assistance = 68assistance = 68

(ECCO PAP = 298)(ECCO PAP = 298)

SC Data WarehouseSC Data Warehouse Builds off of existing legacy systems from state agencies and Builds off of existing legacy systems from state agencies and

private sectorprivate sector Creates a Unique ID (not related to any other number)Creates a Unique ID (not related to any other number) Identifiers are pulled off of the statistical data. Use only the Identifiers are pulled off of the statistical data. Use only the

statistical datastatistical data Data is always “owned” by originating agency. Permissions Data is always “owned” by originating agency. Permissions

required to use and/or linkrequired to use and/or link

Using Data in the Data Warehouse Agencies & Other Using Data in the Data Warehouse Agencies & Other Entities can:Entities can:

Evaluate their programsEvaluate their programs Look at OutcomesLook at Outcomes Understand better how their programs interact with other agency & Understand better how their programs interact with other agency &

other entity programsother entity programs Study Health, Human Service, Education, and Law Enforcement IssuesStudy Health, Human Service, Education, and Law Enforcement Issues Analyze Statistical – Aggregate InformationAnalyze Statistical – Aggregate Information Access Analytic Data CubesAccess Analytic Data Cubes Partner in the Development of Customized Software Applications Partner in the Development of Customized Software Applications

The Client Information The Client Information SystemSystem

Web-based HIPAA compliant secure Client Web-based HIPAA compliant secure Client Information System tracks SC public sector Information System tracks SC public sector clients and services across multiple clients and services across multiple

agenciesagencies. . For For Treatment and OperationsTreatment and Operations Designed to provide a 12-month rolling history of the client’s Designed to provide a 12-month rolling history of the client’s

services. services. Includes management and summary reports. Includes management and summary reports. Medicaid clients served by the Dept. of Health and Human Medicaid clients served by the Dept. of Health and Human

Services operational. Services operational. Discussions with two other state agenciesDiscussions with two other state agencies Legal teams involvedLegal teams involved End product will allow the tracking of SC public sector clients End product will allow the tracking of SC public sector clients

across multiple agencies to ensure better coordination and across multiple agencies to ensure better coordination and management. management.

AIMSAIMS

Web-based database system designed and implemented by the Web-based database system designed and implemented by the SC Budget and Control Board’s Office of Research and SC Budget and Control Board’s Office of Research and Statistics (ORS),Statistics (ORS),

System integrations and coordination utilizes the state’s System integrations and coordination utilizes the state’s HIPAA compliant secure Data Warehouse and Client HIPAA compliant secure Data Warehouse and Client Information System. Information System.

Accessible to all collaborative members for information Accessible to all collaborative members for information storage and retrieval, referral of clients, and meeting storage and retrieval, referral of clients, and meeting reporting requirements. reporting requirements.

PNs use the AIMS individual client records as basic client PNs use the AIMS individual client records as basic client information---scheduled appointments, language, pharmacy information---scheduled appointments, language, pharmacy and transportation needs are viewed up to date, in real time. and transportation needs are viewed up to date, in real time.

Database allows for maintaining information about the client; Database allows for maintaining information about the client; tracking and maintaining client appointments, assessments, tracking and maintaining client appointments, assessments, and referrals; recording information about community and referrals; recording information about community outreach activities and health education.outreach activities and health education.

AccessNETAccessNETRHIO HeadStartRHIO HeadStart

State Data Warehouse used to establish a Record Locator Service (RLS) for the region as well as longitudinal record for over 4 million residents of the state. Specifically, the data includes

• all Medicaid (including pharmacy and physician office visits)• State Health Plan claims • UB-92 inpatient, ambulatory surgery and ED claims• In summary, a secure “bus” to connect to.

As such, this warehouse will provide a nearly comprehensive record of all providers who have served a given patient or client since 1996

• Diagnoses• Procedures• Prescription History

Spiritual

The Palmetto Project: Putting Innovative Ideas to Work in South Carolina-Steve Skardon