High Performance Health Systems Serving Vulnerable

Populations

Fernando A. Guerra, M.D., M.P.H.

Director of Health

San Antonio Metropolitan Health District

2

Objectives

• Review existing frameworks describing:– The healthcare system– The public health system

• Discuss the health challenges of vulnerable populations

• Introduce a comprehensive framework for a high performance health system and implications for “safety net” providers

The Health Care System and High Performance

Tertiary Medical Care

Secondary Medical Care

Primary Medical Care

Population-Based Public Health Services

Assessment, Policy Development, Assurance

Public Health System Infrastructure

Capacity to Deliver Public Health Services

Incr

easi

ng Cost

s

4Relationship-Centered Care; Pew-Fetzer Task Force

The Healthcare System

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Commission Framework for High Performance

The Commonwealth Fund

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Keys to Healthcare System Performance

• The Commission has identified the following seven keys to high performance: – Extend health insurance to all – Pursue excellence in the provision of safe, effective, and efficient

care. – Organize the care system to ensure coordinated and accessible

care for all. – Increase transparency and reward quality and efficiency. – Expand the use of information technology and exchange. – Develop the health care workforce to foster patient-centered

primary care. – Encourage leadership and collaboration among public and

private stakeholders.

The Commonwealth Fund

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Scorecard on the Health System

• Overall, the U.S. health care system scored an average 66 out of a maximum 100 based on 37 indicators of health outcomes – Quality (71)– Access (67)– Efficiency (51)– Equity (71)

• Relative to the benchmarks, U.S. performance averages near 50 for efficiency and around 70 for other domains.

C. Schoen, K. Davis, S. K. H. How, and S. C. Schoenbaum, U.S. Health System Performance: A National Scorecard, Health Affairs Web Exclusive, September 20, 2006 W457–w475

The Pubic Health System and High Performance

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The Public Health System

• Public Health:

“What we as a society do collectively to assure the conditions by which people can be healthy”.

• The Public Health System:

“Activities undertaken within the formal structure of government and the associated parties of private and voluntary organizations and individuals”.

The Future of Public Health, IOM, 1988

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The Public Health System

NPHPS User Guide, 2006

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Public Sector “Safety Net” Health System Model

Common Goal: Healthy People and Communities

Performance Criteria:-Quality

- Efficiency- Equity/Accessibility

- Innovation

Public Hospital and Healthcare System

• Clinical Preventive Services• Primary Care

• Specialty and Acute Care

Academic InstitutionsHealth Professional

Schools• Research• Education

• Workforce Development

Public Health Agency• Assessment• Assurance

• Policy Development

Other Health System Partners

• Private entities•Federal and State agencies

•Non-Health focused local public agencies

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The Ten Essential Services

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Public Health Efforts to Support High Performance

• Turning Point Initiative - Performance Management

• Mobilizing for Action through Planning and Partnership (MAPP)

• RWJ’s Mulitstate Learning Collaborative• ASTHO-NACCHO Exploring Accreditation

Workgroup• NACCHO Operational Definition of a Local Health

Department• Public Health Accreditation Board (PHAB)• Certification of Public Health Professionals

Identifying Vulnerable Populations

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Vulnerable Populations

• Uninsured and underinsured • Recent and/or undocumented immigrants• Persons of low Socio-economic status• Persons with limited English-proficiency• Persons with limited health literacy• Persons with physical and/or mental disabilities • The working poor – often do not qualify for assistance• Racial and ethnic minorities (color)• Teen parents• Others…

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Health Disparities

• HP2020 Overarching Goals: – Achieve health equity, eliminate disparities, and

improve the health of all groups. – Create social and physical environments that promote

good health for all.

• Despite goals clear disparities exist for racial and ethnic minorities across the spectrum of health concerns

• Persons in poverty, with low educational attainment and low literacy have poor access to services and worse health outcomes

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0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

1,600,000

2000 2005 2010 2015 2020 2025 2030 2035 2040

Hispanic NH White African American Other

Projected Population of Bexar County by Race and Ethnicity, 2000-2040

Source: U.S. Census and Texas State Data Center as per 2008

Year

Population

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Age Distribution Bexar County Hispanic NH White

Source: U.S. Census Bureau, 2008

MaleFemale

African AmericanMaleFemale MaleFemale

50000 30000 10000 10000 30000 50000

Age 0 to 4 yrs

Age 10 to 14 yrs

Age 20 to 24 yrs

Age 30 to 34 yrs

Age 40 to 44 yrs

Age 50 to 54 yrs

Age 60 to 64 yrs

Age 70 to 74 yrs

Age 80 to 84 yrs

50000 30000 10000 10000 30000 50000

Age 0 to 4 yrs

Age 10 to 14 yrs

Age 20 to 24 yrs

Age 30 to 34 yrs

Age 40 to 44 yrs

Age 50 to 54 yrs

Age 60 to 64 yrs

Age 70 to 74 yrs

Age 80 to 84 yrs

50000 30000 10000 10000 30000 50000

Age 0 to 4 yrs

Age 10 to 14 yrs

Age 20 to 24 yrs

Age 30 to 34 yrs

Age 40 to 44 yrs

Age 50 to 54 yrs

Age 60 to 64 yrs

Age 70 to 74 yrs

Age 80 to 84 yrs

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Educational Attainment of Population Over 25 Years of Age, Bexar County

(Population 25 years and over)(Population 25 years and over)

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Bachelors degree or higher

Asian African American Hispanic White Non Hispanic 19

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Age of Death Over 75 Years, Bexar County

0%

10%

20%

30%

40%

50%

60%

70%

80%

White Non Hispanic Females Hispanic femalesAfrican Am. Females White Non Hispanic MalesHispanic males African Am. Males

202007 Health Profiles

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Access to Care

• Texas leads the nation in number and percentage of uninsured for both adults and children

• In Bexar County:– 24.6% of adults 18-64 uninsured– 18.1% of children 0 -17 uninsured– 306,340 unduplicated Medicaid clients– 54% of births are covered by Medicaid

2005 Texas Department of State Health Services

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San Antonio’s “Ten Zip Codes”

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“Ten Zip Code” Demographics

Ten Zip Codes Bexar County

(72 zip codes)

Population 421,561 (30%) 1,386,179 (100%)

Median Income $27,075 $44,219

Below Federal Poverty Level

104,458 (25%) 215,680 (16%)

Hispanic 347,102 (82%) 752,532 (54%)

Non-Hispanic White 55,474 (13%) 493,090 (36%)

African American 13,317 (3%) 94,131 (7%)

High School Graduates or Higher Education1

240,290 (57%) 1,067,358 (77%)

Female Headed Households

88,528 (21%) 207,929 (15%)

1) Among adults aged 25 and older. All data from 2000 U.S. Census and American Community Survey.

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Ten Zip Codes - 2008

Ten Zip Codes

% of Bexar County

Population 421,561 30%

Total Births 8,265 30.7%

Late Prenatal Care Births 2,627 36.6%

Birth within 24 Months of Previous 1,694 38.0%

Births To Mothers BMI >30 2,700 38.3%

Juvenile Probation 4,038 39.2%

Family Violence Reports 4,322 41.0%

Single Mother Births 5,154 41.2%

Medicaid Births 5,684 41.7%

Confirmed Child Abuse/Neglect Cases 2,460 43.8%

Births To Mothers Age <18 683 47.0%

Births to mothers < HS / GED 3,731 49.8%

A High Performance Health System Serving Vulnerable Populations

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The “Safety Net”

• Local Public Health Agencies

• Public Hospital Systems and Clinics

• Federally Qualified Health Centers

• Local/State Mental Health Agencies

• Other public sector, non-profit, faith based or community service providers – Homeless service programs– Feeding ministries

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Safety Net Provider Challenges

• High rates of preventable chronic disease• Widening health disparities• Increased health care costs with level or decreased

funding• High rate of uninsured• Challenges establishing medical homes• Health information for clinical and public health needs

remain in silos• Quantity and quality of mental health services• Access to dental health services• Expanding role of providers in emergency response and

meeting the needs of displaced persons

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Need for an Integrated View of the Health System

• Current challenges and resources require cooperation to achieve goals

• Health is more than the absence of illness and injury

• Public health and health care are complementary and interdependent – both sectors must achieve high performance– Common mission and vision– Distinct roles and strategies for achieving a healthy community

• Addressing the needs of vulnerable populations requires cross-sector partnerships and relationship-centered care

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Impact of Health Reform

• Access to care should improve but many may still be left out– How will the expansion of coverage affect traditional

Medicaid providers? What will be the demand for “safety net” services in the future?

– How will areas with high levels of undocumented residents fare with changes in access and funding?

• New level of focus on preventive health services in both clinical and population based services

• Issues of healthcare cost are unresolved

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Priorities for “Safety Net” Providers

• Address issue of health care costs• Assure access to a comprehensive and

well coordinated system of care– Medical homes– Interoperable health records

• Establish effective mechanisms to care for undocumented persons

• Enhance coordination between the healthcare and public health sectors

Questions and Discussion

Fernando A. Guerra, MD, MPHDirector of Health

San Antonio Metro Health Districtfguerra@sanantonio.gov