Clinica Esperanza/Hope Clinic "International Healthcare on the local bus line" in Providence, Rhode...

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INTERNATIONAL HEALTHCARE ON THE RIPTA BUSLINE “A Place to be Healthy” Slides by Ali Bicki, Jenn Pigoga, Jacob Buckley, Valerie Joseph, Annie De Groot, Carmen Shulman, Jillian Peters, and Farzana Kibria

Transcript of Clinica Esperanza/Hope Clinic "International Healthcare on the local bus line" in Providence, Rhode...

INTERNATIONAL HEALTHCARE ON THE RIPTA BUSLINE

“A Place to be Healthy”

Slides by Ali Bicki, Jenn Pigoga, Jacob Buckley, Valerie Joseph, Annie De Groot, Carmen Shulman, Jillian Peters, and Farzana Kibria

Clínica Esperanza/Hope Clinic (CEHC) Mission: n  Offer high quality primary medical care to RI residents

without health insurance n  Emphasis on linguistically-competent, culturally-attuned care n  Focus on prevention and health maintenance n  Run by highly qualified health providers and community

representatives n  Supported by an volunteer staff and paid staff n  Welcomes bright ideas from volunteers and patients “A Place to be Healthy”

Mission Statement

Clinic Footprint

Built with a $90,000 Loan from the City of Providence and $60,000 from LISC

January 2010

May 2008

July 2009

May 2010

Fall 2010

With the support

of volunteers and the

community!

2011-12

2012-13

2014

Need for Health Screening: A local example. A paper on tuberculosis (TB) transmission in Rhode Island illustrates the importance of health prevention activities for all uninsured residents regardless of legal status. Clusters of tuberculosis transmission among uninsured and undocumented immigrants are not uncommon in Rhode Island []. Of the 265 TB patients included in the epidemiological analysis, 176 (66.4%) were foreign born from 42 different countries; 68.2% did not speak English. The predominant country of birth of the foreign-born persons in the TB clusters was Cambodia (12.5%), followed by Guatemala (10.8%), Dominican Republic (10.2%), Laos (6.3%), the Philippines (5.1%), and Portugal (5.1%). The analysis of characteristics of the foreign-born TB patients revealed several possible barriers to TB prevention, including language difficulties, lack of medical insurance, young age and lack of familiarity with the health care system. The authors concluded that “expanded TB screening services that actively move into at-risk communities outside of traditional health clinic sites will be important in reaching these persons during the window period [for prevention].” TB testing was one of the first preventive health programs implemented at CEHC. TB testing is one of several services, with HIV and HCV testing and free vaccines (e.g. flu), that are offered to all walk-ins; registration as a patient is not required.

n  Why provide Free Care? A Cautionary Tale

TB Clusters in RI: Foreign-born

The Uninsurance Trap

The Uninsurance Trap. Perhaps more important for the neighborhoods that are the subject of our work, poor health contributes to the cycle of poverty at the individual level. In 2006, the total health care spending by uninsured persons was estimated at 6.4 billion dollars, the majority of which (5.3 billion dollars) was paid out of pocket.

Health Care Reform will diminish but not resolve the problem. Even after heatlh care reform, free clinics will continue to provide an important alternative source of care to patients who might defer care until it becomes an emergency, or seek primary care in the ER. In Massachusetts, more than 300,000 individuals remained uninsured despite state-wide health reform. The working poor who do not have access to, or cannot afford, either employer sponsored insurance or state subsidized insurance, predominate among the uninsured. ..

Summary of Changes in Medicaid and Health Care Exchanges with the Affordable Care Act

Medicaid   Exchange  Coverage  

U.S.  Born  and  Naturalized  Ci3zens!

All  individuals  up  to  138%  of  FPL  in  states  that  implement  the  expansion.!

Individuals  without  affordable  employer  coverage  can    buy  coverage  through  exchange  marketplaces.  !

Lawfully  Present  Immigrants!

Many  remain  subject  to  a  five-­‐year  wait  or  excluded.  States  may  choose  to  eliminate  the  five-­‐year  wait  for  otherwise  eligible  children  and  pregnant  women,  but  not  for  other  adults.  !

May  purchase  exchange  coverage  and  receive  tax  credits  on  the  same  basis  as  ci3zens.  Individuals  with  incomes  below  100%  of  poverty  who  are  ineligible  for  Medicaid  based  on  immigra3on  status  may  purchase  exchange  coverage  and  receive  tax  credits!

Undocumented  Immigrants!

Remain  ineligible  for  Medicaid.!

Prohibited  from  purchasing  exchange  coverage  and    receiving  tax  credits.!

Source:  Kaiser  Family  Founda3on.  hTp://kaiserfamilyfounda3on.files.wordpress.com/2013/03/8279-­‐02.pdf.  Table  1.    

Post ACA: Many remain uninsured

Time Since Incoming Patients were Last Seen by a Healthcare Provider. Nearly 40% of patients not seen by MD in 3 years despite chronic health problems 20% of currently uninsured patients were last seen outside of the U.S. prior to seeking care at CEHC.

0-6 Months

24%

7-12 Months

32%

2-3 Years 29%

>3 Years 14%

Unknown 1%

Previous Access to Care

n  Primary Care Clinic n  Criteria for becoming a patient

ü Uninsured ü First come first served X Lottery X If already in care at another practice

CEHC Overview

n  CHEER walk-in clinic ü Non-urgent health issue X In need of urgent care

n  Primary Health Care Tuesday, Thursday, Saturday n  Women’s Clinic Monday Night 1x/month n  Vida Sana Program – Health Literacy/Metabolic Syndrome n  PIMHA – “whole patient” job skills etc. n  Financial Literacy, Job Skills – Dorcas Place/CWE/LISC n  Diabetes Club / Group visits with Nurse Practitioners n  Outreach at in South Providence/ North Providence n  Health Screens at CEHC/outreach once per month n  Regular chart reviews – research - quality assurance

CEHC Overview

n  Volunteer base n  10 in 2008- 20 in 2009 n  30 in 2010- 40 in 2011 n  >175 in 2014

n  Board actively involved as volunteers n  Volunteer Medical Director/ Executive Director n  Donated labs, radiology, specialty services, and

medications from WIHRI, Lifespan, local MD providers. n  New volunteers and providers always needed n  (next orientation session is … this Tuesday!)

Clinic Overview: Organizational Structure

14%$

22%$

20%$

26%$

18%$

Chronic(Condi*ons(of(Con*nuity(of(Care(Pa*ents(at(CEHC(201082014(

Diabetes$%$

HTN$%$

Chol$%$

Overweight$BMI$%$

Obese$BMI$%$

81%$

8%$8%$ 3%$

Race%and%Ethnicity%of%Pa0ents%at%CEHC%201072014%

Hispanic$

Non/Hispanic$

Black$

Asian/Other$

Patient Demographics: Race & Ethnicity

Types of Conditions

Demographics: Level of School completed

8th Grade or lower

Some high school

Graduated from high school

Some University

University graduate

But these patients have high aspirations for their children!

Annual Income

If undocumented, work in jobs that do not provide Health insurance, benefits, etc, low hourly wage: $15k per year = $284 per week (if they get that)

Clinic Overview

0"100"200"300"400"500"600"700"800"900"1000"

0"

1000"

2000"

3000"

4000"

5000"

6000"

7000"

2010" 2011" 2012" 2013" 2014"

EMR$Visits$

CEHC$Visit$Trends$201032014$

Visits"in"EMR"

Individual"visits"

Pa;ents"in"con;nuity"of"care"(12"months)"

Pa;ents"in"EMR"

ACA

Clínica Esperanza/Hope Clinic Community Outreach Pilot Survey

Do we serve our Neighbor’s needs? Summer 2014

Introduction ●  What did we do?

o  A community outreach study to assess key factors including insurance status, lead awareness, and community health needs

●  How did we do it? o  By going out into the community in pairs of at least 2

to administer verbal surveys in a convenience sampling format

Why did we do the survey? ●  Compare results from “pre-Obamacare”

survey (Spring 2009) to today’s “post-Obamacare” environment

●  Evaluate health care access in the community

●  Determine whether or not CEHC is serving the community’s needs

●  Assess the awareness of lead paint hazards and testing

●  Funded by the RI DOH

Insurance Status 2014 Study (200 participants)

●  Significant changes since 2009

o  Fewer uninsured (38% vs. 92% in 2009)

o  9% private insurance (vs. 5% in 2009)

o  17% have Obamacare only

●  Today, 33% covered by “public” insurance…including “free care” o  Medicaid/RIte Care, Medicare,

Free Care, or some combination of “public” sources (vs. ~1% in 2009)

Survey: Why did uninsured participants not have Obamacare?

Among the uninsured, having an undocumented immigration status was the most common reason for not obtaining Obamacare coverage.

THE NAVEGANTES

n  Established with support from BCBSRI “Blue Angels” Funding n  The Navegantes/Navigators plan, organize and implement church-

based community health fairs and advocate for members of their community.

n  Navegantes/Navigators meet with patients and help them navigate the system to obtain preventative services, chronic disease management, support for medication adherence, health care access, and other essential health information.

n  The clinic now has five Navegantes health access coordinators. They received intensive training sessions to become competent referral sources, organizers and community educators.

The Navegantes

Percent of Patients Experiencing Improvement in their Chronic Condition EMR records were reviewed and health indicators (HbA1C, fasting glucose, blood pressure, weight, and cholesterol) were tracked. Greatest improvements in overall health indicators were observed in patients with hypertension: 83% of patients with hypertension reduced their blood pressure. Almost three-quarters of patients with diabetes and high cholesterol improved during the time period of this review. Over half of overweight or obese patients lost weight while under care at CEHC. Overall, about 63% of CEHC patients improved at least one of their chronic conditions during the study time period. *Number of patients identified as having the health condition with at least two measurements of the associated biomarker.

54.24% (32 of 59*)

82.22% (37 of 45*)

72.73% (16 of 22*) 70.83%

(17 of 24*) 62.92%

(56 of 89*)

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

% P

atie

nts

that

Im

prov

ed C

ondi

tion

at A

ll

Chronic Condition

Systolic Blood Pressure Changes among Hypertensive Patients. According to EMR records, patients in care over four months experience improvements in their blood pressure. Patients in care at CEHC for over four months decreased their systolic blood pressure by, on average, 12 more points than patients under care for less than or equal to four months (N = 47, P < 0.001). CEHC Navegantes provide one-on-one positive reinforcement sessions to patients. Patients matched with Navegantes decreased their systolic blood pressure by, on average, 24 more points than patients not matched with Navegantes (N = 38, P = 0.008).

-21.7

-9.4

-19.5

4.3

-25

-20

-15

-10

-5

0

5

10

Under Care >4 Months

Under Care ≤4 Months

With Navegante

Without Navegante

Ave

rage

Sys

tolic

BP

Poi

nt C

hang

e

THE HYPERTENSION PROJECT An Assessment of Our Adherence to AHA Guidelines &

an Evaluation of Our Performance

By Carmen Shulman, Jillian Peters, and Farzana Kibria

Blood Pressures at Goal

55%

46%

59%

33%

53%

62%

0% 20% 40% 60% 80% 100%

Clinica Esperanza/Hope Clinic

Charlestown Area Medical Center

Rush University Hypertension Clinic

6 Texas Urban Community Clinics

44 US Community Health Centers

Winthrop University Hospital Outpatient Clinic

CEHC Positives n  Increasing Volunteer Supply n  More Collaborations and Networks n  Improved access to free resources n  $97,000 in donated free care 2010; $163,000 in

2011; more in 2012 n  Demonstrated need for services as state funding

for core services (for example, TB clinic) is cut

Access to Care Constraints n  Increasing demand – waiting list at > 150 n  Many of the requests for care are for minor

medical problems (back pain, rash, STD) n  These patients wait > 4-6 months to be seen n  “Walk In Clinic” may solve this issue n  “Walk In” will also reduce ER use

THE CHEER CLINIC A Nurse-Run walk in clinic for the Uninsured

n  CHEER program runs out of CEHC as a free walk-in clinic for uninsured Rhode Island community members. Staffed by volunteers and nursing providers, CHEER provides non-urgent health care services every weekday!

n  A goal of CHEER is to save patients thousands of unnecessarily spent dollars by deterring them from going to local emergency rooms for non-life-threatening problems.

n  Nurse-Run!

CHEER clinic

Evaluation

1.  Measure use of walk-in non-acute healthcare to the uninsured provided by expanding clinic hours at CEHC

2.  Determine whether providing prospective ER visitors the option of walk-in non-acute care will reduce ER use

3.  Calculate impact in terms of costs avoided and QALYs.

Total Visits: CHEER

Patient Home by Neighborhood

Olneyville 30%

Smith Hill, Elmhurst, Mount Pleasant

15%

Elmwood, Reservoir 14%

Total Providence ZIP Codes: 87% Other ZIP Codes: 13%

Willingness and Ability to Pay for Care

n  Concordance between what CHEER patients were willing and able to pay for their healthcare n  54 (59% of respondents) had no difference between

what they were willing and able to pay n  35 (38%) were willing to pay more than they could

afford—with an average shortcoming of $22.94 n  3 were willing to pay less than they could afford

n  Distribution of what patients would be able to pay: n  $0 43 patients (45%) n  $1-10 21 patients (22%) n  $15-25 26 patients (27%) n  $30-60 6 patients (6%)

Patients’ ER Utilization 32

10 8

13

2 1 0

5

10

15

20

25

30

35

Past Year Past Month Past Week Number of patients who had been to ER in timeframe

65 CHEER patients (49% of respondents) reported they would have gone to the ER

for their chief complaint if the CHEER clinic had

not been available.

Estimated* Costs Avoided Total visits (5 months)** 252 Total visits discounted by 20%* 202 Average cost per CHEER visit $32 Average cost per ER visit in Rhode Island $792 Cost avoided per CHEER clinic visit $760 Costs avoided (5 months) $153,216 Costs avoided (12-month projection) $367,718

*See reasoning in Oriol et al., 2009 **Excluding four patients who were, in fact, referred to the ER

Value of Preventive Services Service, by most QALY-Saving Services

Provided (N) QALYS (Years)

Estimated Value of QALYS ($)

Hypertension Screening and Treatment 145 13.05 $618,426 Vaccinations (excluding Flu) 63 5.67 $268,696 Obesity Screen 123 3.46 $163,936 Flu Vaccine 28 1.91 $90,395 Cholesterol Screening 7 0.63 $29,855 Other* 12 0.23 $11,195 Diabetes Screen 79 0.15 $7,019

5-Month Totals ** 25.1 (22.03-27.34)^

$1,189,523 ($0.55-1.91 million)^

12-Month Projection 60.24 (52.87-65.62)^

$2,854,855 ($1.32-$4.58 million)^

5-Month Return on Investment (ROI)

Operating Cost of CHEER Clinic $37,870 Tests, Other Operating Expenses $11,070 Wages and Taxes $26,800

Costs Saved = ER Costs Avoided + QALYS Value

$1,313,053

Costs avoided by preventing ER visits $123,530 Value of potential life years saved by CHEER $1,189,523

5-Month ROI = (Costs Saved – Operating Cost)

$1,275,184 ($0.60-2.03 million)^

5-Month ROI Ratio = 5-Month ROI ÷ Operating Cost

34:1 (16:1 – 54:1)^ ^Using other QALY estimates available in the literature, we calculated these conservative and liberal estimates

Designing a place-based health intervention that addresses community needs.

Vida Sana / Healthy Life

A Place to Be Healthy n  Vida Sana was created to promote a healthier lifestyle in

Health Disparity Populations (HDPs) at risk for metabolic syndrome n  HDPs in Providence, particularly the up to 50,000 undocumented

immigrants and other uninsured populations, face limited access to care, poor health education, and other socioeconomic barriers which worsen long-term outcomes of metabolic syndrome and other chronic conditions

n  Focus on n  Improving health literacy n  Creating a social learning environment (“A Place to Be Healthy”) n  Measuring metabolic outcomes in participants

n  Funded by the RI Department of Health’s “Center for Health Equity and Wellness Grant”

Vida Sana Mission

n  Create a fun social learning environment where participants learn about nutrition and other healthy lifestyle choices n  Curriculum developed by Susan Oliverio, MD n  Designed to be accessible for either English-

or Spanish-speaking participants with low literacy

Vida Sana / Healthy Life

(1) Train and Certify Navegantes

Gloria Dei Church Since March 2013 # of Participants: 20 # of Navegantes: 3 Site Based Action Team Contact: Kayla Rodriquez, Mercedes Batista

Open Table of Christ Church Since 12/12/2012 # of Participants: 33 # of Navegantes: Site Based Action Team Contact: Anna Vargas

Clinica Esperanza/Hope Clinic Ongoing since 08/22/2012 # of Participants : >50 # of Navegantes: 5 Site Based Action Team Contact: Ingrid Castillo

Empowerment Temple Under Development # of Participants # of Navegantes:2 Site Based Action Team Contact: Akosua Adu-Boahene

Timeline of Vida Sana v  Group 1 at CEHC (Spanish) ~ Aug 2012 v  Group 1 Completion of Program ~ October 2012 v  Group 2 at OTC (Spanish) ~ Dec 2012 v  Group 2 Completion of Program ~ Feb 2013 v  Group 3 at CEHC (Spanish) ~ Jan 2013 v  Group 3 Completion of Program ~ Mar 2013 v  Group 4 at OTC (Spanish) ~ Mar 2013 v  Group 4 Completion of Program ~ May 2013 v  Group 5 at CEHC (English) ~ Mar 2013 v  Group 6 at Gloria Dei Start March 2013 v  Group 5 Completion of Program ~ May 2013 v  Group 6 at Gloria Dei Completion -- June 2013 v  Group 7 at CEHC started June 4, 2013 v  Group 8 (English) at CEHC scheduled June 15 v  Group 9 S(Spanish) at CEHC scheduled June 18

(2) Establish Outreach Sites

Vida Sana Gloria Dei Site

Vida Sana Clinica Esperanza

Vida Sana Open Table of Christ

English-Language Sessions for North African Immigrants

n  Definition of completion: attended at least 6/8 sessions, at least one social event, and at least one educational event

10/24 11/20 12/14 N: 8/10 12/15 20/20 5/13 13/18 10/11

0%

10%

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30%

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50%

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70%

80%

90%

100%

GROUP 2 GROUP 3 GROUP 4 GROUP 5 GROUP 6 GROUP 7 GROUP 8 GROUP 9 GROUP 10 GROUP 11 GROUP 12

Percent Completion by Group

4/10 5/8

Completion (Groups 2-12)

Program Completion: Year 2

n  Approximately two-thirds (69%) of participants completed the program n  Slight improvement

over Year 1 (66%)

1 Session 4%

2 Sessions 17%

3 Sessions 6%

4 Sessions 2%

5 Sessions 2%

6 or More Sessions

69%

Factors Affecting Completion n  Health Disparity Populations face several

socioeconomic barriers to program commitment n  Unable to afford to leave children at home unsupervised n  Need to maintain jobs which conflict with scheduling

n  (YEAR 1 DATA) Only 41% of age 30-40 participants completed the program, in comparison to between 70% and 78% for other age ranges. This population is more likely to get a new job, have changes in family dynamics, or have instability in living/transportation situations

n  (YEAR 2 DATA…relationship did not hold) Those aged 51-60 years had the lowest program completion rate (62%), followed by those <30 years (67%); those aged >60 years had the highest program completion rate (75%)

Impact of Intervention n  Patients had metabolic syndrome, but not all

patients were overweight (they may have been normal weight but had HTN, diabetes, and high lipids).

n  Thus – some results did not need to change. Results are therefore shown as “percent stable or improved”

n  Mainly improved waist circumference, systolic BP, and health literacy n  Slight improvement in other results such as weight

Results Overview: Year 1

n  Percent outcomes stayed stable or improved over 8 week period

82.7% 79.8%

61.1% 59.6%

82.5%

92.2%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Weight Waist Circumference Glucose Cholesterol BP HL Test

Percent Stable/Improved

Waist Circumference Results n  Many kept waist circumference steady n  Those that improved had quite dramatic

improvements N=109 Waist Circumference

Average Start 38.7 in

Average End 38.1 in

% Stable/Improved 79.8%

Average decrease for those that improved

2 in

Weight/BMI Results n  Most improved weight, but only slightly n  Impressive for 8 week study period

N=110 Weight BMI

Average Start 180.5 lbs 28.2

Average End 177.2 lbs 27.7

% Stable/Improved 82.7% 82.7%

Average decrease for those that improved

5.5 lbs 1.0

Blood Glucose Results n  Unable to enforce fasting glucose tests, so

results varied and not statistically rigorous n  Despite this, overall improvement seen

N=108 Blood Glucose

Average Start 124.6 mg/dl

Average End 118.0 mg/dl

% Stable/Improved 61.1%

Average decrease for those that improved

26.8 mg/dl

Cholesterol Results n  Similarly not fasting tested, although

results less varied than for glucose n  Promising overall improvement observed

N=109 LDL Cholesterol

Average Start 190.7 mg/dl

Average End 185.6 mg/dl

% Stable/Improved 59.6%

Average decrease for those that improved

18.6 mg/dl

Blood Pressure Results n  Hard to observe significant and consistent

changes for blood pressure in 8 weeks n  Most patients with >120 systolic at onset

remained stable or had slight improvement N=63 (>120 at onset) Systolic Blood Pressure

Average Start 140

Average End 134

% Stable/Improved 82.5%

Average decrease for those that improved

12

Health Literacy Test Results n  Consistent, large improvement in scores of

health literacy test n  Impact of participants attending a second Vida

Sana program noted (contributed to increase in baseline pre-test and post-test).

N=103 Health Literacy Test

Average Start 71.1%

Average End 90.7%

% Stable/Improved 92.2%

Average increase (% pts) for those that improved

22.9%

Other Findings n  Outcomes relatively consistent regardless of age

and starting BMI n  Glucose and cholesterol appear to improve

based on number of sessions patients attended n  Participants were engaged and enthusiastic n  Navegantes proud of accomplishments and

looking for ways to improve programs n  Some aspects of outcomes improved more

consistently in later Vida Sana programs

Goals for Future n  Setting up “self-sustaining” Vida Sana programs

n  “See one, Do one, Teach one” n  Expand to new sites with more Navegantes n  Provide training, supplies, and support for sites to run

Vida Sana independently n  Having more consistent 3-month and later

follow-up data to observe if outcomes are sustained

n  Continue to reach health disparity populations, with goal of having 1,000 Vida Sana “graduates”

Happy Participants

Setting up “self-sustaining” Vida Sana programs

n  “See one, Do one, Teach one

n  Expand to new sites with more Navegantes

n  Provide training, supplies, and support for sites to run Vida Sana independently

Who have we reached? n  January-May 2014

n  5 groups n  85 total participants n  57 completed (67%)

n  From the publication n  13 groups n  192 participants n  126 completed (66%)

n  Total to date n  18 groups n  277 participants n  183 completed (66%)

We Celebrate Our Patients!

Acknowledgements n  Initial analysis provided by

n  Jacob Buckley (Brown Undergraduate) n  Farzana Kibria (Smith College Praxis intern) n  Shahla Yekta, Ph.D. (CEHC Consultant) n  Valerie Joseph, R.N. (Nurse Manager) n  Ingrid Castillo (Head Navegante) n  Carlos Juarez (Clinic Coordinator) n  The Navegantes

Community Presence

n  Of those who responded… n  50% of CHEER patients had heard of the

clinic through word of mouth—e.g., from a friend or family member

n  19% of CHEER patients had heard of the clinic through other community-based non-profit organizations, their church, another community health center or hospital, or their school or workplace

Conclusion n  CEHC has an important role serving a

basic need n  CHEER program– current data

demonstrates that investment is worth it! n  Vida Sana program appears to be an

effective intervention

Funding Needed n  Support for CHEER

n  $100,000 n  Support for Continuity of Care clinic

n  $100,000 n  Support for Operational Costs

n  $50-60,000 per year n  Few donors contribute to this goal n  Need more support!

40,000 to 60,000 Uninsured in Rhode Island

Improving Access to Health Care – People Stay Healthy

Healthy People build Strong Communities

Free Clinics Are an Essential Safety Net

Especially in these Difficult Economic Times

More to do