Disclosures - School-Based Health Alliance

Disclosures
There are no relationships to disclose
Marcia Dodo, DNP FNP-BC Clinic Manager, Dr. JTMF
Kathryn McCollister, PhD., Associate Professor and Health Economist, Dr. JTMF
Mary Saiz BA,CEO Insuring Services Inc.
Demonstrating The Monetary Value of School Health Services
For Advocacy Efforts and Engaging HMOs
Marcia Dodo DNP FNP-BC., Clinic Manager, Dr. JTMF
Kathryn McCollister PhD., Dr. JTMF
Mary Saiz BA, CEO Insuring Services Inc.
Our Program
Program
Our
Our
Vision
Our Vision
The Dr. John T. Macdonald Foundation School Health Initiative, founded
in July 2000, shares in the vision of serving school-aged children and their
families while striving to become a center of excellence for school health
care.
Our
Mission
Our Mission
• Deliver high quality medical, dental, social and mental health services to children and
adolescents in their schools
• Participate as a community partner to ensure that the health care needs of youth and
their families are met
• Serve as a national and local advocate for school health
• Educate and train our health professions students through service-learning to ensure
the future of health care delivery for our youth
• Increase school performance of the students in the target schools by improving their
health status, attendance, and ability to focus on academics.
• To become a model that is replicable and self-sustainable
About
OurStudent
StudentPatient
Patient
About our
•
•
•
•
•
•
•
•
•
Federally designated health professional shortage areas
Minority status
85% of students on free school lunch program.
Federal poverty level
• 20% of families in NMB
• 24% North Miami
• 30% Overtown
A high prevalence of obesity or overweight (32%) exists among students in these areas
Of 638 second grade students seen for sealant placement, 225 (35%) had existing caries.
43% of parents with children enrolled within the SBHCs report having Medicaid. 5%
reported having private insurance. The remainder reported being uninsured.
Asthma surveillance conducted by the DOH revealed that our schools are in zip code
areas ranked 3rd highest for child ER visits due to asthma.
Estimated 25% have serious mental health issues.
Staffing Pattern
Primary SitesPrimary Sites
North Miami Beach Sr. High
John F. Kennedy Middle
North Miami Sr. High
Booker T. Washington Sr. High
ARNP / MD / PA
LPN / Medical Asst
Social
WorkerHealth
(LCSW
or MSW)
Community
Worker
Satellite SitesSatellite Sites
Fulford Elementary
Greynolds Park Elementary
G. Edelman / Sabal Palm Elementary
Arch Creek Elementary
North Miami Middle
RN
LPN / MA
LCSW
/ MSW
Community
Health Worker
Service
Learning
Service Learning
STUDENTS IN TRAINING ROTATE
THROUGH SITES TO DELIVER CARE
UNDER DIRECT CLINICAL SUPERVISION
•Medical Students
•Resident Physicians
•Nursing Students
•Social Work Students
•Psychiatry Fellows
Services
Provided
Services Provided
•Immunizations
•Physical Examinations
•Episodic care
•Acute care
•Chronic Disease Management
•Telehealth specialty consultations
•Laboratory services
•Pulmonary function testing
•Mental health Services
•Dental Sealant and Varnish Program
•EKG testing
•Insurance enrollment services
ProgramOutcomes
Outcomes
Program
•
•
•
•
•
•
•
•
•
Reduction in 911 calls
Increased access to care
Improved absenteeism rates
87% return to class rates
High detection and on-site treatment of STDs
Annual cost savings of more than $1 million
Reduced ER visits due to asthma
Higher percentages of children receiving annual well child care examinations
Improved oral health status
Program Outcomes
Program
Outcomes: Immunizations
The Work of Our Community Health Workers :
Asthma Home Assessments
Asthma kept from
work/school/home
N
%
Missed School Days
3%
most of the time
some of time
a little of the time
none of the time
Total
5
19
13
43
80
6.3
23.8
16.3
53.8
100
Asthma control rate
not controlled
poorly controlled
somewhat controlled
well controlled
completely controlled
Total
N
1
4
27
30
18
80
%
1.3
5
33.8
37.5
22.5
100
most of time
13%
34%
some of time
50%
3%
little of the time
2nd hand smoke exposure
12%
yes
no
85%
unknown
Amerigroup Member ER/Hospital Utilization for Asthma
Sample of Individual Success Stories
A High school football player with undiagnosed congenital heart disease presented to
school based health center with chest pain. He received an EKG in the clinic which
was abnormal and was then referred to cardiology the same day. He underwent
catheterization the same day and surgery soon there after. He is now in college and
doing well. This would have been a fatal condition if not treated in a timely manner.
An 8 year old girl was seen in clinic with a rash around her eyes. She was seen by the
Dermatologist via telehealth. The Dermatologist diagnosed the girl with eczema
herpeticum . Subsequently she was hospitalized and started on the appropriate
medications. This condition causes blindness if left untreated. The mother had not
taken her child to the ER because she did not have insurance.
Nova Dental Care
Number of children
(%)
Gender
Male
Female
345 (43%)
458 (57%)
Ethnicity
White
Black/African American
Asian
Native American
Multi-racial
Unknown
64 (10.5%)
617 (76.8%)
17 (2.1%)
3 (0.4%)
36 (4.5%)
44 (5.7%)
Ethnicity
Hispanic
Non-Hispanic
135 (16.8%)
668 (83.2%)
School
JFK
NMMS
549 (68.4)
254 (31.6)
Funding
Stream
Funding Stream
2014-2015
PROJECTED 2015-2016
School Health Initiative
Children’s Trust (TCT) $700,000
JTMF 500K
TCT 675K
Batchelor 100K
CMS 800K
39%
8%
24%
53%
Dr. John T Macdonald Foundation
(JTMF)
$500,000
Centers for Medicare & Medicaid
(CMS)
$500,000
Florida Medical School Quality
Network
$35,000
CVS Caremark Charitable Trust Grant
Grant
Partnership with School-Based Health Ccnter to enhance
and expand access to quality health care
• Develop toolkit to obtain designation as Patient Centered Medical Home
• Achieve sustainability
Engaging MCO -Payor Contracting
SBHC Tool Kit
Mary Saiz
President/CEO
Insuring Sources, Inc.
Healthcare Consulting Firm
Tool
Kit
Overview
Tool Kit Overview
•The services being rendered by SBHCs are in line with the health
outcome goals and mandates established by each States' Medicaid
programs.
•The SBHC must be able to demonstrate: their innovation, services, data
measurements and outcomes (analytics) that capture the data which is
mandated by Medicaid.
• The SBHC should develop a presentation that conveys their data and
services in a manner that will demonstrate to the MCOs their ability to
meet and exceed the health assessment goals that both (MCOs & SBHC)
have in common.
ToolKit
KitOverview
Overview
Cont’d
Tool
Cont’d
The development of the SBHC - MCO presentation, must contain:
• SBHC’s credentialing, billing and data collection
capabilities
• SBHC’s clinical reports and data collection (HEDIS, health assessments,
patient encounter data , etc.)
• Highlight the SBHC’s operations, awards, grant partnerships
ToolKit
KitOverview
OverviewCont’d
Cont’d
Tool
The presentation must clearly demonstrate that by
partnering with the SBHCs the MCO’s will have an
increase in member access to care and consequently
achieve the health assessments (data) mandates and
outcomes imposed by Medicaid.
SBHC Tool
Tool Kit
Kit Questionnaire
Questionnaire
SBHC
MCO 2-year
2-YearContracting
ContractingTrend
Trend
MCO Medicaid Payors
Year
School-Based Contracted
AmeriGroup Florida, Inc.
Sunshine State Health Plan
Prestige Health Choice
Molina Healthcare
Sunshine State Health Plan
Magellan Complete Care
United Healthcare
Coventry Health Care of Florida
Humana Health Plans
Preferred Medical Plan
Simply Healthcare Plus
Wellcare of Florida
C
C
C
C
C
C
IN
IN
NC
NC
NC
NC
2013
2013
2014
2014
2014
2014
2014
2015
NA
NA
NA
NA
MCO Contracting Trend
7
6
5
4
3
2013
2
2014
2015
1
0
Contracted
In Negotioations
MCOs
Kathryn McCollister, Ph.D.
Associate Professor and Health Economist
Department of Public Health Sciences
University of Miami Miller School of Medicine
ESTIMATING THE NET ECONOMIC BENEFITS OF
THE ENHANCED SCHOOL -BASED HEALTH CENTER
Overview of Presentation
•Importance of examining financial impact and economic viability of schoolbased health centers
•Outcome domains and specific measures for estimating the economic benefits
of school-based health centers
•Present the cost-savings template developed for University of Miami’s schoolbased health centers with enhancements through CMS Health Care Innovation
Challenge Award
•Present results of cost-savings during CMS HCIA project
Introduction
•School-based health centers effectively reduce barriers to accessing primary health
care services and promote better management of chronic conditions among schoolage children
•Have important role in reducing health disparities among minority and low-SES
groups
•Reduce unnecessary and costly health services utilization such as emergency
department visits
•Provide potential important indirect benefits to families of children attending
schools with a SBHC
Introduction (continued)
•In addition to evaluating effectiveness of SBHCs, sustainability of these programs depends
on showing that they are cost-saving
•Need to critically evaluate both costs of operating SBHC and outcomes to demonstrate that
the benefits of these programs outweigh the costs (i.e., generate a positive return-oninvestment)
•This presentation describes HEDIS and other measures that can be translated into dollars to
assess cost-savings
•Also present the results of an economic analysis of Miami’s SBHC plus enhancements
operating in nine middle and high schools around Miami-Dade County, Florida
HEDIS and Other Measures for Estimating Economic Benefits
Several measures of interest to examine cost-savings of the SBHCs
Healthcare Effectiveness Data and Information Set (HEDIS) measures
Some more directly related to presence of SBHC, others indirectly related
Required Preventative Health Care Procedures
Weight Assessment & Counseling for Nutrition & Phys Activity - Children and Adolescents
Well-Child Visits
Adolescent Well-Care Visits
Children and Adolescents Access to Primary Care Practitioners
Annual Dental Visits
Immunization for Adolescents
Human Papillomavirus Vaccine for Female Adolescents
Treatment of Children With Upper Respiratory Infectiion
Appropriate Testing of Children With Pharyngitis
Follow-Care For Children Prescribed ADHD Medication
HEDIS and Other Measures for Estimating Economic Benefits
Adolescent Girls
Chlamydia Screening
Non-Recommended Cervical Cancer Screening in
Condition Specific Care - Asthma
Use of Appropriate Medication for Children with Asthma
Medication Management for Children with Asthma
HEDIS and Other Measures for Estimating Economic Benefits
Mental Illness
Use of Multiple Concurrent Antipsychotics in Children and Adolescents
(new)
Metobolic Monitoring for Children and Adolescents on Antipsychotics
(new)
Use of First-Line Psychosocial Care for Children and Adolescents on
Antipsychiotics (new)
Follow-Up After Hospitalization for Mental Illness
Alcohol and Drug Dependence
Intiation and Engagement of Alcohol and Other Drug
Dependence Treatment
Other Measures To Calculate Economic Benefits
Sexually Transmitted Infections and pregnancies
HIV
Pregnancy
Other STIs (e.g. gonorrhea)
•
•
Dental Health
Sealants (total cases treated)
Varnishes (total cases treated)
Restorations
Other Measures To Calculate Economic Benefits
Immunizations
Influenza
Tdap
Varicella
Educational Attainment
Graduation from high school
Day missed from school
Health Care Services
Emergency department visit
Hospital inpatient day
Telehealth services
Calculating Cost-Savings from School-based Health Centers.
Outcomes
Monetary Conversion Factors (cost
per outcome in 2013 dollars)
Sexually Transmitted Infections
Chlamydia - number of positive screens
HIV
Gonorrhea
Chronic Conditions
Asthma - controlled cases
Mental Health Disorders
Depression diagnoses
Anxiety diagnoses
Dental Health
Sealants
Immunizations
Influenza
HPV
Tdap
Varicella
Health Services
Well-child visits (resulting in fewer ER visits)
Telehealth services
Educational Attainment
Graduation from high school
Day missed from school
$1,511
**
$380
$2,713
$4,753
$1,060
$359
$35
$37,655
$512
$2,170
$190
$163
$8,000
$18.30
** For cases of HIV, the cost per case is $233,174 based on the lifetime cost of treating a person with HIV from the time of
infection, through the development of AIDS, to death. Messonier et al 1999 (and CDC's Ounce of Prevention: What are the
Returns?).
Cost Savings
Savings Template
Cost
Template
•Organizes outcome domains and specific measures that can be valued
•Units of outcome (e.g., cases of chlamydia treated; immunizations; cases of
uncontrolled asthma treated; well child visits; graduating high school) are
multiplied by their corresponding monetary conversion factor (MCF)
• MCFs often report annual savings associated with avoiding a health condition
such as becoming overweight/obese
•For HPV, HIV and other long-term chronic diseases the MCFs report the
lifetime savings associated with proper treatment and/or avoiding exposure
Cost-Savings Template
Outcomes
Sexually Transmitted
Infections
Chlamydia - number of
positive screens
HIV
Gonorrhea
HPV
Chronic Conditions
Asthma - cases treated
Asthma - uncontrolled
cases
Asthma - controlled cases
Mental Health Disorders
ADHD - cases diagnosed
Total
number
screened
Outcome (e.g.,
number of cases
treated, )
38
2
1
16.6
Anxiety diagnoses
Substance Use Disorders diagnoses
Total Annual Savings
$57,418
*
$380
$37,655
$380
$625,073
$0
66
106
Total Savings Over
the Year in 2013
dollars
$1,511
*
175
Depression diagnoses
Dental Health
Sealants
Varnishes
Caries avoided
Immunizations
Influenza
HPV
Tdap
Hib
Hep B
Varicella
MMR
Health Services
Well-child visits (resulting
in fewer ER visits)
Telehealth services
Educational Attainment
Graduation from high
school
Day missed from school
Monetary
Conversion
Factors (cost
per outcome in
2013 dollars)
$0
$2,713
$287,578
$4,753
$1,060
0
0
0
0
517
107
92.8
40
$359
$185,603
$0
$0
$35
$0
$0
$54,784
$512
--$2,170
-$190
$201,376
$7,600
$163
$8,000
$7,303.85
$18.30
0
$1,427,116
Discussion
Findings show notable savings being generated across multiple areas
•The most immediate impacts are occurring in diagnosing and treating STIs,
improving dental health, and promoting immunizations
•Also improving management of asthma and mental health disorders – results
still being evaluated over a longer timeframe
•Benefits also accruing to health care system from reduced ED visits, getting
families enrolled in Medicaid and connected with health care services through
the SBHCs
•Even more distal outcomes such as fewer days missed from school and higher
graduation rates could be associated with SBHC
Discussion (continued)
•Limitations include no baseline data to analyze changes pre- and post-SBHC
and no control group
•Also reliance on estimates from the literature that are in some cases outdated
or generated from a different population
•Ideal would be to work with a randomized control trial design to be able to
directly assess the impact of SBHCs relative to schools without SBHCs
•Additional multivariate analyses to estimate key predictors of uncontrolled
asthma cases and associated costs in this population (mainly African
American and Hispanics)
References
References
Messonnier, M. L., Corso, P. S., Teutsch, S. M., Haddix, A. C., & Harris, J. R. (1999). An ounce of prevention…
what are the returns?: 1999. American journal of preventive medicine, 16(3), 248-263.
Sullivan, S. D., L. Rasouliyan, P. A. Russo, T. Kamath, and B. E. Chipps. "Extent, patterns, and burden of
uncontrolled disease in severe or difficult-to-treat asthma." Allergy 62, no. 2 (2007): 126-133.
Chesson, Harrell W., Dayne Collins, and Kathryn Koski. "Formulas for estimating the costs averted by sexually
transmitted infection (STI) prevention programs in the United States." Cost Effectiveness and Resource Allocation
6.1 (2008): 10.
Zhou, Fangjun, Jeanne Santoli, Mark L. Messonnier, Hussain R. Yusuf, Abigail Shefer, Susan Y. Chu, Lance
Rodewald, and Rafael Harpaz. "Economic evaluation of the 7-vaccine routine childhood immunization schedule in
the United States, 2001." Archives of pediatrics & adolescent medicine 159, no. 12 (2005): 1136-1144.
Hay, Joel W., and Joel I. Ward. "Economic considerations for pertussis booster vaccination in adolescents." The
pediatric infectious disease journal 24, no. 6 (2005): S127-S133.
Scherrer, C. R., Griffin, P. M., & Swann, J. L. (2007). Public health sealant delivery programs: optimal delivery and
the cost of practice acts. Medical Decision Making.
Contact Information
Joycelyn Lawrence, MD
Project Director
(305) 243-2847
(786) 218-2967
[email protected]
www.schoolhealthinitiative.org
Kathryn McCollister, Ph.D.
Associate Professor
Depart. of Public Health Sciences
University of Miami Miller School of
Medicine
[email protected]
Marcia Dodo, DNP FNP-BC
Clinic Manager
(305) 956-5991
[email protected]
www.schoolhealthinitiative.org
Mary Saiz
Health Care Consultant
Insuring Sources, Inc.
(786) 597-6421
[email protected]
www.insuringsources.com