“Waianae Model of Integrative Healthcare”

Waianae Model of Integrated
Healthcare
Community
Traditional
Healing
Wellness
Our Patients
Family Medicine
Dental, Specialty,
Emergency Care
And Hospital
Referral
March 3, 2006
Enabling &
Supportive
Services
Behavioral
Health/Substance
Abuse Intervention
Community Involvement
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Board Governance – Consumers
State and Federal Political Leaders
Our Kupuna
Community Economic Development
Training Programs (Health Academy)
Patient Demographics: 2005
USERS/ENCOUNTERS
USERS
Medical
24,613
Dental
2,621
Mental Health/Sub. Abuse
2,035
Enabling Services
2,073
Other Professional Services
773
Total
PRINCIPAL THIRD PARTY PAYMENT
SOURCE
CATEGORY
ENCOUNTERS
106,255
6,034
15,108
7,930
2,165
137,492
SOCIO-ECONOMIC CHARACTERISTICS
Income as a % of Poverty Level
USERS
4,328
17.13%
100% & below
16,242
64.29%
12,360
48.92%
1,528
6.04%
Medicare
1,888
7.47%
101% - 150%
151% - 200%
717
2.83%
Private Insurance
6,687
26.47%
Over 200%
5,887
23.30%
Unknown
889
25,263
3.51%
Uninsured
Medicaid/QUEST
Total
25,263
Total
Health Conditions Not Managed
Well by Medicine Alone
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Obesity
Teen Pregnancy
Substance Abuse
And more…
Obesity in the Waianae Population
BMI Study
# Patients
Based on 7/2003 to 6/2004 average
height and weight data collected in
practice mgmt. System and EMR for
patients aged 18+
All population
Average
BMI
15574
31.4
BMI
30-34
BMI
35+
2072
2984
21%
31%
1020
1681
23%
38%
423
462
21%
23%
194
168
16%
14%
116
356
19%
59%
62
47
19%
14%
Top 5 Ethnicity Groups
Hawaiian/Part Hawaiian
Caucasian
Filipino
Samoan
Japanese
6890
3345
1887
981
585
33.2
29.9
27.4
37.0
27.8
Waianae Perinatal Population
Characteristics: 2005
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Total Served: 917 Pregnant Women
Total with multiple perinatal risk factors: 782
Single Women: 76.22%
Uninsured: 16.03%
18 yo. or younger: 17.78%
Past or present use of illegal substances by
patient: 41.44%
Family Based Medicine
• The Primary Care Provider (PCP) Team as a
Medical Home
• Systematically Converting the Emergency
Department Patient to Primary Care
• Bringing Integrative Care to the Primary Care
Team Environment
• Outreaching to High-Risk Patients and
Facilitating Access to Integrative Care
Wellness/Disease Management
• Linked with a Medical Practice – A
Team
• A Little Exercise Goes A Long Way
• Disease Collaborative
• Employee Wellness Program
• AlohaCare Pilot Program
Enabling and Supportive Services
• Case Management Assessment (CM001)
• Case Management Treatment Planning and
Facilitation (CM002)
• Case Management Referral Services (CM003)
• Financial Counseling (FC001)
• Health Education/Supportive Counseling (HE001)
• Interpretation Services (IN001)
• Outreach Services (OR001)
• Transportation (TR001)
• Other Enabling Services (OT001)
Behavioral Health/Substance
Abuse Intervention
• Integration with Family Medicine
Assessment
• Substance Abuse Screening and
Treatment
• Linkage with Traditional Healers
• Linkage with Emergency Medical
Services
Supporting Integrated Health –
People and Systems
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Common Vision/Board Involvement
The Report Card
Electronic Health Record
Clinic Re-engineering
Collaborations with Payors – AlohaCare
Pilot Program
Integrated Healthcare Report Card
Women and Children’s Health
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Pregnant women will enter prenatal care in their first trimester.
Women, age 40+, will receive a mammogram every 2 years.
Active CHC 2 y.o. children will be in compliance with their
immunizations.
Women, 15 y.o. and older will be screened for domestic violence.
Obesity and Chronic Disease
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50% of patients with a BMI over 35 will have a documented weight
reduction encounter.
Individuals diagnosed with diabetes will have documented dilated
retinal exams annually.
Diabetics will have to 2 Hb A1c measures at least 3 mos. apart within 1
year.
People with high blood pressure whose blood pressure is under control.
Ensure the heights and weights are measured and recorded accurately
for all patients (Audit).
Integrated Healthcare Report Card
Access to Primary Care
• Health Center assigned managed care patients will be assigned
or choose a PCP/team.
• Patients who saw their PCP within the last 12 mos. for those 6
y.o. or younger and patients who saw their PCP within the last
24 mos for those over 6 y.o.
• Patients assigned to a PCP who have received a behavioral
health screen.
Behavioral Health/Substance Abuse
• Patients referred for substance abuse treatment that entered
treatment.
• Patients who entered and completed substance abuse
treatment.
• Patients referred for a behavioral health assessment that
completes assessment process.
• Patients assessed as needing behavioral health treatment that
are currently in or who have completed treatment.
Changing the Healthcare Delivery
System
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Toward Consumer Empowerment
A Longer View on the Bottom Line
From Medical Care to Healthcare
Recognition of Special Populations and
Culture
• Codifying and Tracking Performance
Capitating Traditional Healing and
Wellness
AlohaCare – January 1 – July 15, 2004
Health Center
Lomi
lomi
Ho’opono
pono
La’au
Kahea
La’au
Lapa’au
86
Hana
Kokua Kalihi Valley
Kalihi Palama
Waikiki
Waianae
Waimanalo
113
310
95
100
23
40
18
1
104
Grand Total
704
81
105
Diet
Nutrition
Wellness
Other
25
54
2,725
161
440
3
675
1,751
49
551
88
1,212
21
74
40
88
79
4,004
3,651
223
Total #
Services
4,583
210
1,178
490
2,268
118
8,847