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Title: Creating a High Performance Healthcare:


1
.
Creating a High Performance Healthcare
Rural Surgery Symposium - September 18, 2007
Mary Wakefield, Ph.D., R.N., FAAN
Associate Dean for Rural Health and Director
2
Center for Rural Health (CRH)
  • Est. 1980, one of first five in the nation
  • The Centers mission
  • Connecting resources and knowledge to
    strengthen the health of people in rural
    communities.

3
Seven Core Areas of Focus
  • 1. Rural Health Research
  • 2. Rural Health Policy
  • 3. Rural Health Workforce
  • 4. Native American Health
  • 5. Education, Training and Resource Awareness
  • 6. Community Development and Technical Assistance
  • 7. Program Evaluation

4
CRH at a National Level
  • National Resource Center on Native American Aging
  • Upper Midwest Rural Health Research Center
  • Rural People Rural Policy
  • Rural Assistance Center (RAC)
  • Rural Research Gateway

5
A product of the Department of Health and
Human Services Rural Initiative.Established in
December 2002 as a rural health and human
services information portal.
6
RAC Services
  • Every State, DC, Puerto Rico 10 Foreign
    Countries
  • Customized Assistance
  • 4,200 requests
  • Web-Based Services (visits)
  • 2002 (1,350) 2005 (275,402)
  • 2003 (56,027) 2006 (417,017)
  • 2004 (124,133) 2007 (472,723)
  • TOTAL VISITS MORE THAN 1,346,652
  • RAC Health and Human Services Listserv
  • reaches more than 5,600 individuals

7
RAC Web Site
http//www.raconline.org
  • Funding opportunities
  • Information guides on key topics
  • News and Events
  • Experts and Organizations
  • Publications and Maps
  • Success Stories
  • State Resources

8
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9
Office of Rural Health Policy
  • HHS Rural Health Task Force
  • Rural Health Research Centers
  • State Office of Rural Health
  • Rural Hospital Flexibility Grant
  • Rural Assistance Center
  • National Advisory Committee on Health and Human
    Services - 21 member panel 4 year terms

10
National Advisory Committee on Rural Health and
Human Services
  • Key Developments
  • 2007 Report Out
  • Substance Abuse, Head Start and Medicare
    Advantage
  • 2008 Report Underway

11
Concern is Crystallizing
  • "The old models of medical care and public health
    delivery no longer work... the US health care
    system, both public and private,
    is in imminent danger
    of collapse...
  • the public health system is faring even worse
    than private health care."

(AHA Health Research and Education Trust Sept.
2006)
12
What Are the Most Important Health Care
Issuesfor Presidential and Congressional Action?
(Source C. Schoen, S.K. How, I. Weinbaum, J.E.
Craig, Jr., and K. Davis, Public Views on
Shaping the Future of the U.S. Health System,
The Commonwealth Fund, August 2006.)
13
State Initiatives
Illinois All-Kids
MA Strategy for Health Care Everyone does
their part
Retaining/Expanding Employer Participation
Maines Dirigo Health
Vermont Health Care Affordability Act Enacted May
2006
Rhode IslandFive-Point Strategy
Utahs Primary Care Network Section 1115
Medicaid Waiver
California Governors Health Care Proposal
Minnesota Smart-Buy Alliance
New Jersey Raises Age of Dependent Status for
Health Insurance
14
What do we need to Focus on to be the Best?
  • A high performance health system is designed
    to achieve
    four core goals
  • 1. efficient, high value
  • 2. high quality, safe care
  • 3. access to care for all people
  • 4. system capacity to improve

15
International Comparison of Spending on Health
1980 2004
EFFICIENCY
Average spending on healthper capita (US PPP)
Total expenditures on healthas percent of GDP
Data OECD Health Data 2005 and 2006.
(Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006)
15
16
Medicare Expenditures (1970 - 2015)
Dollars (in billions)
Note Figures for 2010 and 2015 are projected
(Source 2007 Medicare Trustees
Report)
17
QUALITY
States Vary In Quality of Care
20002001
Quartile Rank
First
Second
Third
Note State ranking based on 22 Medicare
performance measures.
Fourth
(Source S.F. Jencks, E.D. Huff, and T. Cuerdon,
Change in the Quality of Care Delivered to
Medicare Beneficiaries, 19981999 to 20002001,
Journal of the American Medical Association 289,
no. 3 (Jan. 15, 2003) 305312.)
18
U.S. Adults Receive Half of Recommended Care
Quality Varies Significantly by Medical Condition
QUALITY
Percent of recommended care received
(Source E. McGlynn et al. 2003. "The Quality of
Health Care Delivered to Adults in the United
States, The New England Journal of Medicine
248(26) 26352645.)
19
Primary Care Doctors Reports of Any Financial
Incentives Targeted on Quality of Care
Percent reporting any financial incentive
Receive or have potential to receive payment
for clinical care targets, high patient
ratings, managing chronic disease/complex needs,
preventive care, or QI activities
(Source 2006 Commonwealth Fund International
Health Policy Survey of Primary Care Physicians)
20
National Quality Initiatives
  • Multi-Sector Push
  • The Private Sector
  • U.S. Department of Health and Human Services
  • The U.S. Congress

21
Inpatient PPS
  • FY08 continued 2.0 reduction for hospitals not
    reporting outpatient quality measures
  • FY08 6 additional for total 27 quality measures
  • 1 HCAHPS
  • 3 measures relating to surgical care improvement
  • 2 measures for 30-day mortality AMI and heart
    failure
  • Proposed FY09 5 new measures for a total of 32
    quality measures
  • 1 measure for 30-day mortality pneumonia
  • 4 measures relating to surgical care improvement

22
Outpatient PPS
  • CY09 2.0 reduction for hospitals not reporting
    outpatient quality measures
  • Proposed FY09 10 new outpatient measures
  • 5 Emergency Department AMI Transfer Measures
  • 2 Surgical Care Improvement Measures
  • 1 measure each for Heart Failure,
    Community-Acquired Pneumonia, and Diabetes
  • CMS seeking comment on 30 additional measures

23
Important differences between rural and urban
areas.
24
Important differences between rural and
urban areas that affect health care
delivery
  • Healthcare availability
  • Volume, case and service mix
  • Demographics
  • Income, education, insurance status
  • Health behaviors
  • Population density

25
CMS Hospital Compare
  • CAHs as a group are performing
  • As well or better than urban hospitals on half of
    the pneumonia measures and surgical infection
    prevention measures
  • Not as well as urban hospitals on all of the
    quality measures for AMI and CHF

(Source University of Minnesota analysis of
Hospital Compare Data for 2005)
26
Medicare Hospital Value Based Purchasing Plan
(VBP)
  • Rural hospitals want to participate in a single
    VBP program
  • CAHs want to participate on a voluntary basis
  • Rural relevant performance measures- ER
    Transfer
  • Problem of small numbers in reporting
  • Attention to rural in development of incentive
    structure
  • Careful display of information in Hospital
    Compare

27
QIO 8th Scope of Work
  • 8th Scope of Work (SOW) required QIOs to do
    rural hospital work (Task 1c2)
  • http//www.cms.hhs.gov/QualityImprovementOrgs/
  • Greatly expands activities related to rural
    providers and incentives to work with CAHs
  • QIOs Provide Key Support of Rural Quality
    Initiatives
  • 80 have done joint activities with State Office
    of Rural Health
  • 60 have done strategic planning for State rural
    support
  • 90 cite active partnership and/or joint
    initiatives with State hospital association for
    rural hospitals

28
QIO 9th Scope of Work
  • 9th Scope of Work under development
  • Anticipated focus on
  • Prevention tied to IT
  • Patient Safety
  • Patient Pathways- care coordination

29
Percent of Heart Failure Patients Given Discharge
Instructions - Why Not the Best?
Top Hospitals 91
Average All Reporting Hospitals
Average All Hospitals in North Dakota
One Rural North Dakota Hospital
Top Hospitals represents the top 10 of hospitals
nationwide. Top hospitals achieved a 91 rate or
better
(http//www.hospitalcompare.hhs.gov)
30
Percent of Pneumonia Patients Given Initial
Antibiotic(s) within 4 Hours After Arrival -
Why Not the Best?
Top Hospitals 92
Average All Reporting Hospitals
Average All Hospitals in North Dakota
The same rural North Dakota Hospital
Top Hospitals represents the top 10 of hospitals
nationwide. Top hospitals achieved a 92 rate or
better.
(http//www.hospitalcompare.hhs.gov)
31
ND Critical Access Hospital Quality Networkin
Development
  • FOCUSING ON
  • Develop infrastructure that supports rural
    hospital efforts to enhance quality of care
    provided to rural residents.
  • Position rural hospitals to meet future
    challenges to the rural health care environment,
    including quality-based reimbursement.
  • INVOLVES
  • Critical Access Hospitals (CAHs)
  • Center for Rural Health, ND Healthcare Review,
    Inc., ND Healthcare Association, ND Department of
    Health
  • Plans for future involvement with tertiary
    liaisons, network representatives, rural non-CAHs
  • SPONSORED BY
  • ND Small Hospital Improvement Program (SHIP)
  • ND Medicare Rural Hospital Flexibility Program
    (Flex)

32
Electronic Medical Records and Information Systems
  • Reduce duplicate tests
  • Provide decision support for physicians and
    patients
  • Facilitate referrals,
  • Reduce medical errors
  • Promote better management of chronic conditions
    and care coordination
  • Registries
  • Performance information

33
Physicians Use of Electronic Medical
Records,U.S. Compared with Other Countries,
20002001
EFFICIENCY
Percent of physicians
2000 Data 2001 European Union
EuroBarometer and 2000 Commonwealth Fund
International Health Policy Survey of Physicians
(Harris Interactive 2002).
(Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006)
33
34
Rural Health Information Technology
  • New USDA Initiative on Electronic Medical Records
  • Combines grant and loan funding (2080) _at_ 5
  • Can apply up to one month before end of FY
  • 50K up to 1 million
  • Continuing annual grants and loans for distance
    learning and telemedicine

http//www.usda.gov/rus/telecom/dlt/dlt.htm
35
North Dakota Health Information Technology (HIT)
Steering Committee
  • Vision - implement a statewide health information
    technology and exchange infrastructure.
  • Mission - facilitate adoption and use of health
    information technology and exchange to improve
    healthcare quality, patient safety, and overall
    efficiency of health care and public health
    services in North Dakota.

36
Number of States with High Proportion of
Uninsured Adults Ages 1864 Is Growing
ACCESS UNIVERSAL PARTICIPATION
Data Two-year averages 19992000 and 20042005
from the Census Bureaus March 2000, 2001 and
2005, 2006 Current Population Surveys. Estimates
by the Employee Benefit Research Institute.
(Source The Commonwealth Fund National Scorecard
on U.S. Health System Performance, 2006)
37
Receipt of All Three Recommended Services for
Diabetics,by Race/Ethnicity, Family Income,
Insurance, and Residence, 2002
Percent of diabetics (ages 18) who received
HbA1c test, retinal exam, and foot exam in past
year


Insurance for people ages 1864. Urban
refers to metropolitan area gt1 million
inhabitants Rural refers to noncore area lt10,000
inhabitants. Data Medical Expenditure
Panel Survey (AHRQ 2005a).
(Source Commonwealth Fund National
Scorecard on U.S. Health System Performance, 2006)
38
Health Care Infrastructure Personnel
(BHPr, OWEQA, Division of Shortage Designation,
April, 2007)
39
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40
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41
Using Telemedicine to Improve Access in Rural
Communities
  • The use of electronic information and
    telecommunications technologies to support
    long-distance clinical care
  • Improves communication with providers
  • Provides better health monitoring
  • Saves long distance travel
  • Mental health has proven to be a good model
  • High approval ratings from rural patients

23
42
Barriers to Use of Telemedicine in Rural Areas
  • Provider acceptance
  • Health insurance coverage restrictions
  • Licensing restrictions
  • Lack of local infrastructure

24
43
Current Efforts in Telemedicine
  • Maine Telemedicine Services
  • Links 300 provider sites with specialists at area
    hospitals
  • Has reduced waiting and travel time significantly
  • 87 percent of patients reported that
    videoconferencing consults are just as good or
    better than an in-person visit
  • University of Tennessee Health Science Centers
    Telehealth Network
  • West Tennessee Hospital Telehealth project
  • Five rural hospitals provide specialty care and
    educational services using videoconferencing
    technology
  • Local nurses serve as intermediaries
  • Technology Exchange for Cancer Health Network
    (Tech-Net)
  • Links seven remote cancer outreach clinics with
    specialists at UTHSC
  • Results
  • 4,500 patients have been seen through the
    telehealth network since 2003
  • Time between telehealth patient referral and
    treatment is 39 percent shorter than in-person
    visits
  • 96 percent rated telehealth visits as equal in
    quality to regular
  • office visits, and 53 percent rated them as
    higher quality

25
44
North Dakota Telepharmacy Project
  • Licensed pharmacists provide traditional services
    to registered pharmacy technicians at remote
    sites via audio and video computer links
  • 57 pharmacies involved in project 21 central
    pharmacy sites and 36 remote telepharmacy sites
  • 33 counties (62) in North Dakota and two in
    Minnesota
  • Served 40,000 rural citizens since its inception
    in 2002

26
45
Alaska Community Health Aide/Practitioner Program
(CHAP)
  • Backbone of most of Alaskas rural health
    communities
  • 550 indigenous mid-level medical providers work
    in small community health clinics to provide
    emergency, clinical, and preventive services to
    remote population under supervision of physicians
    at regional hospitals
  • Dental Health Aide Therapists (DHATs)
  • Trained to perform fillings, cleanings,
    uncomplicated extractions, and other preventive
    services
  • Certified after completion of two year program at
    the Otego University School of New Zealand

27
46
Health Policy Forecast
  • Predictions notoriously difficult
  • Early signs of clear skies (initial
    deliberations/ position statements)
  • Chance of late storms

2008 Climate Map
Level Funding
Cuts?
Increases?
47
help everyone, to the extent possible, lead
long, healthy, and productive lives.
48
  • For more information contactCenter for Rural
    HealthUniversity of North DakotaSchool of
    Medicine and Health SciencesGrand Forks, ND
    58202-9037Tel (701) 777-3848
  • Fax (701) 777-6779http//medicine.nodak.edu/crh
  • Email mwake_at_medicine.nodak.edu
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