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Voices of Detroit Initiative (VODI)

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  1. Voices of Detroit Initiative (VODI) Taking Care of the Uninsured: A Path to Reform Lucille Smith, M.Ed Executive Director National Congress on the Un- and Under Insured/Health Reform Congress September 22-24, 2008

  2. VODI: Who We Are…Detroit Wayne County Consortium: Collaborating Around the Uninsured A collaborative partnership between: City of Detroit Department of Health & Wellness Promotion Wayne County Health Department, Community Mental Health Agency Henry Ford Health System St. John Health Detroit Medical Center Oakwood Health System Wayne State University School of Medicine Six (6) Federally Qualified Health Centers (FQHCs): CHASS*, Detroit Community Health Connection*, Advantage Health Centers**, Health Centers Detroit, The Wellness, and Western Wayne ** Detroit Wayne County Health Authority Free Clinics Community Advisory Committee September 22-24, 2008 2

  3. VODI’s Mission • Providing leadership that help organize care delivery, expand and improve access to cost-effective, high quality health care, for the un- and under insured. September 22-24, 2008

  4. How Did VODI Get Started? • 1998 Kellogg Foundation funded 13 cities out of 80 who applied • Kellogg Foundation’s Community Voices Initiative sought to achieve five goals towards improving access for the uninsured and underinsured September 22-24, 2008

  5. Kellogg Foundation’s five goals towards improving access • Sustained increases in access to care for vulnerable and uninsured populations • Strengthening the community safety-net through community driven change and community partnerships • Model should provide system change and be sustainable beyond the 5 years • Development of best practices that could be shared with other communities September 22-24, 2008

  6. W. K. Kellogg National Community Voices Consortium: $65 million Project Nationally List of the 13 National Community Voices Projects Albuquerque, NM Baltimore, MD Charleston, WV Denver, CO Detroit, MI (Voices of Detroit Initiative (VODI) El Paso, TX Lansing, MI Miami, FL Northern Manhatten, NY Oakland, CA Pinehurst, NC Sacramento, CA Washington, DC September 22-24, 2008 6

  7. Detroit Wayne County: • Rising uninsured and uncompensated costs ($400M annually), • Uninsured with 25% higher mortality rate • Since FY2000 number on State Medicaid increased by 40%, • with 60% rise in GF expense • 60% decline in Detroit’s primary care physicians capacity • Significantly higher rates of rising chronic illness in Detroit • which, if not effectively managed in a Primary Care setting, • results in higher ED utilization, and, • a 69% higher preventable hospitalization rate compared to • the rest of the State, and, • therefore higher healthcare costs. • Continuing to do things the same way is not sustainable… September 22-24, 2008

  8. The Condition of Detroit’s Safety-net at the Beginning • Fragmented • Inadequate capacity, especially primary care • Lack of access to full continuum of health services • Did not provide an organized and coordinated system of care for the uninsured • In Detroit Wayne, there is no public hospital or public funding mechanism to support safety-net care September 22-24, 2008

  9. VODI’s Objective • With active involvement in VODI’s collaborative network, VODI will keep enriching the approach to transform systems of care that increase medical services utilization in an appropriate setting for the uninsured, and, therefore improves their health status, reduce avoidable ED visits, inpatient stays and reduces costs People with fragmented lives will never do well in a fragmented healthcare delivery system Smitherman September 22-24, 2008

  10. An Overview of the VODI Project: A Path to Reform The VODI Question: Could VODI transition adults (age 18 to 64), without health insurance, out of the ER to primary care settings by providing: Active ER>>PC Intervention healthcare coverage organized delivery system, and care/disease management? September 22-24, 2008 10

  11. VODI Intervention Model (VIM): Detroit providers agreed to provide care to: 27,500 uninsured Detroiters (13.75% of Detroit’s uninsured pop) Kellogg Grant $ paid for no care, only infrastructure Intervention: ER enrollment + case and care management linked to PCP/Medical Homes VODI Providers provided primary care at no or significantly reduced cost Commitment for the full continuum of care ED Diversion Strategy = significant cost savings Demonstrate the value of managing care of the uninsured. VIM is an active outreach inERs>>>PC sites Enrollment/registration/tracking/utilization data analysis Primary Care Medical Home assignment, apt & use + case mgt September 22-24, 2008 11

  12. VODI Intervention Model (VIM) Required an Organized Delivery System to Provide Care 4Cs • Organized Collaboration The framework for building agreement and commitment • Organized Coordination Working together in a common effort developing a common set of services and activities • Organized Coverage Agreement to pay for a set benefits to a defined population (registration, enrollment, medical home assignment, tracking, and data collection • Organized Care Direct provision of services (medical home use, basic services: PC/Pharmacy/Lab/Dental, Care and Disease Management, etc) September 22-24, 2008

  13. VODI Services: Organize System of Care Assignment/Use of a “Medical Home (PCP)” Provides a Basic Set of Services Pharm/Lab/Medical care/Care management Provides a Standard Eligibility & Registration Process Provides Central Data Collection Provides Common Data Elements Tracks Patient Services Adding Information Technology (EMR) to complete the model September 22-24, 2008 13

  14. During the Five-year (1999-2004) Demonstration; Target enrollment: 27,500 VODI covered 25,373 uninsured individuals in Detroit by 2004 6,535 people were identified as eligible and enrolled in public insurance programs 18,838 uninsured people were enrolled in VODI VODI continues today, and as of January 2008, VODI has enrolled and provided coverage for 52,000 uninsured and underserved Detroiters, (37,000 active), well in excess of the initial goal of 27,500. September 22-24, 2008 14

  15. Characteristics of VODI (uninsured) Population 57% women - 43% men Age - 18 to 64 69% Single 92.4% African-American 64% total household income less than $1000/month 56.7% employed vs. nationally 83% employed Only 20% of VODI enrollees earned more than $8/hr Average annual income: $10,851 53% with 3 or more persons in household 36% with chronic condition Summary: Single, African-American women, less employed, poorer, sicker, supporting multiple family members September 22-24, 2008 15

  16. Active ER Enrollees Whose: First encounter, after enrollment, was in a Primary Care setting: 39.4% Second and later encounters, after enrollment, was in a Primary Care setting: 15% Summary: Transitioned 55% of Active Enrollees out of ER to Primary Care Setting September 22-24, 2008 16

  17. Extrapolated 42% Rev/Cost Savings for Detroit Providers VIM:Results in est. $168 Million in rev/expenditure reduction $232 Million in Uncompensated Care Costs $400 Million in Uncompensated Care Costs September 22-24, 2008 17

  18. ER Utilization for Medical Home Users vs. Nonusers VODI Enrollment from ER and PC sites 300% decrease in ER use for those with Medical Home (MH) use after VODI enrollment MH Use: 31 ER visits/100 enrollees No MH Use: 86 ER visits/100 enrollees VODI Enrollment from ER sites alone 100% decrease in ER use for those with Medical Home (MH) use after VODI enrollment MH Use: 53 ER visits/100 enrollees No MH Use: 97.2 ER visits/100 enrollees September 22-24, 2008 18

  19. Understanding Which Factors InfluencePrimary Care Seeking Behavior • Primary care visits for active enrollees was positively associated with: • Females • Increasing age • Increasing household income • Presence of a chronic condition • Primary care visits for active enrollees was negatively associated with” • 30 hrs. or more worked/week September 22-24, 2008

  20. VODI Intervention Model (VIM) Insurance Assessment Table September 22-24, 2008 X = Element is Present

  21. Plan to Impact Highest Risk GLHP Members With MH, SA, Chronic Pain and Homelessness: 24 Members/313 Admits September 22-24, 2008 21

  22. GLHP Personal Care Model: PCP/Case Management 24 Members/$1M Annual Savings 22 September 22-24, 2008

  23. Detroit-Wayne CountyPersonal Care Model 23 September 22-24, 2008

  24. Community Score Card Tool

  25. Community Scorecard • Healthcare activities of each community should be tracked in nine areas. A community collaborative board of directors should set goals in each of these areas. • Target Population: Community’s Uninsured = ________. Enrollment (share of uninsured enrolled) # established enrollees, new enrollees, Medicaid eligible # of uninsured registrants, # screened and transferred to private insurance • Consumer Profile - demographic characteristics satisfaction with enrollment and care • Resources for Target Population -# of network access points for preventive and primary care, diagnostic/lab, pharmacy, and acute care# of specialty, ED and inpatient care providers linked to primary care centers • Enhanced Funding/Medicaid Match Funds - Federal grants and earmarks, state/county/city funds health system funds, Foundation grants September 22-24, 2008

  26. Community Scorecard • Utilization of Network Services (compared to CDC and published guidelines) ‘Medical Home’, preventive care and primary care visits,diagnostic/lab services, pharmacy scripts, specialty, ED and acute care visits; inpatient admissions and ALOS • Efficiency reduced ED usage (visit/enrollee), rate of preventable hospitalizations and ED visits, effective tracking (% care tracked) • Cost Effectiveness (measured using four benchmarks) MGMA benchmark for physicians costs; University Hospital Consortium for facility costs; Medicaid cost for types of services, and Medicare benchmark for Medicaid payment • Network Financial Viability revenues for care of target population; operating profit or loss on enrolled population; safety-net provider payer balance between Medicaid, Medicare, commercial insurance and uninsured (uncompensated care). Charity care (measured with standard community-wide metric) September 22-24, 2008

  27. Community Scorecard • Quality Measurements (HEDIS) Number of immunizations; frequency for diabetes tests, screening for Diabetes, Hypertension and Asthma; number of cancer screenings; prenatal/postpartum care; surveys on patient's experience; number of well visits; preventable ED and hospital admissions; and, frequency of selected procedures performed September 22-24, 2008

  28. Policy Recommendations • Support Community Initiative for the Uninsured • Universal Coverage and Care • Fund Primary Care that is Linked to the Continuum of Care • Fund Specialty Care that Helps Link the Continuum of Care • Organize Charity Care • Community Choices September 22-24, 2008

  29. END