Immigrants

Prioritizing Public Health-  Movement of People

Whatever are the top three challenges, immigrants are suffering with a disproportionate share of  the poor outcomes.  When I look at outcomes, statistically significant, repeated and triangulated results indicate what is causing excess mortality and costly morbidity worldwide.  My focus is drawn to cultural assimilation as a risk marker.  Culture clashes are going to become more problematic.  Those populations moving from one culture to another are like the canary in the coal mine.  Immigrants harbinger systemic weaknesses such as poor conflict management skills in the general population.

We are all immigrants to a degree.  Only indigenous ethnicities for each nation can be properly considered 'native' in Western Civilization.  Indigenous Japanese are native to Japan;  Indigenous Athenians are native to Greece.  Thus, indigeneity is rare among humans.  Culturally, most humans are immigrants and have a generational memory and story of their journey from one culture into another culture.  This movement is causing an increase in allostatic load, but is  disproportionately distributed among populations.  

The Rohingya remain state-less in a massive flood zone.  It was stressful like this for most all immigrants.  Today's immigrants may be motivated by climate change.  However, motivations to move still include the older reasons like urbanization, war, ecological collapse and persecution also.

Man-Made Disasters

Immigration cycles were relatively more majestic mixing during the era of the Silk Road.  But today, the frequency of human mass movement is increasing.  The globe is a buzz of population-level movement and cultural assimilation.  Even weather events cause surges of immigration.  The tsunami that overwhelmed the Fushika Deinmer nuclear power plant caused a movement of people just as Hurricane Katrina did.   

Within the domain of immigration, the core issues for Public Health range from infectious diseases to the transmission of cultural values.  Cultural superiority or inferiority is often the first value that clashes.  Frequently settled by state-sanctioned violence, the clarification of cultural hierarchy globally, has never been unsettled for so long.  

Since World War I, countries and cultures have moved toward national identities.  Internationally, the issue of immigration is basically legal, political, economic and anthropologic.  Each facet impacts health and wellness.  

What is the agency, and ethic within Public Health that is focused on and expressly for immigrants and immigration?

Equity in Healthcare - Usual and Customary

Equity in healthcare is becoming a buzz word as the evidence of racial and ethnic injustice continues to surge.  However, without inclusive implementation of multi-level policies, the disparities will continue.  The excess and unnecessary disability and death will continue.  In spite of reforms and short-term initiatives, Health Equity will remain a far-off vision. 

As Dr. Billiouxn alluded to in “Making 2019 the Year of Public Health for Louisiana,” if systemic racism, structural poverty and structural violence in healthcare can be conceptualized, expressed and then legitimized, then the culture can be shifted significantly.  Public Health successes will only impact the relative ranking of Louisiana when leaders in all economic sectors expand their partnerships to include those who speak this difficult and critical language. 

Where is the innovative space to have a dialogue about these social, behavioral and environmental drivers?

I see a strong correlation between the 53.1% of respondents citing

changing and improving company culture as their top critical

challenge and the 23.2% of respondents noting that their top

critical challenge is a lack of leadership understanding and

buy-in.    - Steve Waszak

 

Community Engagement and Translational Research

     Community Engagement is the 'final mile' for Public Health practitioners. Helmets, seat belts and smoking cessation would not be commonplace without grassroots activism.  

     Currently, one of our greatest challenges is the chronic and pervasive negative impact of social determinants of health.  All medical sciences have demonstrated racial and ethnic injustice in healthcare by showing statistically significant disparities in healthcare outcomes.  Now, the nation must act.  Not by arguing that these findings are proof of genetic racial inferiority (‘nothing can be done’), but by beginning educational, safe and honest dialogues across the healthcare delivery sector. 

     Let’s talk about community engagement, participatory design of policy and system-wide enforcement of the right to a long healthy life, liberty to access quality care, and the pursuit of wellness.

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Opioid, Violence and Obesity- Psychosomatic Epidemics

Could our emerging health problems reflect chronic dysfunctions in human relationships?   For example, abuse of substances, violence and even sugar may have a root cause in social systems and interactions.  Social determinants of health (SDH), such as incarceration, exposure to guns, health literacy and exercise, are emerging as leading markers for health status.  Many of the SDHs are mind-body conditions that are systemic in our society and community.  Is there a workforce trained and ready to intervene?

NAS is only one sequelae of Opioid Abuse

Neonatal Addicion Syndrome
Not only adolescents and adults fall prey to addiction.  Newborns and young chilcren suffer from neurologic conditions as well as Adverse Childhood Experiences (ACEs).

Social Determinants of Health

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Gun Violence and Conflict
If you want carry a concealed handgun, many states are requiring periodic training at a firing range.  However, we know that lead exposure at these shooting galleries leads to high blood lead levels which are especially harmful to women and children.  Accidental shootings and massacres add to the human toll related to gun violence.
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Obesity is Surging
Both sedentary lifestyles and high fat diets contribute to the epidemic of obesity in Western cultures.  Many of us abuse food as an unhealthy way to cope with SDHs.
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Collaborative Leadership
What does all this have to do with healthcare providers?  Doctors are expected to lead multi-disciplinary teams that address SDHs. Is your doctor's office ready to address SDH?  Are you?

Follow us @MED_WorksBR !  Join our co-op, or subscribe to our services.  MED.Works@Outlook.com... Go!
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Predicting the Path Forward

If we can predict where a natural disaster will strike...

Let us add the power of predictive analytics to your practice.  We have pricing models designed from the solo practitioner to the hospital-based practices.  Contact us today!

HEALTHY STATUS

Sir Michael Marmot, President of the World Medical Association, discusses the Health Gap.  He recommends that all policy formally consider the impact on health equity.  Along with the financial impact, the decision about a new road, or high school for example must include assessments of the differential impact population health.  

ICD-10 Conversion Collaborative

Join other small practices as we implement the conversion from ICD-9 to ICD-10 Fall 2015.  Workshops are starting this month both face to face and online.  Contact us to join up.MED+Works on LinkedIn or by email.

Medicaid PCMH

Last year, the Center for Health Care Strategies (CHCS) reported in their policy brief 10 key factors for reducing disparities.  Focused on small practices serving high volumes of low-income and racially and ethnically diverse patients with diabetes,  their conclusions highlight what is needed to support these practices that are overburdened with both complex chronic illnesses and adverse social determinants of health.  

This three-year study of 36 practices east of the Mississippi River showed that there are key themes that improve care for the 2,781 diabetics enrolled.  While no improvements were noted in clinical outcomes, an analysis of processes in the practices documented the following findings:

1. Practice leadership and culture being the most important – and subjective – factors for success.
2. Maintaining practice engagement was a major challenge.
3. Practices needed both practice facilitation and care management support.
4. Practice facilitation was most effectively provided by an entity external to the practice with the relevant experience and skill set.
5. The belief that the practices would ultimately “take over” and provide care management activities proved unrealistic.
6. Investment in the practices needed to be ongoing, more flexible and “hands-on” because the practices did not have the capacity for uninterrupted or smooth changes.
7. Although financial incentives were viewed as important, incentives were not the primary motivator or driver of change.
8. Healthcare IT was too overwhelming for most practices to implement to its fullest capacity.

While practices associated with MCOs embraced the opportunity to improve, the day-to-day application of Quality Improvement was more challenging for them.  Improving quality and reducing disparities in practices will likely be more sustainable when assisted by primary care case management programs or the state Medicaid agency.

State Medicaid agencies could support small practices by identifying overburdened practices, encouraging support for these critically important practices, by facilitating some of all of the following:

• Reimbursement Health Homes for quality and volume
• Learning collaboratives, initiatives to link small practices with more specialists including behavioral health specialties
• Technical Assistance 
• Analytic information and support
• Care management teams
• Leadership, vision and focus

“Medicaid agencies can partner with health plans and other payers to provide ongoing supports and technical assistance to practices, and ensure that small practices are not left behind.”  CHCS

Place Matters

We have all heard about the social determinants of health and that zip codes correlate to health outcomes (see Life Expectancy in New Orleans below). The evidence as well as the solutions were nicely reviewed at a session of the 2014 National Health Policy Conference.  This is important to all providers because these factors (that are outside of your control) may decrease you performance rankings and perhaps drive patients and clients away from your business.  How can you provide service to vulnerable populations without excessive risk?

"Community Health & Disparity: Moving Beyond Description" is a webinar that lasts about an hour and 30 minutes.  This time well-spent is filled with information, knowledge and wisdom about healthcare disparities.  This is essentially a call to organized action at the community level and providers of healthcare must be well-represented.  As wealth gaps and opportunities for economic equality become political battlegrounds, healthcare delivery systems are dragged into the spotlight because our performance is really a key indicator of the health of the entire community.  The health of your patients says as much about their zip codes as it does about than about your care.

The solutions to the provider's dilemma are complex.  Providers will not be able to hide cherry-picking and patient dumping strategies.  These are not viable even as near-term solutions.  However, a number of policies and practices expressly for optimizing both your clinical practice and payments are available.  For example, if you next step is community engagement, contracting with a physician support entity, upgrading your EHR, or workforce development, reach out to MED+Works to make it happen. Contact us.

Disparities

Just in case you missed it: here's a recap of our #Disparities #EquityChat with @MinorityHealth. Enjoy! http://t.co/GZzZPP7lN5
— Finding Answers (@FndgAnswers) July 8, 2013

Support Providers and Practices

Physician Support Entities (PSE)  continue to be a resource for clinicians.   See the white paper from Center for Health Care Strategies (CHCS).  Click here  to read the paper.

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Triple Aim of Quality Improvement

Dr. Eugene Nelson (2012) has done it.  He has updated my foundational paradigm about quality by collapsing the four parts of the Quality Compass into the Triple Aim-  outcomes, experience and costs.
 

Based on years of work, we finally can define what we mean by healthcare quality-  better care, better health, lower costs.  We can measure each element and we can monitor quality in real-time without bankrupting our organizations.  Its easy...  Until we try to implement it.  When we begin to manage these values into existence and weave them into the DNA of every member of the organization, then it gets challenging.

For example, we know that indiscriminate use of antibiotics is bad, but if your patient's caregiver insists...   We know that frequent trips to the ED are expensive, but try enforcing the out-of-pocket penalty.  We know that EHRs are good for monitoring health outcomes, but who is going to convert all of the old paper records?  Call MED+Works!  We will support your office as you move forward toward improved quality and help you avoid the major setbacks associated with poor implementation.

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Do Low-Income Patients Need Behavior Modification?

At the Diabetes Summit in Baton Rouge, physicians admitted that 1)  the metabolic syndrome requires lifestyle changes in order to be managed and 2) motivating lifestyle change can not be done by MDs, one on one with their patients during a regular office visit.

This is progress.  In fact, the same admission be made for most chronic conditions from migraines to CHF.  Physicians (as much as they might like to) have neither the time nor the incentives to coach patients in healing themselves.   As is often said, ...in developed countries, 'We have traded mortality for morbidity.'  Acute conditions have given way to chronic conditions.  Surgery is being eclipsed by medicines and now perhaps by cognitive behavioral therapy.  We begin to let our diet and exercise be our medicine. But where does the physician fit in to this mega-trend?

Of course one is at the table or on the menu.  So, to be at the head of the table is the physician's best strategy.  Leading a team of professions in a Patient-Centered Medical Home will require a reconfiguration of our concept of medical practice.

Let MED+Works help you grow into a position of leadership in this practice of the future.

MED+Works Wiki

Do you have a project that needs support? Or a paper to share with other Healthcare Quality Consultants?

Click here to go to the MED+Works Wiki
http://med-works.wikispaces.com/

eQuality - Relating the Medical Home, Disparities, and Quality

My interest piqued as the Dr. John Tooker spoke clearly and with authority, "the IT-supported Medical Home eliminates healthcare disparities." Of course, it made intutitive sense. The computerized reminder system for preventive care is not biased by ethnicity, race or nationality.

So, all we have to do is computerize the medical home to eliminate disparities?

Is it that simple? Yes and no. The Reschovsky et.al., 2008 showed that physicians serving ethnic minorities, the uninsured and other low-income patients have difficulty delivering medical-home quality of care. Stevens et.al., 2009 confirmed that there is variation in quality in medical homes which was associated with non-white ethnicity, non-English speaking households, low-income uninsured and low education level.

The inescapable conclusion is that to ensure equality in the care delivered at medical homes, those medical homes that care for low-income, or nonEnglish speakers, or uninsured, or ethnic minorities must receive additional support. These targeted medical homes must have grants to pay for IT improvements as well as the training and organizational changes that accompany EHRs with reminders and other IT innovations.

1. Homer CJ. Health disparities and the primary care medical home: Could it be that simple? Acad Pediatr. 2009;9:203-205.
2. Raphael JL, Guadagnolo BA, Beal AC, Giardino AP. Racial and ethnic disparities in indicators of a primary care medical home for children. Acad Pediatr. 2009;9:221-227.
3. Reschovsky JD, O'Malley AS. Do primary care physicians treating minority patients report problems delivering high-quality care? Health Aff (Millwood). 2008;27:w222-31.
4. Stevens GD, Seid M, Pickering TA, Tsai KY. National disparities in the quality of a medical home for children. Matern Child Health J. 2009.
5. Turner EJ, Bazemore AW, Phillips RL,Jr, Green LA. Will patients find diversity in the medical home? Am Fam Physician. 2008;78:183.