Caring for the Medically Homeless

1. Caring for the Medically Homeless Quality, Continuity, and Coordination of Care for the Poor Bill Cayley MD MDiv

2. Overview Objectives • Discuss ethical principles guiding care of the poor. • Describe strategies to provide a medical home for the uninsured. • Discuss opportunities to educate learners in care and advocacy for the uninsured. Session Outline • “Uninsurance” • Ethics • Medical homes & the uninsured • Education • Open discussion

3. CL’s story • Mid 40s woman • Involved in church, community, theater • Minimum wage job, no health insurance • Type I DM, one prior CCU stay for DKA • Regular, appropriate use of medications and insulin • Initiated PAP paperwork for insulin coverage • Failed to show for work • Found dead at home • No insulin in the house • Vitreous blood sugar approx 900 • What happened? Did “we” fail her???

4. Uninsurance

5. Percent of children & adults w/o health insurance (Jan – Sept 2008) www.cdc.gov/nchs/nhis.htm.

6. Percent of children <18 years of age w/o health insurance www.cdc.gov/nchs/nhis.htm.

7. Percent of adults 18-64 years of age w/o health insurance www.cdc.gov/nchs/nhis.htm.

10. Uninsurance & chronic disease • 2001 California Health Insurance Survey • 55,000 households, adults 18-64 w/ chronic disease • Percent taking medications for chronic disease Med Care Res Rev. 2005 Apr;62(2):231-49.

11. Uninsurance & source of care • Percent w/o usual source of care (2004) • Insured children (<18) 3% • Uninsured children (< 18) 29% • Insured adults (18-64) 10% • Uninsured adults (18-64) 50% • Health, United States, 2006.

12. Do patients tell us??? • Survey of 660 chronically ill adults • 35% never addressed costs with clinician • ONLY… • Only 28% reported physician or nurse ever asked if prescriptions could be afforded • Only 31% of those who reported addressing costs ever were given a less expensive alternative • Arch Intern Med. 2004; 164:1749

13. How do patients cope? • Survey of 4,055 adults • Prescribed medications for hypertension, diabetes, heart disease or depression • 31 % pursued cost-containment • 22% cut back on necessities • 16% increased debt burden • 18% underused prescription drugs • J Behav Med. 2005 Feb;28(1):43-51

14. Underinsurance • Report SNOCAP • State Networks of Colorado Ambulatory Practices & Partners • 1133 patients • Private insurance, Medicare, Medicaid • 36% reported “underinsurance” • 50% of “underinsured” (18% of total) reported adverse health effects of inability to afford care. • JABFM 2008; 21:309-16

15. Cost-sharing = underinsurance? • JAMA review • 132 articles on prescription cost-containment • Co-payments, tiering, or coinsurance • Pharmacy benefit caps • Formulary restrictions • Reference pricing • Cost sharing associated with • Lower rates of drug treatment • Worse adherence • More frequent discontinuation • For some chronic conditions, cost-sharing associated with increased used of medical services

16. Uninsurance… • Disproportionately affects • The young and middle-aged • Blacks, Asians, and Hispanics • Those below 200% of the FPL • Is associated with… • Avoiding care • No usual source of care • Underuse of medication for chronic disease • Financial stress • Often is overlooked in office visits

17. Ethics

18. The agenda of bioethics “Bioethicists commonly address ethical issues arising in wealthy developed countries” “Favourite topics of bioethicists seem trivial compared with the important health issues facing people in the world's poor countries” “Bioethics risks becoming a source of entertainment and spectacle in wealthy societies whose inhabitants overlook the poverty and suffering found throughout most of the world” Leigh Turner, BMJ  2004;328:175 

19. International Declaration of Geneva (WMA) “The health of my patient will be my first consideration” Universal Declaration on Bioethics and Human Rights Progress in science and technology should advance: access to quality health care and essential medicines, especially for the health of women and children access to adequate nutrition and water improvement of living conditions and the environment elimination of the marginalization and the exclusion of persons on the basis of any grounds reduction of poverty and illiteracy.

20. AMA principles of medical ethics A physician must recognize responsibility to patients first and foremost… A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health. A physician shall support access to medical care for all people. (excerpts)

21. ACGME competencies Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

22. Future of family medicine Family physicians are committed to continuing, comprehensive, compassionate, and personal care… must accept a measure of responsibility for the appropriate and wise use of resources… Annals of Family Medicine 2:S3-S32 (2004)

23. Question… A student asks, “What is the most important reason to go out of my way to care for the uninsured?” What would you say???

24. Collaborative responsibility • Responsibility for health should be a collaborative effort amongindividuals and the societies in which they live. Individualsshould care for their own health and help to pay for their ownhealthcare, and societies should promote health and help tofinance the costs of healthcare. • Resnik DB. J Med Ethics. 33:444

25. Ethics of “implicit” rationing • Decisions and rationale to set cost-containing limits are hid from patients. • But, this limits… • Individuals’ autonomy as patients • Individuals’ autonomy as political agents • If individual and political autonomy are…central to healthcare, then informed consent and public deliberationconstitute benchmarks for policies of rationing… (J Med Ethics. 33:704)

26. Ethical foundations of medicine “Traditional” ethics • Beneficence • Nonmaleficence • Autonomy • Justice (???) • However… • “Some physicians believe itis not their personal responsibility to work to rebalance theprinciples of medical ethics” • Challenges • Medical culture of independence, revenue • Educational costs • Culture of “individualism“ JAMA 301: 1482-4

27. Ethical foundations of medicine “Physicians have an ethical responsibility to analyzetheir personal role in creating a just or unjust society” • Are the inefficiencies of old delivery models and 1- or 2-physicianpractices acceptable any longer? • Is it time to correct the imbalanceof reimbursement for procedures and acute care vs preventiveand primary care services? • Must the basic behavior of USphysicians shift from one of autonomous, market-based individualismto one of greater social accountability and team behavior? JAMA 301: 1482-4

28. Do we train out sensitivity? Cross-sectional survey Our health care system treats people unfairly very or somewhat often based on: Fam Med. 2004; 36:715

29. Mission & academic medicine? • 3-fold mission? • Education • Research • Clinical service • Unified mission? • “Pursuit of health in the service of society” Reclaiming the mission of improving health will be a major steptoward recalibrating the 3 activities that support that missionand will refocus faculty—and academic departments—ona common goal. Ramsey & Miller. JAMA. 2009;301(14):1475-1476

30. In short… The vision • Compassion attention to patients first • Reduce poverty and improve access • Wise use of individual & system resources • Patient responsibility and autonomy The challenges • Uninsurance: • Lack of care • Lack of continuity • Medication underuse • Financial stress • Diversity of mission • Costs in medicine • Attitudes in medicine

31. The medical home

32. The medical home • Personal Physician (A) • Physician directed medical practice (A) • Whole person orientation (A) • Care is coordinated and integrated (A) • Quality and Safety (A), (B) • Enhanced access to care (A), (B), (C) • Payment recognizes added value (A), (B), (C) (A) Rogers. Fam Med 39: 697 (B) Rosenthal. JABFM 21: 427 (C) AAFP, ACP, AAP, AOA Joint Statement

33. Evidence for the medical home • Continuity improves health process and outcome measures • Consistent, good quality evidence • Continuity improves individualized management • Limited quality evidence • Minorities receive better preventive and chronic care in a “medical home” model • Limited quality evidence • Primary care associated with “multiple problem” visits • Consistent, good quality evidence Rosenthal. JABFM 21: 427

34. Medical homes & the uninsured • Continuity improves health process and outcome measures • Uninsured lack continuity and underuse medications • Continuity improves individualized management • Uninsured may benefit from individualized attention • Minorities receive better preventive and chronic care in a “medical home” model • Minorities are disproportionately affected by uninsurance • Primary care associated with “multiple problem” visits • Uninsured care is complicated (!)

35. Discussion • How do you care for the un-/underinsured? • Personally? As a practice? • What personal barriers do you find most frustrating in caring for the un-/underinsured? • What institutional barriers do you find most challenging caring for the un-/underinsured? • How have you tried to/been able to facilitate medical home care for the un-/underinsured?

36. Homes for the homeless A few examples…

37. CVFC Diabetes program • Community-academic partnership: $50K grant • Program components • Twice monthly diabetic clinics • Staffing with volunteer nurses and clinicians • Quality indicators, nurse-managed protocols • Paid program coordinator

38. CVFC Educational experiences • Family Medicine residents • Free clinic experience during Community Medicine • Primary Care medical students • Observation of DM clinic program • Barriers • Scheduling • Supervision requirements

39. CVFC Diabetes program SWOT Strengths • Consistency and continuity • Good opportunity for providing chronic care • Ability to focus on significant outcomes • Improvements in individuals’ health • Longer patient visits facilitating greater trust Opportunities • More nursing involvement • Internal research and process improvement Weaknesses • Program dependent on one individual • Inefficiencies • Lack of nursing staff • Lack of an educational component • Lack of reporting on objective measures of improvement Threats/Challenges • Improve data collection • Improve data consistency • Funding • Records infrastructure

40. Delaware “CHAP” “Community Health Access Program” • “Regular source of care” for low-income, uninsured patients via hospitals, CHCs, volunteer clinicians • Study of 795 pts in CHAP > 6 months • Increased PAP, breast exam, mammography, cholesterol screening & influenza vaccination • Percent w/ RSOC increased from 19% to 59% • Percent w/ regular doctor from 13 to 29% • Reduced ED visits “A program providing a RSOC to low-income, uninsured adults had beneficial effects on preventive screening and rates of ED use” J Health Care Poor Underserved. 2005 Aug;16(3):515-35.PMID

41. Student free clinics - Models Mobile “free clinic” (JHCPU 18:744) Urban free clinic collaboration between the pastor of a Lutheran church, a family physician, and a group of 5 medical students. (JABFM 20:572) School-sponsored faculty-student collaborations. (JHCPU 17:477) Interprofessional student clinic in homeless shelter, including CDM. (J Interprof Care. 20:254) Student-run interdisciplinary clinics (JHCPU 16:207)

42. Education

43. Educational opportunities • Service learning opportunities • Free clinics, patient education, advocacy • Participation in clinic operations • Resident involvement, QI • EBM reviews or journal clubs • Critique of sites, medications • Conference presentations • Economics, ethics • Case presentations • Written or oral • Interview based?

44. Student free clinics UCLA mobile clinic project. J Health Care Poor Underserved. 18:744 The health status of patients of a student-run free medical clinic in inner-city Buffalo, NY. JABFM 20:572 Balancing service and education: ethical management of student-run clinics. J Health Care Poor Underserved. 17:477 Students in the community: an interprofessional student-run free clinic. J Interprof Care. 20:254 Insuring the uninsured: A student-run initiative to improve access to care in an urban community. J Natl Med Assoc. 98:906 The UCSD Student-Run Free Clinic. J Health Care Poor Underserved. 16:207 Witnessing and the medical gaze: how medical students learn to see at a free clinic for the homeless. Med Anthropol Q. 14:310

45. Medical student free clinics • Issues identified in the literature • Planning of targeted services needed • Necessary to balance altruism and professionalism • Can serve as introduction to • Health disparities • Planning health education strategies • Community collaboration • Evaluating intervention outcomes • Opportunity to explore tension between “Objectification” (I-it) and “Subjectification” (I-thou)

46. Educating for service? • Wear & Kuczewski • Increase student diversity • Curricular emphasis on empathy • Role modeling • Acad med 83:639 • Baldesari & Williamson • Invested partnerships • Meaningful & relevant learning experiences • Faculty role modeling • Curricular emphasis on scholarship & research • Adv nursing science 31:E1

47. Educating for service? • UW LOCUS program • Students matched with generalist mentor • Clinical & core curriculum, service project • Curriculum: leadership, self-reflection, compassion, self-care, striving for balance, avoiding burnout, and being realistic about what they can accomplish, teamwork, and resolving conflicts. • Acad Med 77:740

48. Discussion • How do you / could you integrate learners into your efforts to provide a medical home for the uninsured? • How could those efforts be adapted to shape learner attitudes and behaviors? • How could those changes be demonstrated and replicated?

49. Discussion