Role of Primary Care in Addressing HIV and COVID Health Disparities

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The Role of Primary Care in Addressing HIV and COVID Health Disparities Deborah Morris-Harris MD Chief Medical Officer, Prism Health North Texas Clinical Director, SCAETC PHNTX Regional Partner 1 Version date_ 06 2021 UTMB conference 1 Conflict of Interest Disclosure Statement No conflicts of interest or financial disclosures No discussion of off label use of medications or devices 2 This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS). Under grant number U1OHA33225 (South Central AIDS Education and Training Center). It was awarded to the University of New Mexico. No percentage of this project was financed with non-governmental sources. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government. 2 Learning Objectives Define primary care and its goals. Discuss Patient Centered Medical Home (PCMH) as a best practice for the delivery of primary care. Discuss the function of PCMH in addressing health care disparities. Examine PCMH's validation during the Syndemics of HIV and COVID-19. 3 3 Primary Care Defined According to what became known as the Millis Commission report (1966), the primary physician will serve as the primary medical resource and counselor to an individual or a family. When a patient needs hospitalization, the services of other medical specialists, or other medical or paramedical assistance, the primary physician will see that the necessary arrangements are made, giving such responsibility to others as is appropriate, and retaining his own continuing and comprehensive responsibility (Millis, 1966, p. 37). 4 Millis, J.S.The Graduate Education of Physicians. Report of the Citizens' Commission on Graduate Medical Education. Chicago: American Medical Association, 1966. 4 Primary Care and the Community Abramson and Kark (1983) pioneered an emphasis on communities and their connections with health practitioners. They viewed community-oriented primary care (COPC) as "a strategy whereby elements of primary health care and of community medicine are systematically developed and brought together in a coordinated practice" IOM in 1984 addressed COPC. That report describedcommunity-oriented primary careoperationally as the provision of primary care services to a defined community, coupled with systematic efforts to identify and address the major health problems of that community through effective modifications in both the primary care services and other appropriate community health programs (IOM, 1984, p. 2). 5 Abramson, J.H., and Kark, S.L.Community-Oriented Primary Care: Meaning and Scope. Pp. 2159 in:Community-Oriented Primary CareNewDirections for Health Services. Washington, D.C.: National Academy Press, 1983 IOM.Community-Oriented Primary Care: A Practical Assessment.VolumeI.The Committee Report. Washington, D.C.: National Academy Press, 1984. 5 The Goals of Primary Care The primary care provider is the patient's first and principal resource and is accessible and accountable Care is continuous throughout the disease course and lifecycle of the patient Care is comprehensive and includes the concerns of family members, caregivers, and the community 6 Title Font 28-32 Font 24 7 https://www.foma.org/patient-centered-medical-home.html A Model for Primary Care 7 Where did the Patient Centered Care concept come from? American Academy of Pediatrics American College of Physicians American Osteopathic Association American Academy of Family Physicians First introduced by NCQA in 2008 8 O'Dell M. L. Missouri medicine. 2016 113(4), 301304. O'Dell M. L. (2016). What is a Patient-Centered Medical Home?. Missouri medicine, 113(4), 301304. The Patient Centered Medical Home model grew out of pediatric practice, particularly in dealing with pediatric patients with complex needs -originally envisioned as a source of patient information for children with complex needs as well as an attempt to coordinate care for these patients that often had multiple types of providers who were previously disconnected 8 What the Model Promises Decreased emergency department visits Decreased all-cause inpatient admissions Improvements in diabetes quality measures Higher rates of preventative health screenings Decreased cost of care Reduced health care disparities The aphorism "a rising tide lifts all boats" is associated with the idea thatimprovements in generalwill benefit all participants 9 https://www.ncqa.org/programs/health-care-providers-practices/patient-ce... Citation: National Committee for Quality Assurance Latest Evidence: Benefits of the Patient-Centered Medical Home June 2019 How do we justify the PCMH Model? How do we know it works? We can examine data from multiple points of view; for the sake of time we will focus on these big "buckets", but a detailed report is available on the National Committee for Quality Assurance (NCQA) Website, the latest from June 2019. The NCQA offers one of the main pathways to PCMH Certification through its PCMH Recognition Pathway https://www.ncqa.org/wp-content/uploads/2019/09/20190926_PCMH_Evidence_R... Has PCMH been shown to: Decrease utilization (e.g. ED treat and release visits, hospitalization)? YES Decrease cost? YES, demonstrated by decreased cost of care in Medicare Fee For Service patients. Improve clinical quality? YES, via improved chronic disease management and preventive care metrics Decrease disparities in care? YES 9 Principles of Patient Centered Care 10 Access Continuity Comprehensive Team Based Care Patient Centered Approach Quality and Safety Care Coordination This is a brief overview of the main principle of Patient Centered Care, as agreed upon by multiple groups: American Academy of Pediatrics, American College of Physicians, American Osteopathic Association, American Academy of Family Physicians And are required to be present in a practice looking for recognition as a PCMH by the NCQA. Patient-centered care is a way of thinking and doing things that sees the people using health and social services as equal partners in planning, developing and monitoring care to make sure it meets their needs. It includes: Access to care when and where the patient needs it An ongoing relationship with a personal clinician and a care team who help provide continuous, comprehensive care Care of all stages of life: acute care, chronic care, preventive services and end of life care A team approach to providing for a patient's health care needs; the team includes clinician, team members (clinical & non-clinical), and the patient/caregiver/family/ community 10 Title Font 28-32 Font 24 Font 28-32 Font 24 11 11 The PCMH Care Team Interprofessional and Culturally Diverse 12 Provider Leadership Nurse Coordination Case Management Navigation Behavioral Health Integration Referral Specialist ER, Hospital, Clinical Trial Networks Continuous Quality Improvement Change Team Engaged Patient 13 Prism Health North Texas PCMH Model 13 Team-based care benefits Patient continuity Allows all staff to work at top of their license Higher staff satisfaction, less turnover Team more engaged with patient care outcomes Better follow up with referrals, retention, minimize "lost to care" Stable 340B revenue by keeping patients on medications PrEP primary care through consistent team relationship Frees up provider time; allows team to share workload Decrease no show rate; increase quality metrics through pre-visit outreach Increase appointment capacity 14 14 PCMH and Healthcare Disparities PCMH's goal is to improve healthcare outcomes for individuals and their communities Patient-centered models co-create health by amplifying the voice of the patient and providing a safety net of high-touch teams to keep patients engaged PCMH's implementation strategy is one of continuous quality improvement using data driven measures, monitors, and mitigation efforts PCMH as a model focuses on root cause analysis; strategy has potential to identify and mitigate inequities due to the social determinants of health 15 Knowing the Community 16 Housing- instability, household size, and density of dwellings Ventilation Employment Income Racial/Ethnic Mix Stigma Transportation Wi-fi Cell Phones 16 Resource Deserts Dallas County 17 1dallascounty.org/hhs, "About Us" 1dallascounty.org/hhs, "About Us" 2https://www.census.gov/data/developers/data-sets/acs-5year.html 3https://www.census.gov/quickfacts/dallascountytexas 4www.visitdallas.com/about/diverse-dallas/-latino.html 5 https://www.census.gov/quickfacts/dallascountytexas 17 Resource Deserts Comparing social determinants of health 18 Characteristic Measure PHNTX Dallas County Income Median $9396 $31,1362 Race % Black 45% 24%3 Ethnicity % Hispanic 42% 43% 4 Insurance %Ryan White 67% 24% no insurance5 Number of Comorbidities Median Index 2 unknown 1dallascounty.org/hhs, "About Us" 2https://www.census.gov/data/developers/data-sets/acs-5year.html 3https://www.census.gov/quickfacts/dallascountytexas 4www.visitdallas.com/about/diverse-dallas/-latino.html 5 https://www.census.gov/quickfacts/dallascountytexas 1dallascounty.org/hhs, "About Us" 2https://www.census.gov/data/developers/data-sets/acs-5year.html 3https://www.census.gov/quickfacts/dallascountytexas 4www.visitdallas.com/about/diverse-dallas/-latino.html 5 https://www.census.gov/quickfacts/dallascountytexas 18 Insurers No Insurance- 4.5% Medicare -3.1% Medicaid 9.3% Commercial 15.2% Ryan White 67.1% 19 PHNTX has 5 large categories of insurers: 19 Service Area Three Well-Placed Clinic Locations Unhealthiest Zip Codes in Dallas New HIV Diagnoses Clinics Located in Zip Codes: 75204, 75208, 75210 https://aidsvu.org/resources/#/ Prism Health North Texas has three well-placed clinic locations. The clinics provide access to residents living in zip codes classified as being the unhealthiest and having the highest number of new HIV cases. https://aidsvu.org/resources/#/ 20 Services At its core, PHNTX provides adult primary HIV care including immunizations, preventative care, chronic disease management of DM and HTN, as well as wrap-around services like -dermatology, high resolution anoscopy, transgender care, substance misuse treatment, and psychiatric care, with onsite laboratories and pharmacies. HIV prevention services ( STI testing and treatment and PrEP) are provided by CDC and state grants. 21 COVID-19 Disruption- Global and Local 22 https://theconversation.com/coronavirus-mutations-what-weve-learned-so-f... https://www.smithsonianmag.com/smart-news/slo-mo-video-shows-just-how-bi... 22 Syndemics Defined Synergistic pandemics that contribute to an excess burden of disease in a population. 151.6 million cases Syndemics is a term coined by Singer in 1996. As a medical anthropologist, he observed the biopsychosocial impact of HIV/AIDS, Substance Abuse, Mental Health, and Violence on communities of color. Today there are 33 million cases of HIV worldwide; 151 million cases of COVID-19; and racism has become a global concern. These represent synergistic pandemics contributing to the excess burden of disease in marginalized populations. 23 The Digital Home Primary Care Provider Access Care Team Availability Continuous Contact Guided Self-care Referrals and Follow-up 24 24 Telehealth Urgency, Challenges and Implementation Telemedicine can be defined as "the provision of healthcare services, through the use of ICT, in situations where the health professional and the patient are not in the same location. It involves secure transmission of medical data and information, through text, sound, images or other forms needed for the prevention, diagnosis, treatment and follow-up of patients''. In response to "Shelter in Place Orders", March 31, 2020, PHNTX launched its telehealth platform, integrated in the EMR Centricity Portal. Challenges included- expanding bandwidth for >20 users, selecting software, purchasing tablets, web cams, and laptops. Provider training, template and protocol development, billing codes, and patient notification and training. 25 ICT=information communication technology; EMR=electronic medical record Information Communication Technology, consisting of telehealth, telephonic bidirectional documentation of patient encounters without video conferencing, and telemedicine, providing two-way, real time interactive, audiovisual communication between the patient, and the physician or practitioner at the distant site using a hub and spoke model, was clearly the answer to maintaining patient engagement during "Shelter in Place." On March 17th-CMS expanded telehealth benefits on a temporary and emergency basis under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act. The benefits are part of the broader effort by CMS and the White House Task Force to ensure that all Americans particularly those at high-risk of complications from COVID-19 were aware of easy-to-use, accessible benefits that could help keep them stay healthy while helping to contain community spread of this virus. Reimbursement on a fee for service basis was available through the Healthcare Common Procedure Coding System Challenges to implementation included- expanding the agency 's internet bandwidth to 1 Gigabyte for >20 users, selecting software, purchasing tablets, web cams, laptops, providing staff training, developing encounter templates and protocols. Patient notification and training followed in rapid sequence over a 10-day time period. Implementation was successfully started on Wednesday, April 1, 2020. 25 Telehealth Appointment Types 26 Results of Successful Telehealth Implementation 27 The agency has tracked service lines including laboratory, follow-up visits, and urgent visits -pre-and post shelter in place. The area in blue, represented by Telehealth starts abruptly in April and has quickly replaced 50% of follow-up visits. 27 Monitoring Clinic Demographics During the Pandemic Characteristic STI Clinic PrEP Clinic HIV Clinic COVID-19 Cases Outpatient Race % Black 25% in Dallas 53% 20% 45% 33% Ethnicity % Hispanic 42% in Dallas 30% 45% 42% 60% Age Median (IQR) 33 in Dallas 28 (23,36) 31 (27,39) 41 (32,52) 34 (28,40) Sex % Female 41% 6% 16% 7% Gender % Trans 0.6% in US 0.7% 3.1% 2% Income %< 100% FPL 19% in Dallas 65% 37% 48% 44% PHNTX serves: a disproportionate number of blacks, hispanic, trans gender and individuals earning less than 100% of the FPL. These patients have poor access to health care and distrust of most care providers. 28 No Language Disparity in Telehealth Usage Patients Scheduled Completed Appointments 29 Meeting the Needs-Agile Responses to Patients' Voices 30 TESTING SELF-CARE REFERRAL 2020 Outpatient Medical Service Expansions Telehealth Nutrition Clinical Pharmacy Psychiatry Transgender Care Anoscopy COVID-19 Testing and Immunization Same Day, Same Week Rapid Start 31 SARS-CoV-2 Testing- Convenience Coverage and Trust Diverse and Representative Staffing 32 A Focus on Quality to Mitigate Disparities Patient-Centered Medical Home (PCMH) Certification Mental Health Certified Medical Home Merit-Based Incentive Payment System Recognition, 3 years consecutively Control of co-morbidities HRSA's HAB performance measures Retention in Care Viral Suppression HAB= HIV/AIDS Bureau PHNTX was awarded ; Patient- Centered Medical Home Certification Mental Health Certified Medical Home Merit-Based Incentive Payment System Recognition 3 years consecutively In addition, control of morbidities, retention in care and HIV viral suppression were above national benchmarks. 33 Controlling Comorbidities - HTN The prevalence of hypertension (HTN) is increasing 30% of patients have Blood pressure (BP)>140/90 66% of patients have BP controlled by lifestyle and stepped-therapy 34 Hypertension is the most prevalent co-morbid condition in our population, with 30% of patients with a BP of over 140/90. 65% of these patients are maintained at normal blood pressure readings with medications and continuous monitoring. 34 Type II Diabetes The prevalence of Type II diabetes mellitus (DM) is increasing 9% of patients are diabetic Control is defined as a HbA1c<9 79% of diabetic patients are controlled by lifestyle measures and intensive stepped-therapy 35 Diabetes Mellitus Type II is the second most frequent co-morbidity at 9% of the HIV population; 79% of patients maintain blood sugars in an acceptable range with intensive medication therapy and diet. Recent studies suggest that some antiretroviral medications contribute to weight gain and DM in this population. 35 HRSA HIV/AIDS BUREAU PERFORMANCE MEASURES Viral suppression Retention in care 36 Viral Suppression at PHNTX83-93% Viral Suppression requires daily adherence to antiretroviral medications, laboratory monitoring, and visits with a provider 3-4x/ year. The per cent of patients achieving this goal varies by race, ethnicity, sexual orientation, and age. Black women and youth have the lowest rates of viral suppression, but over the last two years are approaching the goal of 90% viral suppression. A concept introduced by the United Nation's programme on HIV/AIDS in 2013, 90-90-90 is a set of goals. The idea is that by 2020, 90% of people who are HIV infected will be diagnosed, 90% of people who are diagnosed will be on antiretroviral treatment and 90% of those who receive antiretrovirals will be virally suppressed https://files.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2014/90-90-90_en.pdf 37 78% of PWH Retained in Care Through a Pandemic Year PWH=people with HIV Retention in care requires two or more visits with a provider within 1 year, with a minimum of 60 days between visits. It is a marker for engagement. Even in a pandemic year, 78% of PHNTX patients have been retained in care 38 Disparity Groups Retained in Care National Average National Average 60%; Aspiration 90% Interestingly the gaps are narrower among disparity groups with youth having the lowest retention rates. 39 Dallas County HIV Care Continuum 40 Note in Dallas County those retained in care are 73% compared to PHNTX 78%; Viral Suppression at PHNTX is 89% compared to 63% for Dallas County. 40 Diagnosis and Prevention of COVID-19 841 tests were preformed 199 positive tests administered to 169 unique individuals 200 COVID-19 vaccines delivered to patients 41 During the pandemic services were expanded to include centralized drive through testing and subsequently COVID-19 vaccine administration 169 unique positive patients ; 41 Disproportionate Share National COVID-19 Disparities PHNTX COVID-19 Disparities Rate ratio compared to Non-Hispanic Whites Black or African Americans Hispanic or Latino Cases 1.5 2.1 Hospitalizations 3x 1 Deaths 2x 1 42 The CDC reports the following outcomes which are age-adjusted incidence rates based on 2000 or 2010 Census data per 100,000 group members in the population Note: Race and ethnicity are risk markers for other underlying conditions that affect health, including socioeconomic status, access to health care, and exposure to the virus related to occupation, e.g., among frontline, essential, and critical infrastructure workers Blacks and Latinos had a nearly 3-fold age-adjusted risk of death from COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/infographic-cases-hospitalization-death.html 42 PHNTX COVID-19 Outcomes 43 Morbidity 4 deaths (5% of admissions) Hospital Admissions 75 (13% of ER visits) ER Visits 578 Home Clinic 170 Unique Cases 43 44 The COVID-19 tracking project revealed that the risk of hospitalization was also increased by the type and number of co-morbid conditions. HTN, DM, and obesity tripled the risk of admission, while chronic kidney disease quadrupled the risk. Three or more medical conditions increased hospitalizations by 5X. 44 45 Primary Care Mitigating in Hospital Death Rates Receipt of statins (OR, 0.60; 95% CI, 0.56-0.65; P < .001), 40% reduction in death Angiotensin-converting enzyme inhibitors (OR, 0.53; 95% CI, 0.46-0.60; P < .001), 47% reduction in death Calcium channel blockers (OR, 0.73; 95% CI, 0.68-0.79; P < .001), 27% reduction in death Rosenthal and colleagues point out that negative impact of co-morbidities can be ameliorated by treatment. In hospital ( presumed continued outpatient therapy) with statins, ACE inhibitors, and calcium channel blockers was associated with a reduction in hospital mortality from 25-50%, adjusting for co-morbidity and payor source. 45 Multimorbidity and Disparate Outcomes 46 50 PHNTX Patients Admitted with COVID-19 and Number Comorbid Conditions Including HIV Resource- Rich Primary Care Counterbalancing Disparities in Health Outcomes 47 Socioeconomic status Undiagnosed/ Untreated Conditions Knowledge Gaps Narrow Social Networks Leveraged State and Local Funds Trusted Sources of diagnosis and treatment Broad advocacy and knowledge networks Experience from a local Dallas Ryan White multisite clinic illustrates that a trusted source of diagnosis and treatment can leverage county, state, and federal funds to mitigate the impact of poverty, stress, narrow social networks, and untreated co-morbidities by offering testing, advocacy and referrals to outpatient clinical trials , such as bamlanivumab. 47 Primary Care Provider's Role in Disrupting Unequal Outcomes Throughout the Continuum 48 Testing Provider's Order- Outpatient ER Inpatient Evaluation Admission Treatments Clinical Trials ICU Mechanical Ventilation DNR No advanced directives Discharge Home Hospice LTAC Readmission ER=emergency room; ICU=intensive care unit; DNR=do not resuscitate; LTAC=long term acute care Primary care providers can help to eliminate barriers at each step of the disparities continuum- ordering COVID-19 tests on outpatients, providing education regarding the need for admission, making referrals to outpatient infusion centers, working with hospitalists to continuing medications for co-morbidities shown to be protective, securing advanced directives, monitoring discharged patients and helping to prevent readmission, and finally directing patients to vaccine hubs. 48 Primary Care and PCMH Work 1 case $ Cost of Poor Outcome Viral Transmission $501,000 1 CVD Admission for PCI $22,0582 COVID Hospitalization <6 days $51,3893 COVID-19 ER Visit in Texas $23184 Hospital Cost for Deceased Status >15 days LOS $460,989. COVID-19 Vaccination Prevents Outpatient Prescription Costs $1000 5 Total $1,038,664 49 Reduces HIV Viral Transmission Controls Comorbid Conditions Reduces Hospitalizations Reduces Length of Hospital Stay Reduces Deaths due to COVID-19 in People with HIV Preventing COVID-19/ Vaccination PCMH=patient centered medical home; CVD=cardiovascular disease; PCI=percutaneous coronary intervention/angioplasty with stent; LOS=length of stay 1 https://www.cdc.gov/nchhstp/budget/infographics/hiv.html#:~:text=CDC%E2%... 2 Thirty-Day Readmission Rate and Costs After Percutaneous Coronary Intervention in the United States Avnish Tripathi,MD, PhD, MPH,J. Dawn Abbott,MD,Gregg C. Fonarow,MD,Abdur R. Khan,MD,Neil G. Barry, IV,DO, MBA,Sohail Ikram,MD,Rita Coram,MD,Verghese Mathew,MD,Ajay J. Kirtane,MD, SM,Brahmajee K. Nallamothu,MD, MPH,Glenn A. Hirsch,MD, MHS, andDeepak L. Bhatt,MD, MPH 3 https://www.healthcarefinancenews.com/news/average-cost-hospital-care-co.... 4 https://www.cbsnews.com/pictures/emergency-room-visit-cost-most-expensiv... 5 https://healthpolicy.usc.edu/research/the-value-of-treatment-for-covid-19/ https://www.covid19treatmentguidelines.nih.gov/outpatient-management/ 49 Any questions?Thank you! 50 Feel free to email: Deborah Morris-Harris PhD, MD, EMBA [email protected] Selected References Millis, J.S.The Graduate Education of Physicians. Report of the Citizens' Commission on Graduate Medical Education. Chicago: American Medical Association, 1966. Abramson, J.H., and Kark, S.L.Community-Oriented Primary Care: Meaning and Scope. Pp. 2159 in:Community-Oriented Primary CareNewDirections for Health Services. Washington, D.C.: National Academy Press, 1983 IOM.Community-Oriented Primary Care: A Practical Assessment.VolumeI.The Committee Report. Washington, D.C.: National Academy Press, 1984. O'Dell M. L. (2016). What is a Patient-Centered Medical Home?. Missouri medicine, 113(4), 301304 https://www.ncqa.org/wp-content/uploads/2019/09/20190926_PCMH_Evidence_R... https://files.unaids.org/en/media/unaids/contentassets/documents/unaidsp... Geehan Suleyman, MD, MLS; Raef A. Fadel, DO; Kelly M. Malette, MD et.al. Clinical Characteristics and Morbidity Associated With Coronavirus Disease 2019in a Series of Patients in Metropolitan Detroit. JAMA Network Open. 2020;3(6):e2012270. doi:10.1001/jamanetworkopen.2020.12270 **12. Price-Haywood EG, Burton J, Fort D, Seoane L. Hospitalization and mortality among black patients and white patients with COVID-19. N Engl J Med. 2020;382(26):2534-2543. doi:10.1056/NEJMsa2011686 Ogedegbe G, Ravenell J, Adhikari et.al.,Assessment of Racial/Ethnic Disparities in Hospitalization and Mortalityin Patients With COVID-19 in New York City, JAMA Network Open. 2020;3(12):e2026881. doi:10.1001 Azar KMJ, Shen Z, Romanelli RJ, et al. Disparities in outcomes among COVID-19 patients in a large health care system in California. Health Aff (Millwood). 2020;39(7):1253-1262. doi:10.1377 51 51 Resources National Clinical Consultation Center http://nccc.ucsf.edu/ HIV Management Perinatal HIV HIV PrEP HIV PEP line HCV Management Substance Use Management Present case on ECHO http://echo.unm.edu AETC National HIV Curriculum https://aidsetc.org/nhc AETC National Coordinating Resource Center https://targethiv.org/library/aetc-national-coordinating-resource-center-0 Additional trainings [email protected] www.SCAETC.org 52 Find an HIV TeleECHO clinic in your area: https://echo.unm.edu/locations-2/echo-hubs-superhubs-united-states/ AETC National HIV Curriculum: 6 core modules for self study; regularly updated; CME, CNE [email protected] 52