New study: nearly half of US medical care comes from emergency rooms

The following excerpt comes from the article published October 17, 2017, in EurekaAlert!.


Nearly half of all US medical care is delivered by emergency departments, according to a new study by researchers at the University of Maryland School of Medicine (UMSOM). And in recent years, the percentage of care delivered by emergency departments has grown. The paper highlights the major role played by emergency care in health care in the U.S.

“I was stunned by the results. This really helps us better understand health care in this country. This research underscores the fact that emergency departments are critical to our nation’s healthcare delivery system.” said David Marcozzi, an associate professor in the UMSOM Department of Emergency Medicine, and co-director of the UMSOM Program in Health Disparities and Population Health. “Patients seek care in emergency departments for many reasons. The data might suggest that emergency care provides the type of care that individuals actually want or need, 24 hours a day.”

Although he now focuses on population health, Dr. Marcozzi is an emergency room doctor himself, and works one or two days a week in the University of Maryland Medical Center emergency department, treating patients.

This is the first study to quantify the contribution of emergency department care to overall U.S. health care. The paper appears in the latest issue of International Journal for Health Services.

For this study, Dr. Marcozzi and his colleagues examined publicly available data from several national healthcare databases, which covered all 50 states and the District of Columbia. They studied the period between 1996 and 2010.

For 2010, the most recent year studied, the study found that there were nearly 130 million emergency department visits, compared with almost 101 million outpatient visits and nearly 39 million inpatient visits. Inpatient visits typically involve a hospital stay, but are planned ahead, as opposed to emergency department visits, which are generally at least somewhat unexpected.

Over the 14-year period of the study, more than 3.5 billion health care contacts – emergency department visits, outpatient visits, and hospital admissions took place. Over that time, emergency care visits increased by nearly 44 percent. Outpatient visits accounted for nearly 38 percent of contacts. Inpatient care accounted for almost 15 percent of visits.

Certain groups were significantly more likely to use the emergency department as their method of healthcare. African-American patients were significantly more likely to have emergency department visits than patients in other racial groups; patients in the “other” insurance category, which includes those without any type of insurance, were significantly more likely to have emergency department visits than any other group. And patients living in the South were significantly more likely to have emergency department visits than patients living in other areas of the country.

African-American patients used emergency departments at a higher rate than other groups. In 2010, this group used the emergency department almost 54 percent of the time. The rate was even higher for urban African-American patients, who used emergency care 59 percent of the time that year. Emergency department use rates in south and west were 54 percent and 56 percent, respectively. In the northeast, use was much lower, 39 percent of all visits.

 

Read the full article.

 

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Crossing Paths: High School Friends Reunite in Medical Field

The following article is cross-posted from Med School Watercooler: The Blog of the University of South Alabama College of Medicine.


Less than two miles away from their high school alma mater, Drs. Antwan Hogue and ShaRhonda Watkins have crossed paths again, working together on Green Medicine – an internal medicine multidisciplinary team at USA Medical Center. Dr. Hogue serves as the attending physician and Watkins is the pharmacist.

The two graduated from John L. Leflore High School in 2004, where Dr. Hogue was named valedictorian and Dr. Watkins was named salutatorian. In addition to graduating at the top of their class, former classmates also named Dr. Hogue ‘most likely to succeed’ and Dr. Watkins ‘most intelligent.’ While the two remained friends after graduation, they lost contact as they completed their college career.

Dr. Hogue earned both his undergraduate and medical degree from USA, while Dr. Watkins completed her undergraduate degree at Xavier University in New Orleans. Dr. Hogue then completed his residency training in internal medicine at Palmetto Health Richland in Columbia, S.C. — 680 miles away from Xavier University College of Pharmacy, where Dr. Watkins completed her doctor of pharmacy degree.  After completing his residency training, Dr. Hogue served as a hospitalist and internal medicine physician at West Florida Hospital in Pensacola, Fla., before joining USA last year.

On Dr. Hogue’s first day at USA, Dr. Errol Crook, professor and Abraham Mitchell Chair of Internal Medicine at the USA College of Medicine, took Dr. Hogue around USA Medical Center to get acquainted with faculty. “Dr. Crook told me that we had a pharmacist on the team and that we graduated from the same high school,” he said. “I immediately knew he was referring to the ShaRhonda Watkins I went to school with.”

Dr. Watkins was on vacation during Dr. Hogue’s first day and they met later in the week during rounds. “I walked into rounds and to my surprise I saw Dr. Hogue sitting at the table looking over charts,” Dr. Watkins recalled. “He looked up and realized who I was, and then he immediately stood up and gave me a big hug. We told the residents that we have known each other since we were 15 and had not seen each other since graduating from high school.”

Now, they have been working together on the same team for almost a year. “Our relationship is the same as it was in high school,” Dr. Watkins explained. “Working with Dr. Hogue definitely challenges me to do my best at all times.”

Each day, Drs. Watkins and Hogue — along with residents and medical students — conduct morning rounds at USA Medical Center.  “Rounding serves as a teaching opportunity,” Dr. Watkins said. “While we go through each patient’s information and discuss their medication with the group, Dr. Hogue may ask me for my input or I may make recommendations on different treatment options.”

Dr. Watkins said their dynamic reminds her of the many honors courses she and Dr. Hogue completed together during high school. “He is one of the smartest people I know,” she said. “Working with Dr. Hogue encourages me to read more medical studies so I can contribute to the group and anticipate any questions. It is almost as if I am in school again.”

According to Dr. Hogue, Dr. Watkins is also a valuable asset to the team. “If we need any updates or recommendations on what medications a patient could benefit from, she always knows the answer and keeps us informed,” he said. “Often times you don’t see people that you graduate within a professional setting. To see your life come full circle is very rewarding.”

A native of Mobile, Dr. Hogue said he is both proud and grateful to be back, making an impact in his community. “I always knew I wanted to come back to Mobile,” he said. “It has been a blessing to come back and work with so many familiar faces. I love being in this neighborhood because it made me exactly who I am today. Knowing that I am the attending physician over the team that is caring for the people of this community is extremely fulfilling.”

Dr. Hogue credits his previous friendship with Dr. Watkins for helping him to adapt to his new position. “Having a familiar person that you know outside of work enabled me to acclimate to the team with ease,” he said. “I know she will always have my back, and I definitely have hers as well.”

See more from the Med School Watercooler.

The Imperative for Learning Health Systems to Address Health Literacy

The following excerpt comes from the article by Cindy Brach posted October 11, 2017, on the Prevention Policy Matters Blog at Health.gov.


“Learn or perish” would be an apt slogan for health systems today. The rate of change in health care is high. Technological advancements, research, innovation, and market dynamics all drive the soaring complexity of the health care system. In order to survive, health systems must learn how to adapt, and in the process – we argue – address health literacy.

Integrating Knowledge into Practice

One aspect of a learning health system (LHS), according to the charter and vision of the Institute of Medicine’s (IOM) Roundtable on Evidence-Based Medicine, is “to generate and apply the best evidence for the collaborative healthcare choices of each patient and provider.” This means that integrating new knowledge into practice requires adaptation to the unique context of patients and their families.  

The current model of translating knowledge into practice consists of clinicians keeping up with the research literature, consulting the practice norms of their community, deciding which care is appropriate (i.e., “choosing wisely”), prescribing tests and treatment, with the expectation that patients will be compliant. As clinicians increasingly work for large health systems, care has become more standardized. Evidence reviews inform the development of clinical decision support tools, and performance metrics enable physicians to better understand their personal practice patterns and improve where necessary.  

Under the emergent LHS model, however, clinicians elicit patient goals and preferences, use data to tailor evidence to the patient, and engage in shared decision making. This requires physicians and the health care team to be clear communicators who engage and support patients and families as integral partners in medical decisions.  

Want To Engage Patients? Be Health Literate

Engaging patients in their own health and health care fundamentally relies on health literacy—that is, their ability to obtain, process, communicate, and understand basic health information and services. Because many Americans have difficulty understanding health information as currently delivered, LHSs must reduce the cognitive demands placed on patients and the complexities of the health care system. To disrupt what has been called the cycle of crisis care, caused by the failure to deliver understandable information and simplify health care tasks, LHSs have to:  

  • Structure their delivery systems to take health literacy universal precautions, i.e., assume that all patients are at risk of not understanding.
  • Educate their workforce in communication, engagement, and shared decision making skills so that they can clearly convey tailored evidence and help patients make informed choices that are congruent with their values and goals.
  • Collect data to assess whether they are being health literate organizations that make it easier for people to navigate, understand, and use information and services to take care of their health.

Read the full article.

I Had to ‘Unlearn’ Medicine to Treat Vulnerable Patients

The following excerpt comes from an August 14, 2017, posting written by Anita Ravi in the Fresh Perspectives: New Docs in Practice section of the AAFP website.


Two years ago, I started the PurpLE (Purpose: Listen & Engage) Clinic at the Institute for Family Health, a federally qualified health center in New York, N.Y. We offer a health home for people who have been victims of human trafficking and other trauma, and I meet patients of all genders, ages, documentation statuses and backgrounds who are encountering a range of medical issues.   

…. When I prescribed medications such as ibuprofen, reminding people to “avoid taking these on an empty stomach” was reflexive — until last year. A PurpLE Clinic patient seeking asylum after being tortured while living in his native country had an appointment to address ongoing pain related to his injuries. As I was prescribing him an anti-inflammatory medication, I didn’t think twice about saying, “Make sure you take this with food,” until I noticed his blank stare.

Ten minutes earlier, he had told me he had no income and relied on a friend who worked in a restaurant to bring leftovers to eat; sometimes there were none. I realized that what I was actually telling him with my prescription instructions was that I had been hearing but not listening. I needed to unlearn the idea that common medical advice has universal applicability, and instead learn that some prescriptions need their own treatment — such as assisting with food access — to help a patient.  

My assumptions regarding food have been tested in other ways, too. One patient called to let me know she was running late because she had a chance to get food and hadn’t eaten in three days. This was not an uncommon reason for patients to be delayed, so I said I completely understood, envisioning a very specific scenario.

When she arrived that evening, I asked what she had eaten, and she responded, “Nothing,” because she had only “collected $3.83 worth.” This patient was paying for food by collecting cans and bottles to recycle, and she had come up short.

Hunger is frequently addressed during PurpLE Clinic appointments because they are typically on weekends, when there is limited access to assistance such as food pantries.

“When was the last time you ate?” is something physicians ask when we order labs that require fasting. I’ve unlearned the purpose of this question. Having implemented a way to provide point-of-care access to food, I now ask “When was the last time you ate?” to ensure no one leaves the clinic hungry.

As I mentioned, patients at our clinic often come in later than scheduled for many reasons. Life is unpredictable. Some undocumented patients rely on informal networks for jobs and may find out the night before that a hair-braiding, construction or housekeeping job has become available. Some patients, however, always make it on time and never miss an appointment.

Other patients said they had to decide between eating a meal or paying subway fare — making appointment days particularly difficult. In New York City, where issues such as turnstile-hopping were resulting in arrest,(gothamist.com) it was troubling that attending appointments could be a link in the cycle of poverty and incarceration. To address this, I needed to unlearn that on-time appointments were a measure of success in health care delivery, and our team implemented a system that made subway cards available to patients.

Read the full post.

Examining Provider Bias In Health Care Through Implicit Bias Rounds

The following comes from the July 17, 2017, article by Vidya Viswanathan, Matthew Seigerman, Edward Manning, and Jaya Aysola on the Health Affairs Blog.


In 2015, a 27-year-old patient presented to our primary care resident practice in intractable pain, having been recently discharged from the hospital following surgery for a complex shoulder fracture. The orthopedic surgeons evaluated him the day before and scheduled a second surgery but did not adequately treat his pain. The inpatient nurse had told him he would be discharged with the oral pain regimen he had been taking for the past day or so within the hospital. But upon discharge, he found himself without those prescriptions and came to our primary care practice in severe pain. When we reviewed his inpatient record to determine the reason for this discrepancy, the attending physician discovered the phrase “drug-seeking” in the record. The rationale for this statement was not provided, nor the context. When questioned by his new primary care provider about this, the patient was shocked. He tried to recollect what he may have said to result in that assumption. He had no prior history of documented substance or prescription drug abuse.

The patient in question was a young black male and the victim of a drive-by shooting by a stranger. He had been sitting in the passenger seat of a stationary car when it happened. Standard practice in this type of case involves long-acting oral opioid medication, with gradual adjustments of a medication regimen tailored to meet the needs of the patient. But the patient didn’t receive the standard of care, and we naturally wondered why. The answer may be implicit bias.

The literature suggests that he would be more likely to be perceived as drug-seeking when requesting pain relief, compared to his white counterpart. Bias is particularly well-documented in pain management, with black children and adults receiving less adequate pain treatment than their white counterparts in the emergency department for the same presenting condition, even when accounting for insurance status and severity of pain. Longitudinal, national data on 156,729 pain-related emergency department visits found that even among those presenting with the same condition, non-Hispanic white patients were significantly more likely to receive an opioid than all other ethnic minorities examined. Researchers using an instrument to assess implicit bias in more than 2,500 physicians found a significant implicit preference for white Americans relative to black Americans among physicians of all racial/ethnic groups except for black physicians. Another study found that physicians were twice as likely to underestimate pain in black patients compared with all other ethnicities combined and also more likely to overestimate pain in nonblack patients than in black patients.

To address the case of our patient who was inadequately treated for pain based on apparently false assumptions—and other patients who have experienced a different standard of care due to implicit bias—we believe there needs to be formal discussion of this source of clinical errors at institutions. We propose the initiation of a new kind of case conference—“Implicit Bias Rounds”—to specifically identify and discuss these cases.

How Does Bias Occur?

We conceptualized Implicit Bias Rounds based on theories on why disparities in care occur despite well-intentioned providers and despite the recognition of the importance of cognitive error as a source of diagnostic error. Providers, when faced with the need to make complicated judgments quickly and with insufficient and imperfect information, may rely on assumptions associated with a patient’s social categories to fill in the gaps with information that may be relevant to diagnosis and treatment. Physicians are at risk for relying on stereotypes or assumptions for efficient decision making, even when attempting to be objective. In addition to the assumptions providers may make about patients that are dissimilar to them, they may also unconsciously favor patients whose identity they relate to. Such affinity bias may cause a provider not to consider the possibility of a drug problem in an adolescent that appears similar to him, despite a positive urine screen for marijuana. Current efforts in medicine to combat bias may also serve to perpetuate them: Physician-anthropologist Arthur Kleinman states that one problem with traditional cultural competency training is that it may erroneously characterize culture as static and cultural understanding as a technical skill.

It is not enough to merely consider potential sources of provider bias without considering proposed strategies to mitigate that bias. Evidence tells us that simply adjusting the explicit medical curricula is not enough to change implicit bias; increasing positive role modeling for medical trainees is more effective. Strategies proposed to combat implicit bias include consciously thinking of the patient’s perspective and approaching each provider-patient interaction as a shared negotiation between worldviews. Focusing on specific and unique details about an individual, instead of his or her social category, serves to combat biases by diminishing stereotyping and promoting empathy building. Clinicians who are trained to consider the unique perspectives and experiences of their patients are more likely to show empathy toward them, the study suggests. Priming physicians with information about the relevance or irrelevance of sociocultural factors in medical care can combat cognitive errors that stem from stereotyping. A regular intervention such as Implicit Bias Rounds would serve to implement these strategies on a consistent basis.

Read the full article.

Racial Differences in Outcomes Demand Greater Vigilance

The following excerpt comes from the July 17, 2017, article by Ada Stewart on the Leader Voices Blog: A Forum for AAFP Leaders and Members.


My father didn’t have a documented history of heart disease. He was never diagnosed as having hypertension, diabetes or other conditions that would have alerted us to the fact that he was at risk. So it was a shock — and one of the events that led me to the field of medicine — when he died of a massive heart attack at age 59.  

Unfortunately, his story isn’t unique.

It’s well documented that blacks are more likely than whites to suffer from an array of health conditions, including asthma, diabetes, hypertension and lung cancer. However, a study published this month in Circulation makes it clear just how different the outcomes are for black men compared with those for their white peers. Black men ages 45-64 (like my father) are twice as likely to die from a first heart attack.

My father lacked health insurance, so he rarely sought care and missed opportunities for discussions about risk factors and prevention, blood pressure and cholesterol screenings, as well as potentially life-saving treatment that may have resulted from such visits.

It’s a familiar story. One of the study’s authors said in an interview that “racial and institutional discrimination” and a lack of access to care are major factors in the wide difference in outcomes. In fact, researchers found that black patients actually have a lower risk for nonfatal cardiac events, but that lack of access to care means that too many black patients aren’t properly diagnosed with a heart condition until it’s too late.

Researchers said blacks have a higher burden of unfavorable social determinants of health,  and access to care is only one such factor. Others include limited access to nutritious food, social stressors, poor neighborhood safety and lack of recreational facilities.

Education and health literacy also are social determinants of health, and researchers said lack of patient awareness is a potential issue that should be considered regarding this issue. Although most patients likely would recognize that severe chest pain is a symptom of a heart attack, they might be less likely to recognize milder symptoms that could be cause to seek care.

So what can family physicians do? We can make sure our at-risk patients who do seek our care understand the symptoms of a heart attack and know when they need to seek treatment. We also can talk to them about exercise, nutrition, tobacco cessation and other prevention efforts, as well as the importance of follow-up when they are being treated for conditions such as hypertension and diabetes.

Read the full article.

The Messenger Also Matters: Value-Based Payment Can Support Outreach To Vulnerable Populations

 

The following excerpt comes from the July 10, 2017 article by Ruth C. Browne, Marilyn Fraser, Judith Killen, and Laura Tollen on the Health Affairs Blog.


With the proliferation of value-based payment initiatives and implementation of the Affordable Care Act’s (ACA’s) coverage expansions, states have had many opportunities in recent years to improve the health of vulnerable populations through health promotion, prevention, and care coordination. We believe value-based payment models can and must support accountable health care delivery systems in partnering with community-based “messengers” to engage vulnerable individuals in health education and promotion. We explore one such messenger program, ACCESS, a Brooklyn-based project of the Arthur Ashe Institute for Urban Health, which trains barbers and hairstylists to help formerly incarcerated men learn to recognize and act upon their own health risk factors. Value-based payment offers an opportunity to support programs such as this.

“Messengers,” as we define them here, are community health workers—those who serve “as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery.” Unfortunately, there are few dedicated funding streams available to support the messenger role. Fee-for-service payment arrangements do not reimburse these activities. Value-based payment, on the other hand, not only highlights the need to support messengers but also potentially provides funding to do so.

Value-based payment programs hold the health care delivery system accountable for meeting health goals for entire enrolled or attributed populations, which requires more than just providing better medical care. Shortfalls in medical care are responsible for only an estimated 10 percent of early mortality in the United States, while individual health-related behavior is responsible for 40 percent. Even the finest delivery system can only expect to see a modest improvement in the health of its community if it focuses only on the very thing it has been designed to do—providing medical care to sick people. Value-based payment requires delivery systems to redefine nothing less than their product, place, and providers. The product must be health; the place must be where people live and work; and the providers must include credible, community-based messengers.

Credible messengers can bring to delivery systems important knowledge about social determinants of health that impact individuals’ ability to access and act upon health-related information. We focus here on one social determinant—incarceration. Individuals formerly incarcerated have become eligible for Medicaid in large numbers and, as such, participate in a variety of value-based payment initiatives. New York State, where the ACCESS program has been implemented, is moving aggressively toward value-based payment in Medicaid. In 2015, the state announced its intention to shift 80–90 percent of its Medicaid managed care provider payments from fee-for-service to value-based arrangements by 2020.

In the United States, nearly 700,000 state and federal prisoners are released annually, and more than 11 million cycle through local jails. Incarcerated individuals have poorer physical health status than the rest of the population, a high burden of mental health and substance abuse disorders, and, once they are released, are more likely than the general population to be uninsured. However, under the ACA, more than one-third of inmates released annually from state and federal prisons are estimated to be Medicaid-eligible. If this pattern holds true for those released from local jails as well, there are potentially millions of formerly incarcerated individuals newly eligible for Medicaid—and for the value-based payment initiatives that may come with it.

The burdens of incarceration are distributed unevenly. Sixty percent of New York State prisoners come from New York City, and two-thirds of the 28,000 people released each year return to the city. Some Brooklyn neighborhoods have especially high incidences of incarceration and concomitant prison spending, earning them the dubious honorific of “million-dollar blocks,” even though they are among the poorest neighborhoods in Brooklyn.

At the Arthur Ashe Institute for Urban Health (AAIUH), we found a striking overlap between Brooklyn’s million-dollar blocks and areas where we were already engaged in health-promotion activities. Founded in 1992, the AAIUH is an independent, nonprofit organization that collaborates with community members to incubate, test, and replicate neighborhood-based interventions to improve health conditions disproportionately affecting minorities. Arthur Ashe, a world-renowned African American tennis champion and social justice advocate, founded the AAIUH in partnership with the State University of New York Downstate Medical Center. Using community-based participatory research, the AAIUH navigates disparate worlds—the institutional universe of academic medicine and day-to-day life in multi-ethnic, multi-linguistic neighborhoods.

Among other projects, the AAIUH has a long history of training barbers and hairstylists to deliver health education related to breast cancer, cardiovascular disease, asthma, and diabetes in women, and HIV/AIDS and prostate cancer in men. When we began the ACCESS program in 2009, exploratory work revealed that more than 80 percent of barbers working in our ongoing projects had themselves spent at least one night in jail. This made them particularly credible messengers for our priority population of formerly incarcerated men and the supportive women in their lives. Guided by input from a community-based advisory board, we conducted focus groups of barbers, stylists, and customers to determine the best way to discuss incarceration and health, and which health issues would be most important to the community. Based on that input, the program emphasized cardiovascular disease, stress, and HIV/AIDS. We developed a health curriculum to increase awareness of these conditions, emphasizing prevention and the importance of “knowing your numbers”—that is, understanding health indicators such as blood pressure and cholesterol levels. The curriculum included a resource guide for community health and social services related to the priority conditions and services for the re-entry population.

We trained barbers and stylists to deliver the curriculum in six establishments in the Bedford-Stuyvesant and Crown Heights areas of Brooklyn, emphasizing that health messages must be delivered in a way that could be useful to any member of the community who might know someone who had been incarcerated, instead of focusing solely on the formerly incarcerated themselves. In addition to the health messages and the resource guide, ACCESS included an HIV-focused health education video played several times a day in participating salons and barbershops and 12 AAIUH-sponsored Health Resource Days held at these establishments.

The project evaluation consisted of pre- and post-intervention surveys of patrons. The pre-intervention survey assessed patrons’ familiarity with risk factors, prevention, and resources related to the priority conditions. For example, patrons were asked multiple-choice questions such as: “What are some of the warning signs of a heart attack? What is a normal blood pressure reading?” The post-intervention survey of the same individuals sought to determine whether they had been exposed to the intervention and whether their knowledge regarding any of the previously asked questions had changed. Survey respondents’ ability to identify ways to assess their cardiovascular disease risk increased from 44 percent to 62 percent, and understanding that condom use can decrease the spread of HIV increased from 77 percent to 88 percent.

Read the full article.

Useful Resources: Health Literacy

Health Literacy is key to individuals being able to access, understand, and fully use health information and services. For this reason, the Agency for Healthcare Research and Quality (AHRQ) has developed a listing of tools and other resources to help healthcare professionals in “making information easier to understand and systems easier to navigate.” The resource list is divided into the following topics:

Visit the AHRQ website to learn more about the available Health Literacy Resources.

Workers Who Give Care To The Homebound Often Can’t Afford To Get Their Own

From the article by Shefali Luthra on Kaiser Health News:

For more than two decades, Celeste Thompson, 57, a home care worker in Missoula, Mont., had not had regular contact with a doctor — no annual physicals and limited sick visits. She also needed new glasses.

Like many others who work in the lower rungs of the health care system, she has worked hard to keep her clients healthy by feeding them, dressing them and helping them navigate chronic conditions.

But because of the low wages and the hourly structure of this industry — which analysts estimate is worth nearly $100 billion annually and projected to grow rapidly — workers like Thompson often don’t have health insurance. Many home health agencies, 80 percent of which are for-profit, don’t offer coverage, or their employees don’t consistently clock enough hours to be eligible. They generally earn too much to qualify for public aid but too little to afford the cost of premiums.

“It’s a social justice issue. We have a workforce that is the backbone of long-term [care] services, and they themselves don’t have coverage,” said Caitlin Connolly, who runs a campaign to increase home care wages at the National Employment Law Project, an advocacy organization.

In 2015, Montana opted in to the 2010 health law’s expansion of Medicaid, the state-federal low-income health insurance program. Thompson, who was making about $10 an hour, immediately signed up.

Her vision care was among the first things she focused on. She had not visited an eye doctor in nine years — a problem because her job includes keeping track of patients’ pill bottles and making sure they take the right medications. “I had to use a magnifying glass to see small print,” said Thompson, who now wears bifocals. Her doctor has since warned her she may need a stronger correction soon.

…Thompson is part of a large population of home-based caregivers who might be affected by such changes. From 2010 to 2014, about half a million of these workers gained new health insurance through Obamacare, estimates PHI, a New York-based nonprofit that researches this slice of the labor force and advocates for improved working conditions, in a March issue brief.

Most home care workers’ gains came from living in states that, like Montana, expanded Medicaid. But even with Obamacare in place, many home health workers — perhaps 1 in 5 — remain uninsured. By contrast, about 8.6 percent of all Americans lack coverage.

Read the full article.

The Future of Health Care Is Outside the Doctor’s Office

From the article by Mattie Quinn on Governing:

Eastern Kentucky, with its small communities nestled in the Appalachian Mountains, is well known as one of the poorest pockets of the country. What’s sometimes forgotten, though, is how the region’s economic decline has gone hand-in-hand with a long history of poor health.

In the early 1990s, state policymakers began to grapple with what to do about the region’s high rates of cancer, diabetes and heart disease, as well as the apparent lack of such basic good health practices as preventive screenings. In many ways, the people in the region seemed to be living outside the health-care system. That’s why, in 1994, lawmakers and health officials raised a simple question: How do we get people into the system in the first place?

“We knew we needed to create a position that would work as a patient advocate,” says Fran Feltner, director of the Center of Excellence in Rural Health at the University of Kentucky. At the time, “lawmakers sort of joked that if there was money left after the legislative session, they would create a program that would include an advocacy position,” she says. “Surprisingly, there was money left, so the Kentucky Homeplace was born.”

Kentucky may have backed into the program, but Homeplace has become an innovative model for serving people in poor, rural areas. At its heart is the advocacy position. Those who enroll in the program are matched with a community health worker — usually someone born and raised in the community. The health worker can assist with any number of things that might affect a person’s well-being, from getting them eyeglasses to helping them with food assistance to making sure they make medical appointments. “Those may seem like small problems for many people,” says Deana George, a community health worker with Kentucky Homeplace, “but I know I’ve made the process that much easier for our clients.”

After just a year with the program, George has several positive stories to share. She notes one proud moment of getting free cancer medication for a client — a medication that can run up to $10,000 a month. “When I bump into [clients] at the grocery store and they introduce me to their family, I know I’ve made a difference,” she says.

Not only has the program helped get people into care, it has also seen improvements in diabetes outcomes and in cancer screening rates. Nearly 80 percent of participants receive colon cancer screenings, well above the 40 percent national average. The program, which now serves 36 counties in Kentucky’s Appalachia region, has also introduced a new low-dose screening for lung cancer.

Health policymakers outside Kentucky have taken note. Homeplace, which is run through the Center of Excellence in Rural Health, was recognized as an “outstanding rural health program” by the National Rural Health Association, and the U.S. Department of Health and Human Services applauded its work in colon cancer screening rates. Feltner, who oversees the program, has won numerous health awards throughout the state and region. As she sees it, the community health worker is the key to the program’s success. “We’ve discovered the missing link, and that’s a person on a health-care team that makes sure a client has what they need outside of the clinic,” she says. “If a mom doesn’t have shoes for her kids, she’s likely not getting a regular Pap smear.”

Read the full article.