Assessment of Current Diabetes Disease Management at Gotham
Overall, the diabetes management team at Gotham offers programs that provide services to both inpatient and outpatient. Most of these services have been in place Pre ACO. With the passage of the ACA, Gotham reconfigured its services to meet the ACO standard guidelines.
Evaluation based on those currently enrolled in the program, the clinical diabetes management program at Gotham has been quite effective in reducing the progression of diabetes. Results of diabetes quality metrics measures from December 2008-December 2009 showed that of the 9,320 members enrolled in the program, 44% achieved an HbA1c level of less than 7%, and only about 8% having an HbA1c level greater than 9%. Fifty-six percent of these patients achieved LDL levels less than130mg/dl and 38% achieved LDL level less than 100mg/dl (Gotham.org, 2010). This is comparatively a remarkable achievement in diabetes patient care. The NCQA 2009 State of Health Care Quality external comparison report showed that Gotham hospital disease management in the Bronx area had a remarkable better HbA1c result when compared to other Medicaid commercial insurance patients. The program successfully integrated patient care through effective care coordination and partnership ensuring patient safety and quality of care. [Show me the data. Benchmark and present what you have here in tabular format with the rest of the data.]
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However, the challenge is the utilization of these services by the underserved and uninsured in spite of its availability. Once enrolled in the program, excellent care is given to the patient but the challenge remains in getting patients to be enrolled. Gotham diabetes program gets a lot of state and federal funds for most of its programs so the Hospital is adequately equipped to offer free or subsidized healthcare services to its target population. Judging from the current enrollment status into the diabetes management program, only 9,320 diabetes patients (Gotham.org) are currently in the program in a community of roughly 120,000 diabetes patients (ADA 2010). From a practical point of view, it is premature to evaluate the significant measurable impact since Gotham Hospital’s implementation of the ACO provisions. However, post ACO enrollment in most services at Gotham remains low. As at the time of writing this report, there are no available data both nationally and locally to be used for a comparative analysis of the incidence of diabetes in 2010 and 2011 which correlates to pre and post ACA implementation. [no need to cop out. You could look at data two years prior to the ACA and then post to see any changes and then discuss – no direct link but certainly talk points]
Using the percentage of enrollment at Gotham diabetes program as a measure of access to diabetes care in the Bronx, which has remained low in spite of the ACA legislature, the predominantly Hispanic and African American residents of the community have not shown any statistically significant improvement. Various Factors can be attributable to this.
Socioeconomic challenges: Residents in the Bronx Community as noted earlier are mostly Hispanics and African Americans. Poverty rate is a major contributory factor. As earlier stated, 31% of the average family of four in the Bronx community has a median income of $31,494 ((U.S. Census Bureau, 2006). Research findings have shown that the degree of healthcare utilization correlates with level of income (CDC, 2010) with health care utilization increasing proportionately with income level. Several variables can be factored into the poverty argument. Individuals with high income level are more likely to see the need for getting screened for diabetes while low income earners will hardly have time to think about their health. [Isn’t this all a bit soap box-like? Where is your supporting data? We are getting away from the main issues which are not access alone but more likely utilization and participation in care – there are diagnosed and undiagnosed diabetics] A poor uninsured resident in the Bronx is more likely to have multiple jobs and is also more likely to use public transport to commute to these various places of work. Sometimes as much as four to six hours can be spent in commuting using public transport. All these encroach into valuable time to be used to access important diabetes related healthcare services. Additionally, an individual with multiple low paying jobs is more likely to have less time to think about accessing crucial diabetes related information due to fatigue from long hours of work. All these add up to hinder access to healthcare.
Closely related to the poverty effect is single parenthood and incidence of domestic violence in the Bronx. As noted earlier, 30% of children in the Bronx come from single parent households (Gotham Hospital community service plan, 2010).Most of these single parents who are mostly females have undergone a form of domestic violence. In addition, most of single parents in the Bronx community have multiple low paying jobs in order to meet the basic necessities of their families. Add to the demanding task of raising a child alone by a single parent to the physical exhaustion of work is a background psychological trauma of domestic violence and a picture emerges why this population will hardly think of healthcare utilization. It is with this background analysis that the group strongly recommends the use of local coordinators who live and relate at the level of the poor and underserved to work specifically with the Gotham diabetes team to bring about increase diabetes care utilization. [You have not provided any support to demonstrate the improvement nor have you provided any information about who these people are i.e., training, background, where employed? What does the literature say? Other ACOs? Demonstration project results?]
Another factor of note responsible for underutilization of healthcare services amongst the target population is the low educational level. According to a study by Alguwaities and Shaw (2009), healthcare utilization is strongly correlated with level of education especially amongst diabetes patients. With high level of education, patients are more likely to access healthcare as they see the need for it. With low level of education in the Bronx, utilization of diabetes management services presents a challenge.
Cultural differences and diversity could also be another contributory factor. Most people in the Bronx are first generation immigrants from different parts of the world with conflicting perception about healthcare utilization. Stereotypic beliefs from the country of origin could influence an individual’s perception to healthcare utilization.
Another important contributory factor to underutilization of healthcare services in the Bronx community is the issue of illegal immigrants. According to an estimate by the Federation for American Immigration Reform (FAIR) in 2006, there are estimated 645,000 illegal immigrants in the state of New York. These undocumented residents because of their illegal status do not access the diabetes care made available at Gotham hospital for fear of arrest. Other factors of note contributing to underutilization of the diabetes services at Gotham include: lack of access to information; lack of understanding and language barrier. Knowing and addressing these various factors present a major obstacle to Gotham hospital.
Since the implementation of the ACO in Gotham, there has not been any major strategic change in the operational approach, so the underutilization and low enrollment persists.
The group postulates that the consciousness of the need to prevent diabetes is not deeply ingrained in the mindset of the inhabitants of the Bronx Community served by Gotham Hospital due to strong socioeconomic and cultural factors. In an attempt to address basic life necessities, little time is devoted to address health issues.
A proactive approach will be to reach out to this group of people through a person they can connect and relate to on a personal level rather than on professional or political levels. Hence, the need to hire local coordinators selected from different socio-ethnic groups in the Bronx to work in partnership with Gotham’s diabetes team to bring about a paradigm shift that will improve utilization. The current program at Gotham presently has no such coordinators.
Another point worthy of note is the program’s impact on the younger generation between ages 25-44. [I thought your focus was on the Medicare population and evaluating the effect of ACOs on Medicare spending and health outcomes. How did we get here? You need to support this idea from the literature.] Another group of people worthy of note are children with obesity. While Gotham Hospital diabetes program targets childhood obesity and diabetes, the measurable impact this program has in reducing childhood obesity still remains to be proven post ACO. In the restructuring of the program, childhood obesity prevention program remains intact without any significant changes. While some of the programs aimed at addressing childhood obesity are incorporated into schools, the role parents play in preventing childhood obesity cannot be overemphasized. This is especially true as the incidence of single parenthood is very high in the Bronx. These single mothers who oftentimes are not highly educated do not have a sufficient knowledge of healthy foods which has a negative impact on their children nutritional health.
The younger age group in the Bronx has the potential of developing diabetes in the near future. Gotham Hospital diabetes unit has no program that specifically targets this group of people both pre or post ACO. This group is of particular importance as they can be targeted through the use of Gotham’s Health Information Technology (HIT) in line with the ARRA (Stimulus package) requirement. Social media can be effectively utilized to target this group as it appeals to them.
As earlier mentioned, the HIT at Gotham Hospital is used mainly for administrative purposes and Electronic medical recording. The technology is used for exchange of vital data between the healthcare provider and its ACO units as well as between patients. EMR has brought in improved diabetes care presently at Gotham for inpatients and patients currently enrolled in the diabetes program at Gotham. However, this medium can be expanded to meet design programs that can be proactively used to disseminate basic preventive information about diabetes to the younger age group. Presently, there is no active social media campaign at Gotham post ACO targeted at this age group. The vast majority of the uninsured residing in the Bronx metropolitan area is between 25 and 44 years of age. This group of people may not yet be commonly diagnosed with diabetes, but with unhealthy habits and unhealthy lifestyle, they may place themselves at a considerable risk of developing diabetes later in life. As such, a more proactive approach to reach out to this group will be a good strategy that will help to reduce the epidemiologic disease burden and management cost of diabetes in the long term. [Earlier you discussed that this is a technology and healthcare low literacy group. Which is it?]