Louisiana AFP Members, PCMH Critical to Health Care Revitalization in New Orleans

The health care system in New Orleans used to serve as a prime example of a top-heavy system that delivered low-quality care at a high price. For generations, the city's health care and safety net infrastructure relied on a highly centralized public hospital system that made access to care difficult, resulting in high rates of chronic illness and hospitalization.

"Even if you had good insurance like Medicare, you were likely to get the poorest quality and most expensive care in the country," recalls Karen DeSalvo, M.D., M.P.H., vice dean of community affairs and health policy at Tulane University School of Medicine in New Orleans.

Then, in August 2005, Hurricane Katrina slammed into New Orleans. In the aftermath of the storm, the city's extensive network of levees failed, resulting in a flood that destroyed the city's infrastructure, including its beleaguered health care system. Eighty percent of New Orleans -- a land mass about the size of Manhattan -- found itself submerged.

"We were under mandatory evacuation for a month," said DeSalvo. "A lot of our infrastructure was under water. There was an awful lot of damage to the bricks and mortar."

She added that it was a "very uncertain and scary time -- we didn't know what our future would look like."

In the storm's aftermath, private donations and federal funds poured into Louisiana and into New Orleans itself, giving officials the chance to remake the health care system based on the tenets of primary care and the patient-centered medical home, or PCMH.

"As we were thinking about inventing our future, we said, 'Primary care has to be foundational,'" said DeSalvo, one of the leaders of the health care rebuilding efforts. "We wanted to move ourselves to a place where we could actually lower costs and improve quality."

Perhaps just as importantly, policymakers and officials equated the PCMH with "good primary care," and they made the PCMH the foundation of the city's health care revitalization efforts, according to DeSalvo.

Rebuilding the New Orleans health care system based on the PCMH model was a daunting task from the outset. About a quarter of the state's population lives below the federal poverty level, and nearly 50 percent of the population is either uninsured, on Medicare or Medicaid, or in prison, according to DeSalvo.

The city and the state not only had higher rates of chronic diseases, but also higher mortality rates than other parts of the country, DeSalvo said.

Before the storm, New Orleans had a single federally qualified health center, and most health care services were delivered through the public hospital in downtown New Orleans. By 2010, however, government officials and physicians had built a network of 87 primary care delivery sites in and around the city, greatly expanding access to care. This clinic system currently serves 175,000 patients, which is about 20 percent of the greater New Orleans population, according to DeSalvo.

Many of the primary care clinics in this revamped New Orleans health care system are run by family physicians who are members of the Louisiana AFP and who are enthusiastic about the services they can provide their patients because of the new PCMH model.

For example, physicians at Algiers Community Health Center can provide their patients with access to medical, dental and mental health services. The health center, which is recognized by the National Committee for Quality Assurance, or NCQA, as a Level 3 PCMH, is a part of EXCELth Inc., a private, nonprofit organization funded as a community health center and designated as a federally qualified health center.

The EXCELth primary care network is operated in partnership with the City of New Orleans and the Daughters of Charity Services of New Orleans. It includes seven fixed health centers and several mobile medical units that operate in the Orleans, Jefferson and East Baton Rouge parishes.

By providing comprehensive services, the physicians at Algiers Community Health Center hope to better manage their patients' chronic conditions and keep them out of the hospital and in better general health, according to Louisiana AFP member Danyel Edwards, M.D., a staff physician at Algiers Community Health.

"A lot of the patients we have here have difficulty getting to places," said Edwards. The mix of services offered by Algiers Community Health makes it more convenient for them. "They are more adherent in terms of keeping their appointments," she added. "They really feel like this is their (medical) home."

"This is no longer a top-down model where the doctor does things, and everyone does what the doctor says," said Sarat Raman, M.D., referring to the PCMH established by his health center. Raman is a member of the Louisiana AFP and a staff physician with the Daughters of Charity Health Centers in the Bywater neighborhood of New Orleans. The organization has three clinics in the New Orleans area that are recognized by the NCQA as Level 3 PCMHs.

The clinics employ a wide range of health care professionals, which gives the physicians there the ability to provide an extensive complement of services. The centers employ family physicians, nurse practitioners, medical assistants and care coordinators at each site to help coordinate and manage care.

According to Raman, the model of care is "patient-centric," and has led to improved outcome measures for various chronic conditions, such as high blood pressure, in patients seen in Raman's clinic.

"We have done more with primary care then we ever could have done with (sub)specialists," said Raman, who also is an assistant professor in Tulane University's Department of Family and Community Medicine. He noted that the model allows the various PCMH team players to interact in a variety of ways. For example, care managers do not necessarily need a physician's approval to refer a patient to a mental health professional, which results in better and quicker care for the patient.

"We know the patient experience is good, even though we are taking care of patients who are sicker than the average American," said DeSalvo. She pointed to a Commonwealth Fund 2010 survey that indicates 40 percent of clinic patients in the New Orleans area reported an excellent experience with the health care system; another 90 percent said they had enhanced access to care. In addition, said DeSalvo, 75 percent of patients reported excellent patient-clinician communications.

New Orleans now serves as a prime example of how officials can work with physicians to rebuild a health care system based on primary care and the PCMH. In the process, it has provided valuable lessons for other areas of the country that are struggling to remake their own health care systems.

Ironically, the shift to a primary care-based system would have been impossible without Hurricane Katrina. In 2007, the federal government awarded New Orleans a three-year $100 million Primary Care Access and Stabilization Grant as a direct result of the hurricane. The community was able to use that grant and other funds to help build the network of 87 primary care delivery sites in and around the city.

Also with federal assistance, officials created a loan repayment program to lure more primary care physicians to the New Orleans area, and they were able to use federal funding to provide incentives for practices to be recognized as medical homes.

But the assistance provided by the federal government is only part of the story. The rebirth of the New Orleans health care system also is a result of sound strategic planning and a corresponding commitment to primary care and the PCMH as core building blocks.

Early in the process, stakeholders created a vision statement that says, "health care in Louisiana will be patient-centered, quality-driven, sustainable and accessible to all citizens."

The state legislature, meanwhile, created the Louisiana Healthcare Redesign Collaborative, which is made up of physicians, payers and other relevant stakeholders. The collaborative developed a blueprint for health care reform that addresses the following four key areas:

Although there has been significant progress in rebuilding the health care system destroyed by Hurricane Katrina during the past five years, the community recognizes there still is a need and opportunity to improve, said DeSalvo. "In our next five years, we need to build our medical homes into a medical neighborhood that is not only high-quality and affordable, but is more accountable to the community," she noted.