2017 PCPCC Fall Conference

Panel Touts Success Integrating Primary Care, Population Health

October 23, 2017 11:31 am Michael Laff Washington, D.C. –

By identifying specific public health problems and offering care to people the moment they need it, population health initiatives can work with primary care to improve health outcomes before patients go to their physician's office or the ER.  

Beth Tanzman, M.S.W., (far right), executive director of Vermont's Blueprint for Health program, discusses the state's medical home program during the Patient-Centered Primary Care Collaborative Fall Conference. Evan Behrle (left), a special adviser for opioid policy with the Baltimore City Health Department, and Somava Stout, M.D., M.S., of 100 Million Healthier Lives, also participated in the discussion.

Public health officials discussed successful primary care-population health integration at the city and state levels during a panel discussion at the Patient-Centered Primary Care Collaborative Fall Conference(pcpccevents.com) held here Oct. 11-12.

Baltimore Programs Focus on Children

Baltimore has launched several such efforts. In one example, city health officials decided to tackle one of the nation's highest infant mortality rates and several other health disparities that occur among low-income and ethnic minority groups. The need was great, because social determinants of health contribute to a 20-year variation in life expectancy among residents of different Baltimore neighborhoods.  

Story Highlights
  • A panel of public health officials at the Patient-Centered Primary Care Collaborative Fall Conference discussed successful primary care-population health integration.
  • Programs in Baltimore tackled several health disparities among low-income and ethnic groups, including one of the nation's highest infant mortality rates.
  • Vermont's Blueprint for Health initiative provides participating practices a monthly fee that averages $23 to $32 per patient.

Evan Behrle, a special adviser for opioid policy with the Baltimore City Health Department, described a program that seeks to reduce the infant mortality rate by 40 percent within eight years. B'more for Healthy Babies(www.healthybabiesbaltimore.com) places pregnant women enrolled in Medicaid into a triage system of team-based care focused on reducing premature birth, low birth weight and unsafe sleep. Nurses make visits in targeted neighborhoods using a map that highlights specific corridors of need.

When the initiative began in 2009, there were 13.5 infant deaths per 1,000 live births; by 2012, the rate had fallen to 9.7 deaths per 1,000 live births -- a 28 percent drop. The disparity between white and black infant deaths decreased by nearly 40 percent during that period.

Many Baltimore residents who receive Medicaid benefits need more than health care. To address this, CMS' Accountable Health Communities Model(innovation.cms.gov) screens patients for social needs and refers them to local help. The goal is to reduce the gap between clinical care and social services such as housing, food and transportation.

"We're connecting people with services that already exist," Behrle said.

Another initiative in Baltimore addresses the high opioid-related death rate. Last year, 694 people died of opioid overdose, which was more than twice the city's homicide rate. New treatment programs address the problem by allowing patients who arrive in the ER after an overdose to begin treatment with buprenorphine right away, and peer outreach workers at several hospitals can refer patients who need counseling to community-based treatment centers.

Pointing to another problem, Behrle said that 25 percent of the 62,500 students enrolled in prekindergarten in Baltimore need glasses but do not have them. To help, Vision for Baltimore(health.baltimorecity.gov) launched in 2016. Through the program, city health officials set up mobile clinics outside schools and set up appointments for children's eye exams. Health officials called students' parents before and on the day of the appointment to confirm, and students who needed eyeglasses received them for free.

Maryland law requires vision screening to be provided to all students up to eighth grade, but lack of access to transportation and eye care services meant many students were not receiving the service. With Vision for Baltimore in place, the goal is to reach children in all primary and middle schools by 2019.

Vermont Initiative Boosts Primary Care Access

At the state level, panelists discussed Vermont's Blueprint for Health initiative,(blueprintforhealth.vermont.gov) which supports the patient-centered medical home model.(blueprintforhealth.vermont.gov) Launched in 2006, the model includes 140 primary care practices -- nearly all the primary care practices in the state.

Practices that participate in the program receive a monthly fee that averages $23 to $32 per patient and is calculated based on their performance ratings. Five insurers are participating, including Medicare and Medicaid.

Through the model, children in commercial plans and adult Medicaid beneficiaries reported more primary care visits, and hospital stays and imaging costs were reduced. Lower overall costs for Blueprint for Health patients offset the monthly payments made by insurers. Beth Tanzman, M.S.W., executive director for Blueprint for Health, discussed how the initiative has expanded while improving outcomes and lowering overall costs.

The program also helps address the opioid crisis in Vermont, which recorded 106 opioid-related deaths in 2016, by expanding the use of medication-assisted treatment.

"We've increased access to primary care," Tanzman said. "We reduced the prevalence of chronic mobility disease. It is a good value for our investment."

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