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«1. Applicant: Public Health Trust of Miami-Dade County d/b/a Jackson Health System 2. Medicaid Provider Number: Outpatient-010042101; ...»

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1. Applicant: Public Health Trust of Miami-Dade County d/b/a Jackson Health System

2. Medicaid Provider Number: Outpatient-010042101; Inpatient-010042100

3. Provider Type: County owned public, not-for-profit, hospital

4. Amount applying for: $3,312,944

5. Identify as a new or enhanced program: Enhanced

6. Description of the delivery system and affiliations with other health care service


Effective October 1, 1973, the Public Health Trust of Miami-Dade County d/b/a Jackson Health System (“Trust”/”JHS”) was created by county ordinance to provide for an independent governing body (the board of Trustees or Board) responsible for the operation, governance, and maintenance of “designated facilities.” Currently, the Trust operates six hospitals; two skilled nursing facilities; three primary care centers; as well as four specialty care centers, school-based care programs, and the corrections health services for Miami-Dade County and one insurance organization, JMH Health Plan. The Trust operates a total of 2,106 licensed hospital beds and 343 licensed nursing home beds.

The Trust is the largest provider of healthcare services in Florida and the 4th largest public healthcare system in the United States. Beyond its size and history, Jackson Health System has earned recognition for more of its specialty services than any other South Florida hospital; and JHS is consistently ranked among “America’s Best Hospitals” by US News and World Report.

US News and World Report currently ranks the University of Miami/Jackson Memorial Hospital as the second best hospital in the Miami/Ft. Lauderdale area.

See Attachment I: For more thorough description of the delivery system and affiliations with other health care service providers.

7. Service Area: Miami-Dade County, FL

8. Service Area characteristics (including demographics or population served and distribution of current population served by funding source, e.g., Medicaid, Medicare,

Uninsured, Commercial insurance, etc.):

With over 2.5 million documented residents, Miami-Dade County is the most populated and ethnically diverse County in Florida; 7th most populated in the United States (U.S. Census, 2010). The County’s 2.5 million residents are from diverse backgrounds with approximately 65% of the population being Hispanic or Latino origin. The population is a mix of 78% white (16% non-Hispanic), 19% Black (African-American, Haitian and Caribbean) and 3% unknown or other (U.S. Census, 2010). Given its geographic location and cultural diversity, Miami-Dade County is a magnet for migration from the Caribbean and South America. Approximately half of the population was born in other countries.

Coupled with a large, diverse population Miami-Dade has one of the highest rates of uninsured, and underinsured, individuals in the nation. Over 25% of the population under 65 is uninsured;

notably higher than the state average of 19% (Health Council of South Florida, Inc., Strategic Plan 2008-2011) and the national average of 18% (National Coalition on Health Care, Facts on Health Insurance Coverage, 2007). In addition, the rate of residents living below the Federal Poverty Level (FPL) is also higher in Miami-Dade County 18% compared to the state average 15% (U.S. Census, 2010).

The demographic mix of the patient population served at our primary care centers are estimated

as follows:

–  –  –

9. Organizational Chart and point of contact:

Organizational Chart: See Attachment II.

Point of Contact: Eve Sakran, Director JHS Research & Grants Dept.; Phone: 305-585-7596;

Email: esakran@jhsmiami.org

10. Proposed budget for funding detailing the request:

See Attachment III.

11. Provide a brief summary of your proposed project:

JHS being the only public hospital in Miami-Dade County, is most involved and familiar with patients’ needs across the County; and can demonstrate from our own system’s numbers where the greatest needs remain an issue. The aim of the proposed program is to increase care coordination and improve access to care for patients with chronic illnesses. This would include enhancing JHS’ software solution, Cerner, to include a chronic disease management component;

this will be detailed in the IT section of this grant application. The disease management program being proposed will be implemented at three of JHS’ primary care centers: Jefferson Reaves Sr.

Health Center (JRSHC), North Dade Health Center (NDHC), and Rosie Lee Wesley Health Center (RLWHC); as well as in JHS’s Ambulatory Care Center (ACC)-which provides both primary and specialty care services. The depth and reach of the proposed services into the County depends on the amount funded. If funding is not received at amount requested JHS will scale back the disease management program to target the areas with greatest need and continue to explore strategies and opportunities to implement effective disease management at all locations.

It is estimated that by the year 2020, 25% of the American population will be living with multiple chronic conditions, and costs for managing these conditions will reach $1.07 trillion.

Experts estimate that chronic diseases are responsible for 83% of all health care spending.

Persons living with multiple chronic conditions typically receive health care services from different sources and often from multiple providers. Even when receiving care within a single system. As a result, care for those with chronic conditions is complex, confusing, often fragmented and associated with inefficiency and higher costs (Partnership for Solutions).

Upon review of the number of charity care patients that visited JHS’s Emergency Departments 2 or more times between July 1, 2011 and June 30, 2012 for issues related to the identified chronic illnesses it was revealed that: 1,349 patients accounted for 17,353 patient encounters; with the total patient charges amounting to $62.8 million.

We have determined that there are key diseases that disproportionately impact the population of patients we serve. The Health Council of South Florida’s 2009 Health Snapshot report of Miami-Dade noted that rates of diabetes diagnosis are lowest among Non-Hispanic Whites (6.6%), and highest among minority groups such as Asian Americans (7.5%), Hispanics (10.4%) and Non-Hispanic Blacks (11.8%). According to cause of death and hospitalization data, the Black community in Miami-Dade is disproportionately impacted by diabetes. Rates of death from diabetes among Blacks are on average about twice the rate among Whites and Hispanics.

Additionally, the age-adjusted death rate due to hypertensive heart disease in Miami-Dade was

13.4 deaths per 100,000; worse than the statewide rate of 9.7 per 100,000. With Blacks having more than twice the hypertensive heart disease death rate as compared to Whites and Hispanics, at 23.3, 11.2 and 9.6 per 100,000.

Cases of untimely death, disabilities and hospitalizations attributed to conditions such as stroke, heart disease, infections and other chronic diseases can be managed and prevented by adequate healthcare access and evidence-based practices.

Persons without a medical home or primary care provider are more likely to delay treatment and seek care through the hospital’s emergency department. These patients are often admitted for conditions that otherwise could have been treated on an out-patient basis.

The goal of the proposed disease management program is to improve the health outcomes of the target population and maximize the value of services provided; thereby reducing utilization and costs associated with avoidable ER visits and hospitalizations.

The disease management program will consist of multiple components. All components are designed to improve the patient’s health status by providing education and support to the patient, evidence-based provider decision support, medication assistance, provider performance feedback and population standards of care. For the community, this will mean better health outcomes and improved patient satisfaction; creating a more empowered community invested in their own health, and less demand for services as well as lower costs.

 Medical Home Model The medical home model will coordinate care through the use of electronic medical records and an evidence-based referral system. More importantly, the medical home is where the provider (team) has a relationship with the patient and the patient knows the provider making both mutually accountable for health outcomes.

The new care delivery model at the primary care centers will be based on the National Committee for Quality Assurance’s Medical Home paradigm which places the patient at the center of a supportive integrated network of professionals. Providers will be educated to utilize disease-specific management principles and evidence-based guidelines to holistically meet the patients’ medical and non-medical needs to achieve good health.

To implement this model, the current medical team at each location will need an additional Physician; 2 ARNPs; 2 Medical Assistants; 1 Case Manager; and 1 Administrative

Assistant/Patient Registration. The following positions will rotate between locations as needed:

1 Psychiatric Social Worker and 1 Registered Dietician. Podiatry support services will be contracted.

Patient assignment to team panels will mirror the FQHC panel recommendation initially but will be modified if necessary to meet local needs.

 Provider Education and Support Providers will receive ongoing education and support on evidence-based guidelines on the management protocols for diseases of focus: Diabetes, Hypertension, CHF and HIV/AIDS.

Providers will be trained to use clinical decision support alerts/tools and have access to knowledge-experts for complicated patients. To ensure Providers have an adequate knowledge base of the identified diseases, we will begin with best practice guidelines from recognized experts in the fields. This will be done through a variety of settings; i.e. general staff and departmental meetings, grand rounds, and video conferences.

Additionally, information will be available to providers at the points of care in either a low-tech (laminated practice guidelines) or high-tech (computerized interactive programs) format. This will ensure that the clinical decision support information is conveniently available for the Providers.

Providers will receive alerts when a needed patient activity has not occurred or whenever the defined values for a patient’s treatment plan do not meet the appropriate standard or therapeutic target.

 Patient Education and Support The goal is to support the necessary behavioral changes that promote health and to empower the patient to take a proactive role in improving his/her health. This will include providing patients with the knowledge they need to actively participate in the management of their illness. Patients will be made aware that while most chronic diseases are incurable; their episodes of illness can be limited in frequency, severity, and duration by their own behavior.

Unless a provider knows what the minimal requirements are for care, supports them, and continuously reinforces them with the patient, effective self-management will not be achieved.

Education-Many of our patients lack the knowledge base to interpret or manage the symptoms and signs of their illness. Patients will be educated in a culturally and linguistically appropriate manner on the importance of active engagement in their care process. With the initial education coming from the physician, and reinforcement repeated by the case managers. Additionally, patients will receive guidance on how to change their lifestyle, diet and personal habits to mitigate their disease.

Telephone support-provided by the social workers, is a crucial part of the patient support effort.

Patients may have questions that do not warrant making an appointment to see a provider. They can be provided with information and reassurance over the telephone. Telephone support will also allow for interim monitoring and counseling.

 Medication Access and Assistance PHT/JHS Department of Pharmacy Services employs over 60 pharmacists and supportive personnel that provide medications and clinical services at JHS Main Campus. Pharmacy Services consist of sub-specialty areas including Pediatrics, Mental Health, Critical Care, Adult Medical/Surgical and Ambulatory Care. In addition, clinical pharmacy specialists provide drug therapy consultation in a variety of practice areas (i.e. HIV, organ transplants, neonatology, etc.).

Jackson Health System participates in the PHS 340B program which allows us to provide JHS “patients” medications at a significant discount. As a result of care coordination efforts, JHS will implement electronic interfaces with our local pharmacies which will allow the PCP to receive real-time patient medication adherence information.

 Case Management Case Management incorporates the elements of utilization review and considers the interaction of a patient’s psychosocial and medical need. Case Management will take into account the patient’s individual life issues that interact with their medical problems and result in their high utilization and costs. High-risk population health management is designed to achieve cost savings through concentrated, proactive case management efforts that complement the usual clinical care. These efforts include phone calls to the patient to identify/remind about appointments, lab draws, referrals, and impromptu health education opportunities. The population of patients to be focused on is stratified based on severity of illness and near term risk for the utilization of services. It is this group of high risk patients that the Case Managers will assess and manage.

Case Managers will be for responsible coordinating care and facilitating health action planning with the patient across the continuum of care; focusing their efforts on optimizing the processes of care and addressing unrecognized, sub-clinical, social and psychological contributors to the patient’s deteriorating condition. The aim is to decrease future health resource use and the need for future hospitalizations by increasing the functional status of individual patients.

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