The City of El Paso Department of Public Health (CEPDPH) serves the West Texas counties of El Paso and Hudspeth. The City of El Paso is the principal city in the area and is the sixth largest city in Texas and the 20th largest city in the US with a 2015 census population estimate of 681,124, a 4.9% increase from the 2010 census and a 20.84% increase from the 2000 census (https://www.census.gov). El Paso is located in the Southwest Region of the country and in the Far West corner of Texas abutting the US/Mexico border. El Paso is one of the poorer areas in the nation, with a per capita income of $18,705 that is only 65.50% of the national average of $28,555, thus meeting the criterion of an Economically Distressed Area as defined by the Government Accountability Office. El Paso County's 2014 estimated poverty rate of 23.4% far exceeds the 17.7% state rate and the 15.6% national rate. The leading health disparities in the El Paso area are diabetes, hypertension, obesity, and heart disease. The community also lags behind national rate in having proper preventive dental care. With extremely high rates of uninsured persons with limited or no access to preventive health, local providers face multiple challenges in serving El Paso, a community with a disproportionate physician/patient ratio, a high teen pregnancy rate, and a usage of the emergency room for treating basic and preventable health issues.
Issue: As for health-related services, coordinated system processes among health department and healthcare providers would facilitate access to patient-level data for improved patient care. Referral and follow-up activities are complicated to monitor for staff without system, as well as adherence by the patients, contributing to cases that are lost to follow-up. Moreover, the health services community is at the threshold of implementing a multi-disciplinary, multi-use health information exchange database; however, resources for training, technical assistance, and data analysis are lacking.
To address the problem, the CEPDPH created a multi-year program to address the health disparities mentioned above. With funding through the Texas Health and Human Services Department (HHS) and the City of El Paso, the CEPDPH hired a disease intervention specialist, a health education specialist, a database administrator, and a referral information specialist. This team served as the core strategy for reaching persons who were Medicaid-eligible or who had no or inadequate health insurance. A menu of service was created comprised of breast cancer screening, colorectal cancer screenings, and vaccinations for preventable diseases. A network of partners was created with the major hospitals and other health care providers that participated in the local Health Information Exchange (HIE) to identify clients that could benefit from the preventive health care services.
Goals and objectives: Implementation of HIE for patient care coordination of 750 persons. Increased access to cancer screenings based on recommended screening guidelines by 50%. Provide a continuum of care after screening services through HIE referral system to specialized care for all patients screened; improved communication among a network of partners through an electronic messaging application for follow-up care and testing;
1. 826 individuals were identified as in need of, connected to, and received one or more preventive services by using standardized data collection;
2. 100 persons were linked to cancer prevention, early detection, and healthy lifestyle programs;
3. approximately 55.74% of Medicaid and low-income uninsured females between the ages of 50 to 74 identified through the HIE received subsidized breast cancer screenings
4. approximately 68.63% of Medicaid and low-income uninsured persons between the ages of 50 to 75 encountered in HIE completed a colorectal cancer screening
5. within 30 days of having their electronic health record uploaded to the HIE database, 40 persons with abnormal results were referred to specialized clinics for diagnostic services;
6. sixty percent (496/826) of the program's participants were followed-up with education and/or referrals for further testing
With the practice, the CEPDPH was able to reach a population that may have not otherwise obtained the recommended preventive health care services. The impact was realized in a cost per capita of $300.27. This is derived from the program budget of $248,022 used for serving 826 clients over a one-year time frame.
The CEPDPH website is: https://www.elpasotexas.gov/public-health
Issue: As for health-related services, there is a lack of effective coordinated processes to address public health needs, with healthcare prevention and treatment provider unable to share and access patient-level data for improved patient care. Referral and follow-up activities are complicated and confusing for staff, as well as the patients, contributing to cases that are lost to follow-up. Moreover, the health services community is at the threshold of implementing a multi-disciplinary, multi-use health information exchange database; however, resources for training, technical assistance, and data analysis are lacking. The CEPDPH targeted adults who are Medicaid-eligible or have inadequate or no health insurance. Using a needs assessment/chart review with three local hospital networks, these were University Medical Center of El Paso, Las Palmas and Hospitals of Providence.
According to the U.S. Census Bureau, in 2016, the City of El Paso was comprised of approximately 683,000 residents (https://www.census.gov). Of the said amount, eighty percent of the population identified as being of a Hispanic or Latino origin. Characterized by high poverty rates, the population had a per capita income of $18,705. Additionally, according to the American Community Survey, computed from 5-year estimates based on 2012-2016data, approximately 30% of El Paso residents ages 18 years and older were estimated as having no health insurance coverage in 2016.
Those targeted in the HIE program were persons 50 years and older who lacked vaccinations and/or cancer screenings. Specifically the program focused on promoting pneumonia vaccinations and breast and colorectal cancer screenings. Using a standardized REAL data collection and analysis to improve access to and utilization of preventive health services, 826 individuals (110%) were identified as in need of, connected to, and received one or more preventive services. The initial goal was to reach 750 independent persons. As per the data analysis of persons reached, 20% were Medicaid recipients and 80% were low-income and/or uninsured individuals.
The program was based on two (2) models that together formed the basis for implementation and long-term success. These models are the Collective Model and Health Information Technology. The Collective Impact Model is based on the assumption that a singular approach is insufficient in satisfactorily addressing complex social problems (Krania and Kramer, 2011). In fact, the model affords a more encompassing approach at managing large group efforts in bringing about change. There are five key elements that comprise the Collective Impact Model. The following gives a brief overview of how the proposed program employs these elements:
Element #1: Common Agenda â€“ the proposed program brings together the CEPDPH and its partners in quarterly discussions to foster a greater awareness and joint planning efforts in improving staff readiness and confidence in employing preventive health techniques when necessary. This is accomplished through periodic reviews of existing policies and procedures in how preventive health issues are dealt with and how frontline staff members engages the public.
Element #2: Consistently measuring results â€“ the program staff used a circular approach to process evaluation in order to continually learn and share with program partners the short-term successes and to identify areas needing improvement in order to address them in a timely manner. The Plan-Do-Check-Act Cycle, described in the evaluation section of this document, is a commonly used approach for conducting ongoing process and outcome evaluation in order to continually enrich the process throughout the program period. It serves to ensure that lessons learned through the process can serve for future activities that will support greater awareness and staff's skill sets in the service areas, as well as fostering a responsive network of partners in linking persons to needed services.
Element #3: Mutually-reinforcing activities â€“ with a staff comprised of health care professionals and with program partners able to leverage their own skill sets to serve the greater good of influencing and coordinating a higher degree of systemic changes, the CEPDPH was successful in implementing far-reaching and coordinated strategies, than through unplanned and disparate activities.
Element #4: Continuous communication â€“ As mentioned before, communication with partners was maintained through formal meeting documents, such as meeting agendas, minutes, and other program materials; thus creating a historic record of the program.
Element #5: Backbone organization(s) â€“ While the CEPDPH worked with its partners as needed to ensure community-wide coordination. The CEPDPH ensured that all program activities were accomplished in a timely manner.
The Health Information Technology is essentially information technology in health care settings. It calls for the use of secure exchange of health information across providers in order to reach mutually-beneficial goals. These goals include: improved health care quality and effectiveness, increased health care productivity; reduced health care costs; extended communication among health are professionals; and increased access to affordable care (Agency for Healthcare Research and Quality, 2006). These goals are made possible with the newly-adopted HIE and the network of providers that contribute to it. Pursuant to these overarching goals, the El Paso Regional Data Validation HIE is comprised of the CEPDPH, community clinics, hospitals, non-profit organizations, and private and public healthcare providers from El Paso and Hudspeth counties. The collaborative was established to mobilize clinical information electronically across various healthcare entities, such as those previously listed but also to recruit others. In effect, HIE was created to facilitate a secure and private exchange of electronic health information with the aim of improving patient care and outcomes while lowering healthcare costs. As a centralized model system, the medical records of all HIE patients is stored in a master database that can be accessed and transmitted by any provider within the HIE. Before combining efforts, the CEPDPH primarily exchanged health information through two systems. The first system, the Paso Del Norte Health Information Exchange (PHIX) aimed to solve the problem of defective and ineffective health information sharing through three key services. These services include a centralized data repository that stored the health information of patients in one location, a HIPAA- compliant emailing service for effective communication between providers, and a navigation service to support physician practices on the use of electronic health record (EHR) technology while adhering to federal and state reporting guidelines. The second system, the CEPDPH's Health Providers and Associates database, provides a safe and efficient method to share information with health care organizations and providers within the County of El Paso. The two systems are now integrated into one comprehensive HIE.
To give an example of the collaboration within the network of partners and the exponential outputs of the HIE initiative, in program year 2015-2016, the overall impact of health care preventive and treatment services, project coordination across partners, and cost-saving strategies is apparent in all six (6) complementary Delivery System Reform Incentive Payment (DSRIP) projects. In collaboration with El Paso and Hudspeth County partners, approximately 4,500 clients received one or more types of preventive health services that protected them from illness and aided in their well-being. Based on guidelines established by the United States Preventive Services Task Force, recommended cancer screenings were provided at no cost to 200 low-income uninsured clients over the span of the year. The CEPDPH program staff also conducted follow-up services to assure a continuum of care after the screening process was given to all clients. Immunization services offered through all six projects that were tracked through the advance voucher system was an impressive 1,191 for children vaccines (MMR, TDAP, Varicella), 292 HPV, 57 influenza and 97 pneumococcal. Treatment services from the health department's Preventive Medicine Clinic including testing and follow-up for sexually transmitted infections were provided to 226 clients as part of the Border Public Health Interest Group and Community Health ATLAS DSRIP projects. Emergency Medical Services personnel also provided blood pressure monitoring, glucose test, immunizations and colocare kits through the Neighborhood Fire Station. Clients served were immunized against influenza and pneumonia for a total of 1,132 and 282 vaccines respectively. The HIE project was instrumental in identifying clients in need of recommended cancer screenings and pneumonia vaccines and assuring service was rendered through the interface of local providers and health department's electronic medical record systems. Similarly impressive was the CEPDPH's three-year Health Initiative which offers most of the other projects array of preventive health services, as well as teen pregnancy prevention and Hepatitis C follow-up. More than 200 teenagers participated in parenting classes, family planning counseling, and referred for testing of sexually transmitted infections. The Hepatitis C project included partnerships with Federally-Qualified Health Centers and local medical specialists. The program now included the delivery of services through telemedicine for special populations.
The current practice is better in a variety of ways. First, the partners are now able to track client/patient data over time. Secondly, because the HIE data is readily available to all subscribers, clients can be identified relatively quickly preventing a lags in time. Third, the CEPDPH targeted some of its DSRIP/Medicaid Waiver (MW) funds to address this need. The HIE, which was spearheaded and currently led by the Paso del Norte Health Foundation (PDNHF), underwent a multi-year development process, and all of the major health care networks in El Paso have entered into agreements with the PDNHF as partners using the HIE system. The CEPDPH is participating in the HIE by tracking its various preventive medicine services to the community, as well as linkage to care. These services include immunizations, cancer screenings, Hepatitis C (HCV) screenings, screening and treatment for sexually transmitted diseases (STDs), and preventive and restorative dental services. The HIE is equipped with GIS capabilities, making it feasible for identifying hotspots within the region where, for example, infections of STDs and HCV may be occurring at higher rates. The evolution of information technology has created an opportunity for the healthcare industry to provide an improved, lower costing, and efficient patient care system.
In 2014, the CEPDPH developed a trans-organizational system for conducting research and implementing public services through a united front, whereby four service agreements and business associate agreements would then be executed. Early in its inception, the Border Public Health Interest Group (BPHIG) facilitated one strategic analysis of the standard operating procedures across partners to create a functional multi-agency work plan, and subsequently implemented a standardized referral interview instrument to enroll, serve and track clients through, as well for conducting future strategic planning, informing policy, and developing programs to meet the public health needs of the community. This is exemplified through the creation and maintenance of the BPHIG, comprised of researchers from the three major El Paso area academic institutions (University of Texas El Paso, University of Texas Houston School of Public Health, and Texas Tech University) supported by epidemiology services from the CEPDPH. The BPHIG came to fruition through the CEPDPH's Medicaid Waiver program, which currently encompasses six (6) programmatic/research initiatives. The research components of the Medicaid Waiver Program are sanctioned by the Institutional Review Boards (IRBs) of each of the mentioned academic institutions.
Additionally, the CEPDPH's Medicaid Waiver partner - the El Paso Fire Department, operates the Neighborhood Fire Stations for Health Screening/Health Promotion project staff, which has recorded significant progress on patient impact and services, thus helping to improve the health status of participants receiving Medicaid and for participants that are low-income and uninsured. This was accomplished by promoting and providing critical vaccinations and select health screenings through the El Paso Fire Department scheduled clinics. A major undertaking for the Fire Department was the conversion of an older fire station at 5415 Trowbridge Drive to a community outreach facility in order to increase access and expand locations of services. The facility is now aptly named the Safety & Health Outreach Center (SHOC). This facility is centrally-located and is widely-known by community members, which has served to more effectively reach out to them for the use of clinic services.
On another front, New Mexico State University (NMSU) and the CEPDPH are testing the likelihood among Hispanics obtaining a colorectal cancer (CRC) screening by having a mobile app send them periodic reminders and brief prevention messages. The research is being conducted through random selection, with 60 persons in the test group and 60 persons in the comparison group over the course of one year. Moreover, with the support of the CEPDPH, the City of El Paso Fire Department, created a new access point for low-income and uninsured individuals for preventive health services (blood pressure, glucose, and fecal occult blood test, pneumococcal and influenza vaccinations) targeting 1,000 person a year over six years.
Currently, the BPHIG is in demonstration year seven of the projected seven-year plan and is supported by the City of El Paso, collaborative educational institutions, and the CEPDPH's Medicaid Waiver initiative. The BPHIG has made advances in the study of border health issues by analyzing data collected and using findings to develop strategies for successfully connecting persons to preventive health services and a variety of health resources. One example of this success is the use of the CEPDPH's database consisting of about 3,000 records of which investigators identified about 300 participants in need of essential immunizations including tetanus, diphtheria, measles, mumps and rubella. These immunizations were previously not offered because the target population for immunizations consisted of older persons and vaccines were limited to pneumonia and shingles. The address this issue, the CEPDPH integrated the additional vaccines and provided them to 150 participants. Numerous outreach events were conducted to provide services in underserved communities with approximately 141 outreach events completed by BPHIG members. Furthermore, a total of 662 service vouchers for linking participants to cancer screenings and immunizations were issued. The BPHIG also welcomed two (2) new regional partners, they are New Mexico State University and New Mexico Medical Center. These partnerships expand the BPHIG's scope to an interstate collaborative, thus increasing its capacity and expertise on border health.
The program had an evaluation component through which evidence of accomplishment, evidence of completion, and evidence of effectiveness can be measured commensurate with the program's stated goals and objectives. Restatement of goals: A nurtured healthy and sustainable community; improved communication among a network of partners through an electronic messaging application; decreased cost of care as result of improved patient care-coordination; decreased cancer incidence rates, improved informed decision-making processes for public health services, and detection of breast, and colorectal cancer at early stages. The evaluation plan included both process and outcome evaluation activities utilizing universally-recognized methodologies. In particular, the program called for the Plan-Do-Check-Act (PDCA) Cycle as the basis for performing program activities, collecting and analyzing data, and completing an evaluation process. The data elements consisted of key indicators, comprised of the number of partners/stakeholders; percent increase in leveraged resources (in-kind, cash, staffing); the number of partner agreements developed; the number of policies or procedures created, amended, or rescinded; the number of small media coverage; the number of participants trained; the percent of participants trained who reported an increase in knowledge; skills, abilities; and the number of trainings conducted. PDCA is a cycle that begins with planning, including defining specific problems (the lack of skills among staff members in dealing with clients with mental health issues), developing a theory to resolve the problem, setting up performance expectations, and identifying key steps to achieving an intended goal (Tague, 2004). By using this model, the program manager led the staff and partners in identifying key data variables and a united data platform crucial to measuring the success of the long-term strategic plan, and as preparing and analyzing project data for the planning project. This included compiling the data through an MS Access spreadsheet. The staff is well-versed in organizing data using a variety of graphics (tables, pie charts, bar graphs) to represent a collection of data sets. Hard data was organized in a manner that demonstrates a clear picture of how the program is being implemented and what affects it has brought. A narrative was written quarterly to help explain programmatic data sets and the effectiveness and efficiency of the program. In keeping with this evaluation model, the CEPDPH performed both process and outcome evaluation on the proposed program. Process evaluation consisted of bi-monthly project reviews and QI activities in order to identify and describe evidence of fidelity and necessary deviations from the stated activities, whereas outcome evaluation served to identify and describe evidence of accomplishment and evidence of effectiveness. Correspondingly, process evaluation served to make improvements to the program as needed. As for quality assurance, data was shared with partners and will be evaluated to ensure that all program activities and projected outputs and outcomes remain on schedule. Program reports were written using aggregate data suppressing all private information.
On the other hand, outcome evaluation consisted of utilizing evaluation checklist instruments based on the program objectives, as well as one-on-one and evaluation activities with partners in order to answer whether the proposed program was effective and to what extent. Using a program logic model as a basis for data collection and evaluation, the CEPDPH was able to create a spreadsheet to compile, store and submit data for reporting and evaluation purposes to the project officer. As a result of its comprehensive evaluative functions, the CEPDPH's progress reports to funders contain both qualitative and quantitative data, thus demonstrating a well-rounded approach to answering key evaluation, such as What was provided to whom?â€ What outcomes resulted?â€ How did community members respond to the services?â€ and What impact, if any, did the service(s) have within the target community, and to what extent?â€
Lessons learned and accomplishments: Through participation in the Region 15 Regional Healthcare Partnership (RHP)'s Healthcare Data Exchange Learning Collaborative, the CEPDPH was able to connect with other healthcare providers who were interested in 1. health information technology, 2. a secure means to promptly access patient health records, and 3. an efficient method to share health information amongst collaborators. The HIE meetings provided insight regarding opportunities to create an area-wide data exchange system under the regional partnership. Members of the learning collaborative discussed ways to market the HIE and how to garner and assess the healthcare community's attitudes toward the HIE network. A proposed assessment would query both large scale hospitals/health systems and small single-provider offices. Another lesson learned during the meetings pertained to the importance of providing education about how the HIE works and how it can be tailored to meet healthcare provider needs.
To address the concerns of cost for onboarding smaller practices, PHIX contracted with a new vendor to connect with physician practices. In the new agreement, the price of onboarding would decrease while the value to providers would increase as the addition of a quality dashboards would assist with patient care management, risk assessment, and quality-measure evaluation. There were two costs associated with onboarding smaller practices to HIE, 1. the HIE vendor costs and 2. the EHR vendor costs. In comparison to other HIE vendors, the HIE vendor cost of the new merchant was significantly lower. The EHR vendor costs were also eliminated for many practices as the new vendor's product was able to centralize data from approximately 40 EHRs without generating additional costs.
As part of the MW program's commitment to improve quality of care via the interchange of timely, reliable, and relevant health care information, the staff was actively involved in continuous quality improvement activities. MW staff conducted follow-up calls to offer participants with additional services that were not previously received. During these calls, personnel also received feedback that would assist with project improvement planning. Furthermore, the addition of a new Compliance and Quality Assurance Assistant would support the MW program with conducting project audits to ensure compliance with state and federal regulations. Finally, as an active participant in the RHP 15 meetings that addressed data exchange concepts and the future of health information technology, the team learned about the importance of collaboration for a seamless healthcare data transmitting system in El Paso and Hudspeth counties.
The sustainability of efforts will be realized by implementing a multi-pronged approach as follows.
Policy and systems: The CEPDPH is dedicated to ensuring that its policies and systems remain conducive to addressing the community's public health needs through empirical data gleaned from periodic and sustained needs assessments designed for identifying health disparities. Joint planning: through the network of partners, efforts will be sustained in the coming years by continuing coordinated planning efforts that maximize the use of HIE across the partners.
Fiduciary viability: The CEPDPH is currently exploring the possibilities of creating a fee-for-service for its preventive health services that are currently afforded through federal funding. This will entail having the CEPDPH register as a Medicaid/Medicare a provider and private and accept private insurance.