A Report on the Second Year of the San Mateo County Adult Coverage Initiative and Systems Redesign for Adult Medicine Clinic Care

A REPORT ON THE SECOND YEAR OF THE SAN MATEO COUNTY ADULT COVERAGE INITIATIVE AND SYSTEMS REDESIGN FOR ADULT MEDICINE CLINIC CARE Submitted to The San Mateo County Health System by Embry M. Howell, Urban Institute Dana Hughes, University of California/San Francisco Sarah Benatar, Urban Institute Ariel Klein, Urban Institute Ashley Palmer, Urban Institute Genevieve Kenney, Urban Institute May 2010THE URBANINSTITUTETHE URBANINSTITUTETHE URBANINSTITUTE iExecutive Summary Since early 2008, San Mateo County has undertaken a comprehensive health systems redesign initiative to expand adult health care coverage. This effort is intended to improve access to high quality care for uninsured and underinsured adults and improve the financial sustainability of the San Mateo Medical Center (SMMC) and related delivery systems. This report summarizes the findings from the first 18 months of the Urban Institute’s four-year evaluation of these efforts. Health systems redesign in San Mateo County includes four components currently being phased in at primary and specialty care safety net clinics across the Health System and in partnership with Ravenswood Family Health Center: • Team-based care to increase efficiency and leverage physician time through the use of other health professionals, such as nurses. Patients are seen by the same physician, nurse, and clerical staff team each time they visit a clinic. • Disease management, primarily focusing on diabetes management, including an automated diabetes registry, group visits where diabetes patients learn about self-management, and the use of diabetes retinal cameras to do on-site screenings. • Advanced Access scheduling to improve patient flow and reduce waiting times for appointments at select clinics. Such an approach allows more patients without an appointment to be seen. • Electronic medical records (EMRs) to increase efficiency and coordination of care. Some of these changes have been implemented to date. EMR implementation is the most widespread change and has been completed in all SMMC primary care safety net clinics as of the close of 2009. Adult coverage expansions started in September 2007, when the county received a three-year grant of $7.5 million annually from California’s Medi-Cal Hospital Financing Waiver. The county used these funds to expand the public coverage program that provides coverage for uninsured adults whose income is less than 200 percent of the federal poverty level. The program was later renamed San Mateo Access and Care for Everyone Program (ACE). The evaluation reveals strong progress along several dimensions where the redesign efforts and coverage expansions are achieving intended results: • Focus group interviews and patient surveys show high satisfaction when care is received from safety net providers. • Clinic staff report improved clinic operations and an increased focus on providing high quality primary care. • ACE enrollees experience dramatic increases in having a usual source of care (48 percentage point increase) and in having a particular doctor or other health care provider they usually see at the usual source of care (51 percentage point increase). • They also experience increases in having a doctor visit in the past 12 months (28 percentage point increase) and, for those with chronic conditions, receiving routine care for their condition (36 percentage point increase). ii• ACE enrollees’ improved health is reflected in a reduction in the proportion who reported having any days within the past month when their activities are limited due to physical or mental health problems (6 percentage point decrease). Claims data from the Health Plan of San Mateo, the ACE administrator, provide additional evidence of adequate care while enrolled in ACE: • Among those enrolling in the first year of the program, 83 percent of ACE enrollees have at least one ambulatory care visit during their first year of enrollment. • HEDIS measures show that ACE exceeds performance standards on almost all areas of diabetes care management. In addition, the report highlights several challenges to improving care for low-income adults. The greatest challenge facing SMMC during 2009 was a large increase in demand for services as a result of the recent recession. Enrollment in the county-sponsored coverage program, ACE, doubled between January 2008 and December 2009. During this same time frame there were limited increases in the capacity of the county’s safety net clinics, resulting in long waits for clinic appointments. The evaluation revealed several other indicators of these capacity constraints: • Focus group participants, as well as “secret shoppers” hired by the county, report severe difficulty getting appointments. • Clinics experienced reduced appointment availability just after implementing the EMR during 2009. • Preventive care use was low, while the proportion of enrollees with emergency