Safety Net Hospitals and Primary Care: Challenges and Opportunities Under Health Reform
Mitchell Katz, MD, Director, LA County Health Department
Safety net hospitals, whether governmental or non-profit, are those with large shares of uninsured and underinsured patients. Traditionally, most have focused on emergency and inpatient to meet the needs of patients who have been uninsured and who often present with late stage disease because
they haven’t had good primary care. Often these hospitals have been the major teaching centers and provided expensive services such as trauma centers and burn units. The Medicaid expansion and development of health exchanges as part of the ACA have challenged safety-net hospitals to focus more on providing primary care. Although a switch to primary and other forms of ambulatory care is necessary, it requires major transformation of most safety net hospitals. Strategies for developing patient-centered primary care homes, sufficient ambulatory specialty care access to support primary care, and managed care infrastructure will be discussed.
Mitchell Katz, MD, Director, LA County Health Department
Dr. Mitch Katz is the Director of the Los Angeles County Health Agency, a newly created agency that combines the Departments of Health Services, Public Health, and Mental Health into a single entity so as to provide more integrated care and programming within Los Angeles. The Agency has a budget of 7 billion dollars, 28,000 employees, and a large number of community partners. For the past five years Dr. Katz served as the Director of the Los Angeles County Department of Health Services (DHS), the second largest public safety net system in the United States. During this time, he created the ambulatory care network and empaneled over 350,000 patients to a primary care home. He eliminated the deficit of DHS through increased revenues and decreased administrative expenses, and used the new ACA funding to pay for a modern electronic health system, Orchid, which has now been implemented in 90% of DHS clinical sites. He has moved over 1000 medically complex patients from hospitals and emergency departments into independent housing, thereby eliminating unnecessary expensive hospital care and giving the patients the dignity of their own home. Dr. Katz continues to see patients every week as an outpatient physician at Edward R. Roybal Comprehensive Health Center and sees patients on the inpatient medicine service at LAC+USC, Harbor-UCLA, and Olive View-UCLA Medical Centers.
Before he came to Los Angeles Dr. Katz was the Director and Health Officer of the San Francisco Department of Health for 13 years. He is well known for funding needle exchange, creating Healthy San Francisco, outlawing the sale of tobacco at pharmacies, and winning ballot measures for rebuilding Laguna Honda Hospital and San Francisco General Hospital. He is a graduate of Yale College and Harvard Medical School. He completed an internal medicine residency at UCSF Medical School and was an RWJ Clinical Scholar.
He is the Deputy Editor of JAMA Internal Medicine, an elected member of the National Academy of Sciences (previously the Institute of Medicine) and the recipient of the Los Angeles County Medical Association 2015 Healthcare Champion of the year.
Global Refugee Crisis to Local Health System Response: Directions for Primary Care Research
Fern Hauck, MD, MS, University of Virginia
Mark Harris, MBBS, MD, FRACGP, University of New South Wales, Australia
Kevin Pottie MD, MClSc, CCFP, FCFP, University of Ottawa
Kim Griswold, MD, MPH, FAAFP, University at Buffalo, State University of New York
The number of people displaced by war, conflict or persecution has hit a record high—close to 60 million worldwide, with 20 million of these being refugees. Most face an uncertain future. Those who are resettled to a developed country are among the lucky ones. Nonetheless, they face many challenges in their new home, including accessing culturally sensitive health care. From the perspective of health systems and providers, caring for refugees pose many challenges beyond the more obvious one of language differences. In this plenary, we will describe the scope of the international crisis and challenges in providing medical care after resettlement, the research landscape for refugee centered primary care, evidence-based guidelines for migrant health policy, mental health assessment and treatment, and how primary care and public health can collaborate with other disciplines to study refugee health, health care and wellbeing.
Fern R. Hauck, MD, MS is the Spencer P. Bass, MD Twenty-First Century Professor of Family Medicine and Professor of Public Health Sciences at the University of Virginia. Dr. Hauck’s medical degree is from St. Louis University School of Medicine and her residency training was conducted at the Maine-Dartmouth Family Practice Residency. She received postgraduate research and health policy training through the Robert Wood Johnson Foundation Family Practice Faculty Development and Research Fellowship at Case Western Reserve University School of Medicine, the Centers for Disease Control and Prevention’s EIS Program, and as Senior Scholar in Residence at the Agency for Healthcare Research and Quality, Center for Primary Care Research. Dr. Hauck has considerable global health experience and maintains an active interest in this area. She has worked in Southeast Asia, Africa and the Caribbean, including a year as a refugee camp doctor on the Thai-Cambodian border. In October 2002, Dr. Hauck founded the International Family Medicine Clinic in the University of Virginia Department of Family Medicine, which she continues to direct. In this clinic, she and colleagues provide comprehensive primary health care for the growing number of refugees in central Virginia. Dr. Hauck has developed curricula in cultural competence and global health for medical students and residents, including establishing a multidisciplinary Global Health Leadership Track for several residency programs in the UVA Medical Center. She is involved in ongoing research in refugee health, healthcare access and quality improvement. She participates in several local and international organizations related to global and refugee health.
Mark Harris, , MBBS, MD, FRACGP is foundation Professor of General Practice and Scientia Professor at the University of New South Wales, Australia and Executive Director of the Centre for Primary Health Care and Equity there. He is a fellow of the Australian Academy of Health and Medical Sciences. He has conducted extensive research in the prevention and management of chronic disease and health equity in primary care over 30 years. He has worked as a volunteer clinician with the Sydney Asylum Seekers Centre since 2000 and was awarded a humanitarian award by the Refugee Council of Australia in 2010. He is currently conducting research on refugee primary health care in Sydney as part of the Optimise project which is led by Monash University.
Kevin Pottie, MD, MClSc, CCFP, FCFP is an Associate Professor and practicing physician at the Departments of Family Medicine and Epidemiology & Community Medicine, Bruyere Research Institute, University of Ottawa, Canada. He led the Canadian Evidence Based Refugee Guidelines in 2011 and is a currently leading the 35 country European Centres for Disease Control Guidelines for Migrant Children and Adults. In 2013, he won the Canadian Geeta Gupta Equity and Diversity Award for outstanding leadership for minority populations. In 2016, his CMAJ guideline: Caring for a Syrian Refugee Family won various awards. Kevin Pottie has served on the WHO Guideline Review Committee (Geneva), the Canadian Task Force for Preventative Health Care, the GRADE Working Group and the Cochrane Equity Methods Group. He has also held refugee health field positions, notably, Republic of Georgia 1995 (MSF), Republic of Congo 2007-08 (MSF), and Lebanon 2013 (Syrian NGO). He has published over 100 peer review papers.
Kim Griswold, MD, MPH is an associate professor at University at Buffalo’s Jacobs School of Medicine and Biomedical Sciences with appointments in family medicine, psychiatry, and public health and the health professions. She trained as a nurse before going to medical school and has a long-standing interest in the primary care of underserved populations. She began working with refugee and immigrant populations in the 1980s. While in medical school, she worked as a nurse at VIVE La Casa, the largest residential facility in NYS for asylum seekers. In her primary care practice she cared for refugees on the lower west side of Buffalo. Kim is particularly interested in the cultural expression of mental health and/or illness in diverse populations. Currently, with her Nurse Practitioner colleague, she provides integrated primary care to a population with serious mental illness, and is the medical director of the WNY Center for Refugee Survivors of Torture, through grants from the NY State Health Foundation and the Office of Refugee Resettlement to Jewish Family Service.
East of Last Chance: Finding Research Paradise on the High Plains
Jack Westfall, MD, MPH
The High Plains of eastern Colorado have been referred to as a dwindling remnant of the “worst hard time.“But eastern Colorado is much more than the crop circles and dusty dirt roads one sees from a 30,000 foot flyover. The vibrant life of rural community members is evident in their downtowns, coffee shops, health care, and schools. Rural communities have been discovering innovative local solutions to local problems for centuries. To experience those solutions takes time; windshield time, listening time, kitchen table time, friend time. How you spend your time is a choice. The High Plains Research Network’s job is to spend time with people in eastern Colorado, engaging local residents to find solutions, and help make these solutions usual care. We have found paradise on the eastern plains of Colorado. Where is your research paradise? Thou mayest.
Jack Westfall, MD, MPH is a family physician in search of rural goodness. Jack grew up in a small town on the windy plains of eastern Colorado. After attending medical school at the University of Kansas, he completed his family medicine residency at Rose Hospital in Denver, and joined the faculty in the CU Department of Family Medicine. With support from the Robert Wood Johnson Foundation, he started the High Plains Research Network, a geographically-based, community and practice-based research network in eastern Colorado that continues to address health issues important to the communities. An engaged Community Advisory Council of farmers, ranchers, teachers, and students guide the work of the High Plains Research Network. Dr. Westfall firmly believes that access to healthcare is a right, and he works fervently to integrate primary care, behavioral health, and community organizations into local communities of solution. Dr. Westfall spent 2.5 years as the chief medical officer for the Colorado HealthOP non-profit cooperative. He is now back full-time at the University of Colorado School of Medicine working on engaging rural and urban underserved communities to find and create local solutions for local problems.