NIH CLINICAL CENTER GRAND ROUNDS
Episode 2009-010
Time: 1:01:58
Recorded March 18, 2009
"Post-Katrina Health Care: Present Status and Future Considerations.”
Dr. Keith C. Ferdinand, chief science officer, Association of Black Cardiologists, and clinical professor of cardiology, Emory University
“Recovery and Rebuilding the Safety Net Post-Katrina.”
Dr. Karen DeSalvo of Tulane University School of Medicine
ANNOUNCER: Discussing Outstanding Science of the Past, Present and Future – this is NIH Clinical Center Grand Rounds.
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ANNOUNCER: Greetings and welcome to NIH Clinical Center Grand Rounds. Today, two speakers will discuss how Hurricane Katrina has affected health-care delivery in the New Orleans area. First, Dr. Keith C. Ferdinand, chief science officer of the Association of Black Cardiologists and clinical professor of cardiology at Emory University will take on the topic: "Post-Katrina Health Care: Present Status and Future Considerations." He will be followed by Dr. Karen DeSalvo from the Tulane University School of Medicine who will discuss "Recovery and Rebuilding the Safety Net Post-Katrina."
We take you to the Lippsett Ampitheater at the National Institutes of Health Clinical Center in Bethesda, Maryland, where Dr. Frederick Ognibene, Director of the NIH Clinical Center's Office of Clinical Research Training and Medical Education, and Director of the Clinical Center's Clinical Research Training Program, will introduce today's first speaker.
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OGNIBENE: Good afternoon and welcome to today's grand rounds. Our speaker will present on the aftermath of Hurricane Katrina. It was a very tragic event with far-reaching and long-term consequences particularly in the areas of health care and its aftermath. A number of the staff from the NIH were very engaged in the acute events and the recovery. I know you will join me in welcoming our speakers to talk about the lessons learned.
Presenting first is chief science officer to the Association of Black Cardiologists and the clinical professor of cardiology at Emory University and also director of cardiovascular health at the St. Thomas Health Center in New Orleans. And prior to Hurricane Katrina, he was medical director of Heart Beats Life Center and professor of clinical pharmacology at Xavier University, a New Orleans institution impacted very heavily by the storm. Dr. Ferdinand is also the author of a newly-published book, “Overcoming Katrina,” which tells the story of 27 African-American residents of New Orleans that fought to survive the storm and its aftermath. He received his bachelor's of science degree from the University of New Orleans and MD degree from Howard University College of Medicine. He completed an internship of the New Orleans Hospital and residency in internal medicine at the state medical center and completed a cardiology 2 fellowship at Howard University Hospital.
Presenting next is dr. Karen DeSalvo with the Tulane School of Medicine, the vice dean for community affairs and health policy and serves as chief of general and internal medicine in the geriatrics section and holds the C. Thorpe Ray Endowed Chair. She has been an active leader in the health sector recovery since Hurricane Katrina. She received her bachelor's degree from Suffolk University in Boston and earned her MD degree along with a master of health. She remained at Tulane and was a fellow at Harvard University and earned a masters degree in clinical epidemiology there. Her research and policy interests focus on improving the quality and effectiveness of care particularly among vulnerable populations. Her research demonstrated the value of patient's perceptions of health and risk stratification and prediction tools. We will have them both speak and have plenty of time afterwards for questions from the audience. First is Dr. Ferdinand.
FERDINAND: This is a wonderful opportunity and I have to thank a few people before I get started. John Gallin, the director of the Clinical Center, the great organizer of this event, although he said it was his staff, and not he. Admiral David Rustein and I just met Admiral Carol. We also met with the officers of the corps who were able to come 3 to Louisiana post-Katrina and remain engaged in the recovery and we appreciate that. And my friend from the organization of cardiologists who firsthand visited New Orleans and is aware of the impact on the health care infrastructure and the people of that area. I’m going to discuss the post-Katrina health care in New Orleans and show you a few scenes. I know most of you are aware this is an on-going process and I want to revisit some of the things that happened very briefly. I’ll describe the affects of hurricane Katrina, the disruption and damage to the health care infrastructure and some of the positive efforts. Some of my work has been with the St. Thomas Health Center, a non-for-profit inner-city clinic in uptown New Orleans, one of the first to open post Katrina, and I’ll show you some of the growth. And I’ll discuss very briefly the Association of Black Cardiologists Health Outreach Prevention and Empowerment Program called, “HOPE”. It's a program which I initiated when I fled to Atlanta. People asked what they could do to help. Funds were given to our association and we distributed those to New Orleans.
This is a map of New Orleans. It bends here, hence the term, Crescent City. This area here, which is light gray, is where he French Quarter and uptown areas of New Orleans were. They were not heavily flooded. Most of the areas in dark red were flooded. This large area here is called New Orleans East because it is to the east of the industrial canal. And it is at the industrial canal where you had one of the major breaches in the lower Ninth Ward.
I’m a child of the lower Ninth Ward. I was raised in the segregated south. I was educated and nurtured there. One of my life goals was to come back and service my community so I had a clinic on this side of the industrial canal, we were damaged and essentially have not been able to rebuild. This is downtown New Orleans. This disk is the roof of the Superdome where people had been housed as the shelter of last resort. The Convention Center has been fixed and many of the areas outside of the center remain heavily damaged. This is the breach at the levy. This patchwork should be housing in a very organized fashion. Wherever you see these dark areas, these were houses that were washed away. There is some redevelopment but to a large extent, this largest black community in New Orleans remains a desert.
The key findings from Louisiana Health Care Delivery Financial System post-Katrina -- and I mention these to show you where we come from. At the time of Katrina, because of the large nature of this most unnatural disaster, our command structure was fragmented, inadequate evacuation. Many of the people who remained didn't have housing because of the large service industry in the hotel/motel convention business. People who catch buses to Canal Street serve and work in the hotels and then bus themselves back home and didn't have adequate transportation and there was no uniform way of doing that. Absence of uniform electronic health records. I think this is important for the nation.
People showed up in Atlanta, Dallas, Little Rock with very serious medical conditions and all they could tell the provider was, I was on a white pill, blue pill, yellow pill. We didn't proactively do personnel deployment. I’m aware the corps is actively engaged so that this doesn't happen again and even recovering dead bodies. The truth is, the official death count was stopped in October of 2005. I was in New Orleans in April of 2006 and saw the recovery of two young children in the lower Ninth Ward. So the official body count was anywhere from 1550, to 1560. We are convinced it goes much beyond that. The physicians who stayed and struggled were working in an arena in which we can't predict what they saw. One physician was indicted for murder. She was subsequently relieved of the charges and there still is an effort to try to blame clinicians for what happened for the collapse of the health care infrastructure and I think it's inappropriate.
This is an alternative weekly, March of 2007. This is a person with their head held in their hands. The mental health stress of undergoing such a large disaster, 1,500 plus deaths in a city which is quite small, is a huge burden and looking at the landscape and how it's changed, many people are still having difficulty when they return and try to cope. At that time, primary care was a huge burden. Karen will share good stories and I will also, the primary care delivery system is being built although it's not coordinated at the level we would like to see. Local emergency room still board mental health problems. There is a deficit in psychiatric beds.
This is a quote from our friend, David Meyers in 2007. If you lived in certain areas outside of the center of this city, this quote probably still remains appropriate. I’m telling people, don't bring your parents back if they are sick.
So where are we now? This is as of today. Plaquermans Parish, the tip of Louisiana as it goes into the gulf is an isthmus. Has no inpatient facilities. Saint Bernard Parish, a sizeable area, outside of the lower Ninth Ward has no inpatient services. 7 part of my life experience was being a member of the Louisiana state board of medical examiners. Licensed physicians, respiratory therapist and other health professionals. I was able to get these data. Looking at the physician workforce in Orleans Parish in the St. Bernard Parish, you can see St. Bernard was small in terms of physician size before august 2005. They had almost no significant recovery posts. The New Orleans physician addresses, you can see the big drop-off post-Katrina. There has been some recovery but the numbers are still down. However, the census of New Orleans went from a high of 453,000 to as much as 250,000. Although there has not been an uptake of the last year or two in New Orleans. It somewhat plateaued. So the census is down but the number of physicians is down such that the number of physicians per person in the Orleans Parish area remains very similar. And this is showing it is down somewhat from post-Katrina, but you can see it came back up in 2008.
Now, why did it come up? One thing is that the medical centers have essentially rebuilt and many students are motivated to rejoin the medical center at Tulane and LSU. Many of the physicians now are located downtown in the medical center. If you go into the Ninth Ward in New Orleans East, you go into some other areas that are far 8 away from the rebuilt areas, you still have a disproportion degree of primary and specialty physicians. These are the hospitals that are within Orleans Parish, our name for county. Children's Hospital is in uptown New Orleans close to Tulane and was not heavily damaged since it's close to the river, and I showed you demographics, the population and flooding. It's close to the river where most people now live.
University Hospital, which is serviced by Tulane and LSU, and is uptown, and Tulane Hospital itself. One of the questions is, what we will we do in the future? Louisiana State Board of Medical Examiners passed an emergency rule. There is a permit that anyone who wants to volunteer, and this doesn't apply to federal employees or members of the corps, but private citizens who are health professionals who want to volunteer, can fill out a volunteer services form, an agreement between the state of Louisiana and the person who is referred to as a volunteer.
If you revisit this map, and I suggest to you downtown, the sliver by the river, was an area which topography said that over the centuries had built-up. This was the area that the river slowed and I’m sure the waters as they spilled over, became somewhat higher. This is where most of the health care is now structured. If you go out to the lower Ninth Ward and you can see the size there. It was huge. When people visit, they are surprised. They thought this was some little enclave where African-Americans resided. When I was a child, it was up to 40,000 people and it was a bustling neighborhood with schools, churches, et cetera. Or go out to New Orleans even. This huge area where much of the black middle-class life, these areas still are inadequately served.
One of the questions that has arisen is, should we go to New Orleans East and build a hospital? And there are various answers to that question. Thomas is professor and chairman of community health sciences at Tulane and he wrote an editorial this year and had some questions that need to be answered before we rebuild a hospital for inpatient services. Question number 1, will the hospital make enough money to stay afloat? There is actually some degree of a disservice that is made to any private hospital services in New Orleans because they have to taken the heavy amount of uninsured persons and the undocumented immigrants who have come and done an excellent job to help and clean and rebuild America. One of the problems is, when those people come for emergency service and follow-up services, they have no health insurance. The hospital then has the problem of an uninsured population. The second problem is, Louisiana doesn't just have a deficit of beds. You can make the case, we always had enough hospital beds. We have a deficit of primary care and prevention.
We and Mississippi fight from year to year in terms of mortality rate. 49th in mortality rate including child and adult disability and death. Our per capita spending has been equal to the national average and twice that of Canada. And the leading causes of death are crime and diseases. Cardiovascular disease, cancer and diabetes which can be prevented or delayed by appropriate utilization of healthy behaviors and preventive medical services. So just building inpatient beds even in New Orleans East and the Ninth Ward wouldn't be the answer to the disparities we see in health care there. That being said, Methodist Hospital located in New Orleans East, there is an effort to set up a 80 -- 80-bed taxpayer and borrowed funds facility.
There is a concern that more hospital beds means more costly services and lower-quality. We are going to address this as we attempt to rebuild the health care infrastructure. New Orleans East is heavily populated when compared to some of the neighborhoods because of its size. There are 85,000 people and perhaps as many as 95-1 100,000 as we speak. New Orleans health department from the director, Dr. Stevens desires to have funding for violence prevention. Many of the young adolescents returned without supervisors. They are under educated and unemployed and sustain criminal activity. That's what they do on a daily base. He would like to fund youth summer programs and I would suggest that the youth summer program would take into account vocational training so these young men have other outlets. 40 million dollars for the methodist hospital. My last conversation two years ago is this probably is going to become a reality. Primary care clinics and renovation for the delivery of services. Let me spend the last 5 minutes with the St. Thomas clinic. This was a very small setting in uptown New Orleans in what was called the St. Thomas housing project since been raised. And faith-based organizations and volunteers founded the St. Thomas clinic. It now is a private 501(c)3 supported activity and has become one of the success stories of New Orleans. The clinic, because it's located in uptown close to the river, was not heavily damaged during the storm. And it was one of the first clinic to open and see patients as the city repopulated. The mission of the health center has been to provide culturally confident health care regardless of the ability to pay, achieve community health-driven, health initiatives. New patient populations are burdened by the heavy influx of temporary laborers without insurance. 12 and there are persons still who aren't able to find their positions. We have residents from LSU who are proceeding with their medical training and St. Thomas is known throughout the region as an LSU brisk center. They brought digital mammography to the area post-Katrina and many providers will send people there for screening. They also have sub-specialty care clinics no more than once or twice a day. The they provide fellows for service on Friday afternoon to rheumatologists, gynecologists, eye exams, pulmonary, and EMT are all available. It's been designated as a mental health resilience center.
This is not what the psychiatrists who help people with counseling says posttraumatic stress remains a primary problem. I already mentioned their landmark breast digital mammography screening that is being done there. One of the successes of St. Thomas is the multiple grants, including the Bush-Clinton Katrina fund, Episcopalian church, social services block grant, Association of Black Cardiologists, where I’m chief science officer, primary care access and stabilization grants and Avon and Komen and Blue Cross Blue Shield. It's a model for care. We were able to place cardiac ultrasound there. We have interventions for low cost for those who are uninsured and digital mammography proceeds as we speak. They have two primary care physicians, 3 nurse practitioners and 14 contract employees who do sub-specialty care.
These are the services. Here are the demographics primarily African-American although a demographic shift in New Orleans and much of the middle-class never returned. The teachers were fired post-Katrina. Many of the government workers never returned and many physicians in the private sector because of the financial and psychological stress have been unable to rebuild. The age, many uninsured persons don't have Medicare unless they are disabled. The gender, typically don't seek care until they are sick or have a problem, males. And the monthly visits are starting to grow, 2007, 2008. And the burden of uninsured status is 75% of their patients. This is disproportionate to the area. It may be as much as 25% in the general area but because of St. Thomas's mission to serve those who are uninsured, they have a disproportion of a mix. ABC HOPE is the program that the Association of Black Cardiologists initiated. We raised and distributed over $400,000 in funds and part of ABC HOPE was to fund an oral history report from 27 African-Americans forwarded by Jimmy Carter who sees this as a human rights issue. It's called, Overcoming Katrina any funds from this work will be given right back to the Association of Black Cardiologists who will distribute them. Thank you very much.
[applause]
FERDINAND: I will now introduce my partner in crime. I’m LSU and she's Tulane. I don't hold that against you. Karen DeSalvo has been known throughout the Orleans area in public health serving the under served and rebuilding the infrastructure of New Orleans. She is the chair of internal medicine in geriatrics but a street physician and she treats people wherever they are, whatever is their stage in life. Dr DeSalvo's slides should be coming up next.
DESALVO: Thank you very much. And thank you again for having us here today. It's been a terrific evening and morning and it's a great chance to tell you not only what happened but where we are.
I’m going to speak about the recovery and rebuilding of the safety net in particular after Hurricane Katrina. And focus on three main areas. One is just to make sure that we describe the impact on the safety net because the safety net is probably a little bit different than you might have imagined in your head. I also want to share the story of the acute response which was aimed at providing services and standing up to health sector with support from the public health sector service and federal resources as well and describe how that was as viewed through my eyes. And certainly I want you to appreciate how early responses led to meaningful changes in the infrastructure including 15 on-going federal support that helped us leverage the little bit we have gotten -- or a lot from philanthropy.
The flooding in the city, the real story here for us, because the storm comes and goes but the flooding leaves quite a bit of damage behind and that has been one of the reasons we had so much trouble getting back on our feet. The safety net system of our city was really the linchpin of that was the charity hospital system which was in downtown New Orleans and as you can see from this image, this is the building behind it and some people wading through the water. It was actually in a flooded area and all of the clinics for the safety net system predominantly for the city happened downtown at this site in adjacent buildings. The University Hospital campus also flooded. And importantly, the two medical schools are located adjacently to the charity hospital system. The workforce for charity hospital and the clinics that operate in tandem with it, predominantly came from those two medical schools. The VA is just across the street and it was flooded as well leaving a boat behind after the water receded that had been used for -- not really parking but for evacuations.
For our standpoint at Tulane School of Medicine, we had to figure out what to do next. All of the buildings where we worked and saw patients and did our research and taught students were flooded and closed and stayed that way for some period of weeks. At least under water. We didn't reopen for example the School of Medicine at Tulane until March of 2006 at which time the first floor wasn't really open and we didn't have climate control or internet or phones. So technically, we didn't open until July of 2006 when the medical students were ready to come back. Something about medical students and their power to get a University moving.
But nonetheless, in the meantime, we had to find a place to go and we were hosted in Houston by Baylor who had their own experience with tropical storms and let us set up shop for teaching and for is some research and administration, importantly.
The goals of the administration were first of all, in case you didn't know this, we lost our server. And so we had no idea who worked for us and how much they got paid and those sorts of things. We had to actually reconstruct our university. But we also wanted to get back to the core business of what we do, especially for the School of Medicine, which is training and teaching of health professionals and we also wanted to get the faculty and our staff back to work, not only for a sense of normal see but also because it's important for them to be together to support each other and feel like they are doing something meaningful with their day. And of course it's no small issue you worry about being financially solvent.
There is an added sense of community responsibility that our senior leadership, especially my president, honed in on right away. That was the fact that we are the largest employer in New Orleans and so we have a business responsibility to the community to get back up because we not only employ folks but then the businesses around us are dependent. When we reopened the undergraduate campus in January of 2006, the population of the city rose by 20% overnight. We also felt a strong service to our patients’ responsibility and didn't want to just have to do that remotely but trying to sort out how to get back to work in our own facilities as quickly as possible.
This is University Hospital which is operational now. There was a lot of confusion about where we were. We did work on the street. First we made t-shirts because that's what all people do when they are trying to form a team and the t-shirts said, doctors without hospitals. It didn't say without clinics. We realized that we needed to do something more creative and get back to work. And I say we, it was really -- this was in the minds and the hearts of our trainees in particular who were the shining stars of this recovery effort. This is photographs of two of the ring leaders. There were others from the Tulane medicine pediatrics training program who worked and trained in this safety net system of downtown New Orleans. Around September 10 they landed in Baton Rouge at the emergency operation center there. Were dissatisfied with what they were given to do in Baton Rouge and decided to jump on an ambulance that was going to New Orleans and go around town and figure out what needed to be done and how they could help. And they did just that and they found that there were 50 responders in need but there were citizens being pulled out of their house whose had not evacuated. These were people who were the sickest of the sick and poorest of the poor who hadn't wanted to leave for a variety of reasons. When they were evacuated from their homes they were in pretty dire shape with respect to pulmonary disease and diabetes.
This is at the end of -- it's an open-air ferry landing site where they set up shop and were seeing as many as 150 people a day, many first responders. Quite creative in the places they found to work. They did it in partnership with the police. So sometimes they were in police stations if they weren't flooded. Sometimes they were in the tents police set up to service themselves or sometimes they just found an open-air spot. And there was a time when we were seeing as many as 400 visits a day and doing quite a number of things, as you can see, including IV infusions for first-aid responders and other folks. 19 I’ll just tell you quickly what we saw looking back at the data we kept at the time. I think many of you who worked in that area would recognize these statistics. Mostly middle-aged men. About a third relief workers, a variety of other people coming and going. We saw a lot of dermatologic issues and upper respiratory diseases. We saw quite a bit of medication refill requests because of the people who had chronic disease and in fact, people just really came in because they needed information about where to go or how to find their doctor or if the water was safe and they also just wanted to get their prescriptions refilled and sometimes all they knew it was blue and not much more than that. We had quite a bit of support and in fact, the first thing we ran out of was prescription pads. We didn't have enough of those to go around. But we certainly benefited from the large donations and supplies. I still have some of the durable medical equipment and supplies in the clinic.
This is a picture of the military dropping off supplies at the Covenant House site. We had a great amount of planning support. This was by my estimation, one of the most important first steps that was taken by the Public Health Service was to form what we called for awhile, the 9:00 meeting where people came together from all walks of 20 life who were interested in standing up, the health care sector in the city. It's one thing to write prescriptions and try to figure out what the rash is. It's different exercise to stay in hospital and get 911 going again and figure out how to do more complex care like evacuate burn patients, for example. We had support for things that we didn't know existed like d mats which was an entirely new resource but now we are familiar with them and thankful for them.
We did try a couple of different varieties of temporary hospitals. We had the USNS Comfort come in support for a few days and it was the most coveted place to work by everybody who was volunteering on the street because it had air-conditioning and a large-screen tv and a cafeteria which was a bonus. Everywhere else you got to be assigned was generally open-air without any electricity. We did have tent charity hospitals and this is an interesting story but it is now part of our lore and saga. You can't do this with temporary sites on the street, even though it was possible, we needed more sophisticated levels of care and without any hospitals in which to work, we were relied upon with what turned out to be the military binging in resources. And it became a temporary charity hospital for a time inside of the convention center and in spite of what some people, Tulane and LSU did work closely together on the street, as you can see in this picture.
This is the LSU emergency medicine folks who ran that tent hospital. We were referring people back and forth between our community clinic tent sites and the tent hospital in the convention center. Eventually, we started to clean up and looked forward to getting on with the business of really creating a health care system and not just doing something temporary. The looking forward was something that started in very early October. This was something that was initiated by the CDC and Public Health Service to help us think about whether we wanted to rebuild what we had or if we wanted to maybe think about doing something different.
And I’m going tell you a little bit about why we would even consider doing something different, though Keith has mentioned it. The opportunity is obvious. We had a clean slate.
So, on the one hand we had nowhere to work. We were doctors without hospitals or clinics but we could really take opportunity from this tragedy and rebuild a modernized system not only with information technology support, so replace our paper records with electronic health records, for example, but really build a system that was in a vision of what people would really want to have if they could have the choice. And in fact, this vision of a person-centered health system that is value-driven, sustainable and accessible to all of Louisiana is the vision statement we ended up with but it comes from the thinking of the Institute of Medicine. It was our chance to rebuild on this clean slate.
Why do something different? If you don't know, you're not reading the newspaper. Louisiana is unfortunately a state that is always ranked last in many categories. We have in the Medicare population, for example, the worst documented quality of care for that population at the highest cost. We also have poor health outcomes as ranked by just about any measure you can figure, whether that is death from diabetes or smoking rates or health literacy. We have a very high risk population. We have a lot of poverty in our state. Our population has high rates of poor literacy. We suffer from significant health disparities, not only because we have a higher proportion of minorities, especially New Orleans, but they are more aggravated when it comes to death from cancers and chronic disease. And our population has a pretty high burden of chronic disease.
So people had poor access to care for a lot of reasons, one of which is we had low rates of insurance coverage in Louisiana, not the worst in the country, but some of the worst. And part of the reason for that was because we had historically used our public hospital system, the charity system for the care of the uninsured who instead of using federal dollars to provide Medicaid coverage, for example, we had put it into a pool that was covering the uninsured. So our safety net system had been this financially and geographically centralized system. Katrina, therefore, really exposed those frailties in the safety net system because it was all downtown. When it flooded, the physical building was knocked out for 14 months, actually they were not able to reopen University Hospital but all the associated clinics we really had significantly less capacity than before. And also financially because the money flowed into that hospital. So when the hospital wasn't open to work, there was nowhere for the money to flow.
So, there was a lot of confusion about how you would keep delivering those services and in fact if the clinic like St. Thomas or the other ones were open and seeing those same patients, how could we redirect that money? We never really figured that the out in 3 1/2 years though we had several proposals on the table. The redesign we chose to do was to create a system that was more flexible for disaster and one that was much more distributed financially and geographically. We have been doing a lot of planning.
This is a full-time job pretty much in Louisiana post-Katrina. But it has been an unusual circumstance partially because in those early days, we really didn't have our normal jobs to do and we were not working in our normal places, especially in New Orleans. It wasn't as though the hospital administrators went to their offices and stayed there all day and the clinic folks went to their clinics and the nursing homes went to their sites of care. We were working in mixed up co-located sites and in some circumstances weren't working because there wasn't population yet to be served. It gave us an opportunity to begin thinking about what we would want this new system to look like to, develop that vision and real tow figure out how we would turn this ship. We didn't want to go back to that high-cost, low quality system that was really more hospital focused. We wanted something that was going to be better to meet the needs of the population. If you want to change your outcome, change the system.
So through the course of the last 3 years, we have been going through overlapping planning efforts that started down here with what I call the framework group, led by the feds. We evolved into something called the Redesign Collaborative which the governor put together. This came up with 4 tenets of health care reform that they continued to carry forward. I want to drive home the point that this Redesign Collaborative and the work that has come out since about the forum and Medicaid reform is groundwork we started after the storm, especially this framework group was a lot of public health minded folks who were trying to figure out how to make a difference in populations.
This is the 4 areas of reform. And it goes without saying that there was discussion about we forming health care financing to expand coverage. We wanted to have better quality than we had. We didn't think 50 was a good idea anymore or 51 in some surveys. So we wanted to create a quality forum to set a table where stakeholders could set the bar and we could try to achieve that. That forum has taken over the work of delivery reform as well as health information technology reform. The health information technology piece, like many states, whey physicians offices only 15% of whom were using health information technology.
We learned quickly we couldn't find our patients because we didn't have databases of them. We didn't know who was on coumadin and we didn't want to go through that experience again. Then the fourth area was delivery redesign with focusing on infrastructure structure. While we made progress in all those areas, I’m going to talk to you about the progress in the delivery redesign piece because it's my special love story and it's where the country can learn some things about how communities can come together to do better. So I mentioned that our safety net system observe the storm was 26 concentrated downtown, that it was convenient to trainees. Convenient to the medical schools. Not so much to the population. So some of those early sites where we set up tents or invaded buildings like the Covenant House, really were truly temporary, make-shift sites.
We also learned to use mobile medical units in those early days. They have now taken root and grown into these neighborhood health centers, access points. There are across the city, 83 access points part of the primary care access and stabilization grant serving 140,000 people. As of last month, we now can boast that we have the highest density of high quality primary care in the country. We have what is called recognized patient centered medical homes. We didn't just put primary care there, we put high quality primary care and we are continuing to move forward in that direction. I’m pretty much out of time. But I want to mention one or two other things. This is an underpinning of this whole health care system. It's not just about medical care but health is more than just getting people a doctor. We know the social determinants of health are important and never do you see that more than when your entire social fabric was destroyed as in New Orleans. We have to attend to adequate housing and making sure that people have access to economic opportunities and build this thing with the community in mind and the safety net system therefore is not just about medical care anymore. It's really about resiliency and thinking about the holistic approach to care.
I’m happy to answer questions about the impact of this on Tulane School of Medicine. I want to just make sure I highlight the fact that for many institutions, as Keith mentioned, this was life changing and for us it led to a change in our mission as a School of Medicine to heal communities. One of the things I get to do every day is take on the road with my team learned over here on the left, and try to expand it into new health centers to help these neighborhoods that want to build their own community health sites to grow and foster that kind of high-quality patient-centered care across the community. This is a story about policy and all that.
But I guess I’ll end and Keith can join me while I mention this. These are two fellows who were getting evacuated at the top of the garage at Tulane hospital. It says “Homeless Cardiology Fellow: Will Cath for Food!” In my mind it exemplifies the resiliency and sense of humor that so many people had in New Orleans. And I had the privilege of watching people rise to the occasion. It's been a remarkable journey. I thank you to you who continue to rise to the occasion for us. Thank you
QUESTION: I’d like to thank you for sharing your information. My question is, are there any discussions going on in Washington currently about distributing any funds to support your efforts?
FERDINAND: I’m not in Washington.
DESALVO: Well, the primary care access and stabilization grant was actually -- is funded through 100 million dollars of taxpayer monies. The story behind that is, clinics like St. Thomas and like our covenant house site had formed after Katrina or reformed, as the case may be for St. Thomas, and were living largely off philanthropy because most of the patients we take care of were uninsured. We had funding through a block grant program and wanted to extend that. So the community came together there was a hearing, energy and commerce put together a hearing where we got to spend several hours talking about the value of primary care and rebuilding the post-Katrina health care system in New Orleans. The result of which was a community letter that requested Secretary Leavitt to give the bulk of the $161 million he had left to allocate from his disaster relief funds to supporting primary care the and hospitals for example signed that letter in support of that. So therefore, 100 million of 3 years for support for these clinics while we as a state could sort out how to financially support them going forward, whether that was going to be reallocation of existing funds for the centralized charity system we used in the past or whether we were going to expand Medicaid or do a combination thereof. And he did. He chose from his $161 million to give 100 to primary care infrastructure support which we are all still living on. We have 18 months left. We had 35 million that went to workforce support for loan repayment programs for people working in this medically under served area and then the rest of it went to hospital support. Hospitals weren't happy about that once they realized it was going to happen. But in the end, it's been a really great success story. For the state's part, we have been or have a waiver into the federal government for a Medicaid program requesting that we can reallocate what is called, disproportionate share money, the funds that Louisiana used to fund their safety net to, use that instead to certify primary care clinics. So certified medical homes, for example. You know it's quality. You know they are seeing patients. So redistribute that from hospitals and then also to expand Medicaid coverage. 30 we just put that waiver in December and now it's languishing between administrations. But it is the final step in our reform effort. We have the delivery system. We built the quality forum. It is established standards and we have got a lot of hit work going on in the community. We really need to figure out how to sustain that safety net now using different financing mechanisms.
FERDINAND: One positive thing that did happen, St. Thomas health center, which I mentioned was a small clinic located in the housing project which is since had its demise, has become a fairly qualified health center. So the reimbursement for Medicaid is 133 times the baseline. That really helped St. Thomas and that just happened within the last week or so. In terms of various clinics, Karen has been at the forefront trying to integrate the clinics into a health care delivery system. To a large extent they still remain somewhat separate in terms of diagnostics, referrals to specialists and inpatient services. At every level we need to do more in terms of integrating the clinics, not just in finding a medical home, but what happens in that medical home and you need specialty care and care beyond the primary care level.
DESALVO: I want to follow-up here with a comment. Our urban area was very different from other urban markets. New York City, Baltimore, Dallas, Boston, which had a landscape dotted by more neighborhood health centers that had FQHCs. So we did not only in three year's time, immediately recover and put Humpty Dumpty back together again but learn the policies, rules and then train up our community, how to run one, it's a complex system. So we are trying to do what other communities have done in 30 years in four.
[low audio]
FERDINAND: I see your question. But one of my life experiences in the public health service was to work in the community health center in the desired projects and lower Ninth Ward. Those started to lose some of their impetus when the funding went away and since Katrina, they have not reopened. So the primary care centers and karen and I go back and forth on this. Although they are there, they are small and I don't think it's an integrated health care delivery system.
QUESTION: You both have mentioned the importance of having a uniform electronic health care records, maybe even in the city of New Orleans or in the state of Louisiana. How close are you to implementing something like that?
FERDINAND: St. Thomas has electronic health records. So a person who say member of the St. Thomas community, if they go to another provider, we can get the records to them electronically. In Louisiana public health initiative, they did want to have one integrated health care electronic records system but I think that particular mission has fallen aside as we speak. And the city health department wanted to put each person's electronic health record on a flash drive and there were big screenings. You heard about the talk and people went to the zoo in New Orleans, these people lined up and got their information t never came to pass. There weren't enough flash drives. There wasn't integration and I couldn't find my flash drive for my lecture this morning. So you know what happens with the records.
DESALVO: We do in this clinic system about right now it's about 60% of those clinics using electronic health records and we are adding on the school-based clinics. I know we are ahead of the curve nationally. What we are doing is not rebuilding with paper. We are trying to do this much more smartly.
QUESTION: Just to follow-up. You sort of alluded to the problem. You still have to have that on a server somewhere. And if you're entire physical infrastructure is damaged, what will happen to your electronic records?
FERDINAND: right. The question is what happens to the records when the server gets flood ed? Two ways to do that. One, have back-up data off site in Dallas or high ground somewhere and the other is have web-based health care records where you can get access to it electronically and send it to a server in Minnesota somewhere and get that information by a pass word and an access number. The St. Thomas health clinic uses an off-site server. The Louisiana State Board of Medical Examiners, we have a server there located in Dallas. So in the future, and that's not for health care delivery. That's for the licensing and administration of physicians. In the future, if that happened again, we would be able to identify who our licensed providers are because there is a server in Dallas. I don't know about the other centers.
DESALVO: We are using web-based asp models. So it's hosted elsewhere and they have redundant systems. The VA is a great example of how that works well in Katrina. They have national database of electronic health records and their patients could identify them. They can proactively find the cancer patients, find the patients who had or couldn't go without immediate care and attention and they were able to also service them at other sites. We don't -- technology doesn't allow systems to talk. It allows your banks to talk about your bank records but not your medical records. So it's more a technological issue than a will on the part of the community.
QUESTION: I was wondering how mental health has been integrated in this system and how at what point do you feel you are in terms of the needs of the community for mental health.
FERDINAND: I’m going to address that is and Karen and I made that reaction for a long time. If we start fussing and fighting then -- I think the mental health system is very poor. The first responders are the police. There are not enough inpatient beds or acute psychiatric care and the police will come to the house and usually take the person to a regular emergency medical room and sit with the person for the hours it takes to give them a shot of antipsychotic, calm them down, observe them, try to find a bed. Many patients are shipped out of the air if they need long-term inpatient care. Or if they settle down, they are sent back to the street. Now what is the problem with that? That's not integrated long-term mental health care. The police in New Orleans are under a lot of stress because they are dealing with youth who are robbing and killing. They don't want to sit in the emergency room for 12-23 hours baby-sitting what they would consider something outside of the police initiative. So there are adverse, when you call the police, they are adverse to coming. They don't want to come. They don't like coming. They are not trained. And we had several instances where the police have been attacked and one police woman was killed, or the police persons have killed the mental health person they are coming to intervene on. It's very, very unacceptable conditions. And most people have true serious psychiatric patients, schizophrenic, uncontrolled bipolar patients, they shouldn't be in New Orleans. That's not my harsh view of it but that's the way I see it presently, 2009, March.
DESALVO: I agree with that. And I guess there is probably 3 layers or 3 buckets. There is the severely mentally ill, the site for that -- the site of care for that population before Katrina. They were largely flooded everywhere and they have been through some reorganization or getting back on their feet but the resources are available to those patients and that service is still pretty anemic. There are two other buckets. One are people who have the depression, anxiety, PTSD that is recognized. So several clinics are participating in a project funded through Red Cross that is actively screening and identifying folks who have anxiety, depression, who present in a clinic or faith-based setting and trying to get them to service. So there is an underpinning, maybe 40% of the population has something like that, according to Kessler's work. Then there is the other folks who were not sure what the anger is about. So some of the young kids who are acting out or some of the -- a lot of people, frankly. I think we're not -- they are not diagnosable in the traditional way but I think there is still a lot of anxiety. Gustav was the storm we had last fall, very rough on the population. It was clear to me we were not well yet because we had issues. So what we are trying to do from the primary care framework is the warm hand off. If you come into my clinic, then we will screen you at the outset in our electronic health records. You get flagged and you can be seen. We have those trained in counseling or we also have a med psych on site. Other clinics have similar programs. You will stay in there. What we learned though, is that people want the stigma of mental health is phenomenal. Quick story. We work with this great organization called, Church Nurse Program, funded by Baptist Community Ministries and they train these nurses whose work in these different churches in town. We were going to do a health fair with them. It was our first event in the church. And we were talking about what we would screen for and what we would do there. I asked about mental health screening. And just the two item quickie. And Ruth, who is the lead for it said, not so much. I don't think people want to have mental health screening at a health fair. She said, but HIV screening would be really great. And I guess for me, I just thought, I don't think I’d want to have my HIV screening done in a public health fair venue but the stigma was so much greater for this population of mental health screening than HIV that -- and I was disconnected from that obviously.
FERDINAND: What I think each community needs is what I saw in Emory. They have a program where even if you're Medicaid, uninsured and in the grading system, you can get a psychiatrist who unfortunately right now may be will write medications. A psychologist to do intervention, a peer buddy, someone who is recovering from serious illness to help guide you and a system of home care where there is someone on site often a person who has recovered who makes sure that the person that who has the serious academic illness, major depression, bipolar, gets their medications and then job training where they can work in cafeterias, the public sector. It takes a lot of money and coordination. New Orleans is not there right now. And I pretty much feel that they are doing everything they can with the mental health facilities but you need to have that type of coordinated care. You can't just write a prescription and can't just do counseling or home care. It has to be all integrated.
OGNIBENE: Actually it's exactly 1:00 and I don't want to interrupt. I want to thank both Karen and Keith for their time and for their extraordinary efforts. Certainly acutely and in follow-up. We appreciate that. I hope you can stick around for a few more questions. Please come down and continue the discussion. So thank you, all.
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ANNOUNCER: You've been listening to a discussion on how Hurricane Katrina has affected health-care delivery in the New Orleans area. Our speakers were Dr. Keith C. Ferdinand, chief science officer of the Association of Black Cardiologists and clinical professor of cardiology at Emory University who spoke on the topic: "Post-Katrina Health Care: Present Status and Future Considerations." He was followed by Dr. Karen DeSalvo from the Tulane University School of Medicine who talked about "Recovery and Rebuilding the Safety Net Post-Katrina." This lecture was recorded March 18, 2009. You can see a closed-captioned videocast of this lecture by logging onto http://videocast.nih.gov -- click the "Past Events" link, or by clicking the "View Videocast" link for today's podcast at the Grand Rounds podcast page at www.cc.nih.gov/podcast/grandroundpodcasts.html. The NIH CLINICAL CENTER GRAND ROUNDS podcast is a presentation of the NIH Clinical Center, Office of Communications, Patient Recruitment and Public Liaison. For more information about clinical research going on every day at the NIH Clinical Center, log on to http://clinicalcenter.nih.gov. From America’s Clinical Research Hospital, this has been NIH CLINICAL CENTER GRAND ROUNDS. In Bethesda, Maryland, I’m Bill Schmalfeldt at the National Institutes of Health, an agency of the United States Department of Health and Human Services.
