Improving Outcomes Will Take More Than Clinical Care

Marcia Frellick

April 20, 2018

NEW ORLEANS — In the wake of the devastation caused by Hurricane Katrina, it became clear that restoring health services in a broken system would not be enough, said Karen DeSalvo, MD, a leader who helped reimagine the city's health system after the disaster.

"When we were knocked to our knees by that storm, we made a choice to stand up together as a community and move forward to build a health system that would be, for the people of our community, one that they deserve," said DeSalvo, who was, at the time of the hurricane, vice dean for community affairs and health policy and professor of medicine at the Tulane University School of Medicine in New Orleans.

The designers of the new system were determined that the focus would not be sickness, and that it would not perpetuate generations of healthcare disparities, she told Medscape Medical News. Instead, it would address problems further upstream.

The ultimate test for a community is a disaster. If you build a system strong enough for that stress test, it's going to do better for people every day.

"The ultimate test for a community is a disaster. If you build a system strong enough for that stress test, it's going to do better for people every day," she told the audience during the opening of the American College of Physicians Internal Medicine Meeting 2018, held in the city devastated by the category 5 hurricane.

The overarching goal after the hurricane was "resiliency so this would never happen again," she explained. That meant everything — from moving away from paper-dependent systems to moving away from pouring money mostly into hospitals instead of clinics.

Because so many people were trapped by water and debris after the storm had passed, providers were forced to come into communities to care for patients. Until Katrina, health services for the poor and uninsured were provided through the state-run public Charity Hospital, but that was permanently closed after the storm.

Tulane was able to staff six makeshift sites that served 450 people a day, not only to treat physical complaints, but also to deal with emotional issues, DeSalvo reported. The providers also helped relay information such as where to buy food and when schools would reopen.

Those tent sites were the genesis of several dozen permanent clinics that, with the help of government funding and philanthropy, now serve 160,000 people — many of whom, before the storm, lacked access to care. The clinics operate under the patient-centered medical home model as part of 504HealthNet.

During the rebuilding process, providers had to learn to work in teams, DeSalvo said. It took many community leaders to solve the problems they were facing, including volunteer nurses, physicians, social service agencies, and public health officials.

If a person with diabetes has no home or refrigeration, prescribing insulin is useless, she explained.

DeSalvo served as the acting assistant secretary for health at the US Department of Health and Human Services from 2014 to 2016. In that role, she oversaw the development of Public Health 3.0, an approach to health policy that focuses on the social determinants of health to create lasting change.

Some health systems are way ahead in their embrace of the concept, she pointed out. Kaiser Permanente, for example, is not only asking the right questions about whether someone is going to bed hungry, but is also getting people who are hungry connected with foodbanks and providing grants to support foodbanks.

And partnerships have developed — between leaders in primary care who offer smoking-cessation programs and governing bodies — to bring about smoke-free cities so that the healthy choice is the easy choice, she said.

Mental Health Services

Building partnerships to make mental health services more available has been the focus of the post-Katrina work of Benjamin Springgate, MD, from Louisiana State University in New Orleans, who is principal investigator of the community resilience learning collaborative and research network (C-LEARN), a National Academies of Science initiative to test interventions that promote resilience in communities that have experienced or are at risk for natural disasters.

People who lost family, friends, homes, and schools in the hurricane experienced massive stress but, at the same time, mental health services were closed down.

In the aftermath of Katrina, Springgate helped found REACH NOLA, a nonprofit organization created to help expand the behavioral health capacity of the region.

The community-based network relied on church leaders to talk with people experiencing stress, and to refer them to neighborhood associations with community health workers who could direct them to mental health services and provide information about rebuilding homes (Ethn Dis. 2011;21[3 Suppl 1]:S1-20-9).

"We were able to train several hundred safety-net providers from about 80 agencies," he reported.

Many behavioral health services were still not available years after the hurricane, so the network helped fill those gaps in care. "We continue that work today, developing the same type of connectedness and utilizing similar types of partners," Springgate said.

Internists should develop community-based partnerships now, before the next disaster strikes, he urged.

"We're trying to develop relationships all around the country," he said. "It doesn't have to be the case that we're all starting from scratch every single time."

DeSalvo and Springgate have disclosed no relevant financial relationships.

American College of Physicians Internal Medicine (IM) Meeting 2018. Presented April 19, 2018.

Follow Medscape on Twitter @Medscape and Marcia Frellick @mfrellick

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