Podcast Episode Transcript: Serving the safety net community

With L. Gordon Moore, MD

Gordon Moore: Welcome to 3M Inside Angle Podcast. This is your host, Dr. Gordon Moore. And with me today is Iliana Gilman, who is a principal with HMA. Welcome, Iliana.

Iliana Gilman: Thank you, Gordon. I appreciate the opportunity to be here.

Gordon: Thanks so much. I really appreciate it running into you at a State of Reform Conference in Austin, Texas and hearing you talk about some of your work. But before we get into that, could you just tell me what is HMA?

Iliana: Sure. HMA is a independent national research and consulting firm in healthcare that has consultants from all areas of state Medicaid directors to commissioners, to primary care physicians, policy advisers. And then there is an area that HMA has that’s under the umbrella of community strategies, which is where I do most of my work. And with community strategies, we’re looking at things that address more of the social determinants of health. So we work with a lot of county and public health departments with some of the MCOs, who are looking at various alternative payment models, and community based organizations, foundations, and hospital systems, both in the public and the private sector who are also interested in looking at utilizing social determinants of health in their healthcare practice.

Gordon: And that’s somewhat along the lines of what I heard you talking about at the State of Reform Conference, and you’re describing some of the work and leading a panel talking about social determinants of health but, also, how you had been an administrator for a Episcopal health care centers. Could you describe what that was? And then I want to ask some questions about some of the challenges you faced.

Iliana: Sure. Yes. So I had the tremendous privilege and responsibility to lead an organization here in South Austin that was part of the Episcopal Diocese. It’s a mission of the diocese, if you will. And the name of the organization is El Buen Samaritano, which is The Good Samaritan in Spanish. And the main mission was to serve the Latino immigrant community. And so in addition to just having the primary care and behavioral health set of services, we also had a food pantry, English, ESL classes, computer literacy classes, and of course a church. We had a campus there where we had different buildings and provided these services.

And the church, we did a lot of coordination around spiritual services. So that ranged from having the priest do one-on-one counseling with individuals who sought that to prayer groups, and then a little bit more focused initiatives like meditation for pain management and then some yoga practice as well for folks suffering from depression.

Gordon: So when you talk about social determinants of health, most healthcare organizations are thinking about and starting to figure out how to connect. And you actually had a lot of that as part of your larger enterprise.

Iliana: Yes.

Gordon: And so that probably gives you a lot more insights then. I come into things as a family medicine physician. I think, oh, there’s stuff out there. Who are they and where do I connect with them? And I don’t want make that culturally appropriate and linguistically appropriate. Oh, my gosh. So that was part of it right from the start. I’d like to know more about right now is the healthcare delivery aspect of that. What was it? What sort of services do you provide? You said mental health and primary care?

Iliana: Yes. So we did a lot of chronic disease management and then acute care. We did a lot of family planning as well. Here in Texas, there’s about 50 percent more female Latinas that get pregnant as opposed to the white counterparts of women under the age of 16. And so that was a big area of focus for us, was getting ahead on pregnancy prevention and a lot of STD testing. As you can imagine, there’s—as I was with the organization throughout those five years, really became apparent how important it was to not just focus on the actual service itself but then to also be looking at the nuances, right?

So it was really important to have close relationships with the providers because NDMAs as well, that was also a very important aspect because, from them, you learned a lot of little subtleties. So for example, IUDs and married women, they say they had like their third child consecutively and her husband did not believe in contraception. And so we heard a lot of things like, well, we would suggest an IUD or a Mirena, whatever it would be. And they would often refuse it because they were scared that the husband would feel it. And so then we’d see them nine months later, here we go again with another pregnancy.

And so figuring out ways to get around things like that was really important. Oftentimes, some of it required counseling with the couple. And other times, there was really just nothing that you could do about it. And so even though we were offering the services, there were all kinds of barriers that we had to take into consideration. So yes. And definitely, mental health was big for us. Once the administration began it’s focused on immigration policies, we had a slew of ICE raids here in Austin that really affected the community that I served.

And not only did we experience a downturn in terms of no one was coming probably for about a good month, month and a half. But when people finally began to return, for the first time, we saw an increase in mental health services by 30 percent, which was huge. And we never saw it go back down after that. So part of things like becoming a trauma-informed care organization were really important because during that time—so part of, I think, one success was that we hired people who knew the population that we serve from a very personal perspective, whether it be because they have family members who were immigrants themselves or they were immigrants or they had been previously receiving services at El Buen.

And so when things like that happened and the community was affected, staff was affected, too. And so really creating awareness around the trauma, right? And then, inherently, ICE raids aside, people getting here, their journeys are often very, very traumatic. And so we’re dealing with not chronic disease management, one thing, and then co-occurring with mental health issues. It’s tough work. We definitely saw a lot of provider fatigue around this.

Gordon: Yeah. It’s interesting. When I think about policies around healthcare, one of the things that is a little bit frustrating to me is the blanket approach, one size fits all. And I remember you commenting about healthcare being local. And what I’m hearing you describe is it is, really, a very nuanced understanding of the people that you’re serving and what their needs are and how to meet them. Do you have specific ways of assessing that in gaining that understanding? Do you have feedback sessions with the providers with the different components of your organization coming in and saying these are the needs? How did you work that to gain that level of understanding?

Iliana: Yeah. A lot of it was just organic, right? And just this ability to have—we had, I think, at that time, seven providers. And so as we rolled out different initiatives, for example, we wanted to be able to do warm handoffs—because most people landed because they were coming in with a fever or an infection or something very acute. And I wanted to administer the PHQ-9. And when you make that kind of change— for every visit, not just for a yearly—at every visit, just administer the PHQ-9. And so whenever you make those kinds of adjustments, well, it requires a lot of coordination with the team.

And so that’s when you start to get real about, okay, how is this actually going to happen and you’re walking through the steps with staff, that’s when things begin to surface, right? We would have to do a lot of adjustments as we started to see how people would react to that. And so a lot of it was just trial and error and being able to interact very directly with the staff, which is challenging. I mean, to be transparent providers and staff often didn’t want to play nice with administration. And that’s just a very common thing that I’ve seen among all of the safety net clinics here in Austin. And I know a lot of my colleagues back then felt the same way.

And so I think for me, what allowed us to get past that was simply how invested we were in the community and the people that we were serving. And that always pushed us through and allowed us to have this kind of dialogue because, really, we just wanted to make sure we were doing everything possible to get them the best level of care.

Gordon: And that broke through what was initially the resistance of the clinical staff?

Iliana: Yes, yes. Every time you add a different layer of work or processes and then you’re working with a 15 or 20-minute visit, those little changes aren’t necessarily welcomed all the time, right? And so, that, you need to be able to have dialogue explaining why it’s important, figuring out through technology or mainstreaming things, like how can we do this with the least amount of disruption during a visit. And so, yeah, there were—another example was we did our Title X Family Planning Program.

And that program is a state-administered program but it gave us the flexibility to utilize federal funds in ways that we weren’t able to utilize them otherwise. And so, for example, because of our mission and the people that we were serving, we were not asking for a lot of documentation, basically. If they had a bill, showing that they were part of a resident of the county, regardless of their ability to pay, we saw them. We just made it very easy for anyone to come in and get services with us.

So Title X allowed us that flexibility. A lot of the other programs did not. And so we were very excited to introduce this new service. But Title X had its own set of requirements outside of documentation. And part of that, too, is asking very personal questions about their sexual activities. And we really had to work with the Title X administration team, which was amazing and worked with us tirelessly to try to get to a point where we figured out how to ask the question so that it would allow for us to get to a point where we understood what we were, what kind of person we were speaking with in terms of their needs, their very specific needs. We were starting to see a lot of trends surface, which we hadn’t really been experiencing that. But we had been doing a lot of outreach to youth. And we wanted to make sure that we were being as culturally responsive as possible and sensitive.

And so every time we began to identify a particular population, and like you said, everything is local, we really had to go back to the drawing board and say, how do you customize, what is the best way that you can approach someone so that you get to do what you need to do for them to improve their health.

Gordon: Just for people who may not know. Tell me just briefly, what is Title X?

Iliana: So Title X is a state-administered program that is awarded or funded by the federal government. And it is family planning services, essentially. And you get paid for everything from contraception to STD testing, annual checkups. You get funding for contraception. You get 340B Pricing, so discounted for nonprofits, for medications. And so it’s a program that’s intended for the safety net community that does the range of those services.

Gordon: Got you. But in exchange for that, there is a package of reporting stuff and things you have to do. And it sounds like a bunch of that goes to the clinicians where they have to perform certain extra tasks.

Iliana: Absolutely, yes.

Gordon: So that’s also interesting to me. One of my little bugaboos is that, going back to the PHQ-9, which is for a brief assessment for screen for depression, it’s like, I think about that in the context of a vulnerable population that’s being stressed. That’s very logical. It makes good sense. And then so it’s like, okay, yeah, we should probably do that. And we could do maybe the PHQ-2 and then the 9 and then figure out where to go. And knowing that you guys have mental health services on site, that’s a huge boon because I know in practices where they don’t have good access to all these providers.

It’s like, wow, as a clinician, I don’t even want to ask the question because I have no place to send them. So it’s great that you actually had the capacity to go there. But then, I’m thinking, okay, now you’re saying we should also screen for STIs and do that work. And it’s like, yeah, yeah, that makes sense. We should absolutely do that. And then I’m thinking, okay, we should probably also screen for domestic violence and screen for chronic disease and start managing that. Absolutely. You know what, that absolutely makes sense.

And I’m starting to think, oh, wait a minute, I’ve got a 15-minute visit. And that’s complicated stuff. It’s like, I don’t have time. How am I supposed to do all this? Did you run into that?

Iliana: Oh, yes, absolutely. But those were the kinds of very practical barriers that we had to face. And so we have to be very selective with what we did and what we didn’t do. We really leaned on our MAs to support the providers as much as possible, really giving them the training that they needed so that they could be working at the top of their license. And you figure out all kinds of different strategies like also creating a career ladder for them if they wanted to become an RN, having different tiers of MAs that did different levels of work based on their comfort and interest. And so a lot of it is just thinking outside the box.

Another thing that we did was, for example, when we started telepsychiatry, of course, we just had no access to psychiatrist here locally. It was probably about a four to five-month wait for those kinds of services. And so telepsychiatry was tremendous. It was wonderful for us. I was very concerned that our clients would not like it with this idea of talking into a TV about your medication for your depression was—I was unsure. And actually, the opposite happened when we started it. They loved it. They loved the service. They were excited they could get their medication through these two doctors that we used regularly, who were amazing.

It was our staff that said there’s a lot of work around this and often needed translation services and then closing the loops and getting the prescriptions done. And there was a lot that went with it. It wasn’t just they go in, they see the doctor, they get their prescription, and they leave. So all of that case management and support and care coordination that needed to go into it, added another layer of administration that our LPCs, our counselors, our MSWs, they were like, “I don’t have time to do this. We are here to provide counseling services, not to do care coordination.”

So we had to get additional staff to support them with this particular service. And so we ended up hiring case managers. Again, some who were interested in beginning a career or a school in becoming a counselor, getting their certifications, and so we had to get creative about doing that. And of course, almost everything that requires additional funding, we had to figure out where we would get that funding for. So the more robust our services became, the more overhead we needed, the more resources we needed.

I think we’ve touched a little bit on all of the data we need to collect. So we did have an EMR. But when I got there that first year, providers were entering information all over the place. So we had to spend a lot of time streamlining what we were collecting, where providers were entering it, so that the integrity of the data was—we had confidence in the integrity of the data. And that took about a year and a half. That took a very long time. And again, a lot of it was a pain. They didn’t want to do it.

And I understand. As administrators, you’re caught in this tug all the time where you understand that you’ve got to have this data in order for you to be able to go out and ask for money from foundations to write into your grant or whatever to make the case for capacity building. And then you have the data, and then guess what, you need somebody who’s going to do the analysis of the data. So you need an analyst. So that’s more overhead. And then you need a quality team and, wow, we’ve never had a quality team before. And then we get a quality team together.

Oh, now, we can’t become a federally qualified health clinic because of the governance restrictions that we have. And we don’t want to add all kinds of additional administrative layers for that. But at the same time, we need to be able to demonstrate that the work that we do has quality outcomes that we’re measuring certain things. And so we decided, all right, well, let’s go after a patient-centered medical home recognition. And that was a two-year process, took a very long time, but it actually ended up being a fabulous model for us to use simply because it flattened the organization in a lot of unexpected ways, and not just within the clinic but also across the services, the very services that we offered.

So we had people who were tending to the community garden and responsible for the community garden along with teachers from the Computer Literacy classes with MAs in particular work groups all trying to figure out like, okay, on this quality measure, how is this going to happen? And I think that was for the first time where we had started to break through on some of those service silos that were definitely very prominent when I first got there.

I was the first not just female but non-priest that was the executive director for the organization. And I think it was an interesting assumption that a lot of folks made that, here, we have a woman and that’s Latina and that’s young and going to come and make the organization better but really not considering all of the rigor and discipline that goes into that, which was very counter to the culture of the organization. At the same time, the culture of the organization was what made the organization so wonderful. It has a lot of heart but very little structure.

And so with something like pursuing a PCMH recognition really required a shift. One of the things that I did—and it wasn’t just staff, it was also our board, right? Our board had a lot of parishioners again with no healthcare background. And one was viewed as basically a social service organization. People came to it because they loved the ESL classes and those services that we offered or the food pantry or just very supportive of the church or cared about our community very deeply.

And when I came in, beginning to talk about El Buen as a healthcare organization rather than a social service and how all of the services were a part of healthcare was a very tricky thing. And I think by the end, we were able to get there. But that shift and that mentality of how all of these services that we offer contribute to the health and the wellness of individuals was kind of a stretch in the beginning. But it was a wonderful thing to see evolve over time.

Gordon: So I’m thinking, you had mentioned working on chronic conditions, and I know that there’s this link between state level policy around healthcare payments were on Medicaid, for instance, that goes the cascades down to managed care organizations trying to manage two capitated payments from the state for subsets of Medicaid population saying, we can do a better job of reducing unnecessary stuff, unnecessary hospitalizations because of the management at the health insurance level. But the real action is, like, in the clinic that you were managing, that’s where things really happen to help people reduce stuff.

So do you think that your organization had an impact on that? And if so, how did you know and what did you do to get there?

Iliana: I think, for us, the first thing that comes to mind is we needed to get paid for our community health workers, which were a team of eight people. And the way that we organized our community health workers was by specialty. So somebody focused on family planning, somebody focused on diabetes. Everybody had their niche in terms of what aspect of healthcare they were interested in, they knew about. And then they worked with individuals that they were set up with a care team on. But I didn’t have any funding revenue for community health workers.

What we did was we partnered with our healthcare district to say, we need money for our community health workers because they’re a vital part of the team. And they really support the providers, but more than anything, help with adherence to medications, figure out, identify some barriers they might be experiencing, whether they don’t have money for healthy food or whatever it would be, transportation.

One of the ways that we were able to do that and we were actually beginning to start having a conversations on this with some MCOs as well, one in particular that was very serious about it was, we said, okay, if we’re going to get paid for a community health worker, then how does that prevent a provider visit and how do you prove that? And that was a very interesting situation where we knew we were doing that already, but how—okay. Now, let’s look operationally, how do you prove that?

So we had to start with, first of all, they have to get trained in our EMR. That was a lot of work, right? Just to be able to read patient’s information. A lot of them, Spanish was their first language and so how to get around a lot of those very practical things, provide the investment to—a lot of people want to hire community health workers, but they don’t want to invest in their education and their development so that they can be as effective as possible.

But once we were able to do that, then we figured out, all right, here’s how the care team’s going to work and here’s how we’re going. And these are the very specific visit types that we’re going to refer them to the community health worker that were typically booked with a provider. And that happened with a variety of different things, like medication refills, just very basic things that, again, would take up a 15-minute visit. But instead, they went with a community health worker, and they took that visit off of the provider’s plate, but at the same time, updated their EMR, which is where we would pull the visit and be able to send that over as part of our data reporting to the health care district. And then at the same time, the provider and the care team would receive updates from whatever it was that the community health worker did during their visit.

And then we had to do things, too, like create panels for them, again, create some structure and some rigor where, before, there was just a lot of flexibility. So is that kind of a good example?

Gordon: Yeah, I think so. I mean, what I’m hearing is the description of how, sort of, starting from, not entirely from scratch but you’re starting with the concept of a highly successful intervention type, which is community health workers who can engage closely with individuals with needs and how you built a program around that and then started to build the infrastructure that would help them be successful if their work would also measure some of the impact.

Some of the challenge that I’m thinking about is that, sometimes, it’s hard to know. It’s hard to quantify and, certainly, hard to quantify in a dollar way what’s the impact of that kind of thing. And so we have proxies. We can say, well, maybe we missed a visit here and we reduced some other event. But it’s hard to prove something that didn’t happen unless you have larger data sets. I see that in claims datasets. We can look at a population of people and say, the probability is that 15 percent of people will be in the emergency department. And half of that is potentially preventable emergency room visits, and that number went down over years after the implementation of a particular program. But you really need large data for that. And so it’s hard to know.

And so you’re left then with pulling stuff out and hoping because it aligns with known researched interventions that, therefore, you should be given credit for doing that because you’ll never have sufficient denominators to prove it in the data.

Iliana: Exactly.

Gordon: Yeah. That makes sense to me. So I’m thinking that we are moving towards wrapping, and I want to give you a chance to touch on any other areas or that you think our listeners would need to know.

Iliana: I think when we’re talking about social determinants of health, we can’t not address health equity. Because to me, that’s front and center when you’re looking at social determinants of health. You’re looking at adding an array of different services because of the supports outside of a clinic that individuals need to either get healthy or maintain their health if they’re already healthy. And things like basic food needs, education, even the spiritual services and supports, that’s a big deal. Those kinds of wraparound services are really indicative of poverty.

And so when we were looking at things like program development adding more services, it always had to be front and center, this idea of health equity. Because as working individuals—I grew up poor. I grew up on the border, here in Laredo, Texas, and was raised by my grandmother. And those were some of the happiest years of my life. And I was too young to understand, one, that we were poor but, two, to even appreciate what it’s like to be worried about, can I afford my medication, be worried about—I would hop on the bus with my grandmother during the day to get to her doctor appointments. I never once appreciated the fact that we needed public transportation and we didn’t have a car to get to our doctors. So it took us an hour to get there versus 20 minutes.

There are so many considerations to take into account that, normally, if we’re wrapped up in, okay, what’s the data that we’re going to be entering, what’s a best practice right now, adding things like telepsychiatry, those are all services that, I think, we’re like, yes, people need them, but how they’re actually delivered, why do they actually need them, those are all really important questions. Is it relevant? Is it relevant to our patient?

I always think it’s a privilege to work in this field, understanding that you’re actually contributing, not just to the health of individuals but addressing that gap in poverty, looking at equity, and really, also, a sense of social justice. And so I always want to remind people who are in healthcare because it is a difficult field to be in. It’s hard. There’s always changes. The money’s tighter. People are getting sicker. It’s a hard field to be in. I’ve noticed, if you just pause for a minute and you remember, this is why I love being here because this is the kind of impact that I’m having in my community and my contribution. I think it makes it all worth it despite all its complexities.

Gordon: That sounds like a perfect ending. So thank you so much for your time today.

Iliana: Yeah. Thank you, Gordon. I really appreciate this opportunity.

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