PUTTING THE PATIENT FIRST Recommendations for Creating a Vibrant Safety Net System for the People of Nashville A Report by the Indigent Care Stakeholder Work Team / March 5, 2019 Inaugural Members of The STakehaIder Work Team Dawn Alexander, RN, MHA, MBA Chief Nursing Officer Nashville General Hospital Richard Manson, JD Founder of Manson, Johnson, Conner President of SourceMark, LLC Rosalyn Carpenter Vice President, Diversity & Inclusion Catholic Health Initiatives Brian Marger, MBA Chief Executive Officer TriStar Summit Medical Center Judy Cummings, DMin, RN New Covenant Christian Church Senior Pastor Councilman Bob Mendes At-Large Council Member Metro Government of Nashville and Davidson County Member, Waypoint Law, PLLC Lemuel Dent, MD, MS, MSCR, MMHC, FACS Chief Medical Officer Nashville General Hospital Sara Finley Principal Threshold Corporate Consulting, LLC Talia Lomax-O’dneal Metro Finance Director, Mayor’s Office Metro Government of Nashville and Davidson County The Honorable Harold Love, Jr., PhD Tennessee State Representative, District 58 Pastor of Lee Chapel AME Church Veronica Mallett, MD, MMM Senior Vice President for Health Affairs and Dean of the School of Medicine Meharry Medical College William S. Paul, MD, MPH Former Director of Health Metro Public Health Department of Nashville/ Davidson County Freda Player-Peters Senior Legislative Advisor, Mayor’s Office Metro Government of Nashville and Davidson County A. Dexter Samuels, PhD, MHA Executive Director at the Meharry Center for Health Policy and Senior Vice President for Student Affairs Meharry Medical College Renata Soto Co-Founder and Executive Director Conexión Américas Contents Executive Summary.................................................................................................................... 1 Nashville’s Health Care Infrastructure....................................................................................... 7 History of Nashville General Hospital...................................................................................... 10 Current State of Indigent Care................................................................................................. 14 Market Conditions.............................................................................................................. 16 Nashville General Hospital............................................................................................... 17 Nashville’s Three Major Hospital Systems........................................................................ 21 The Safety Net Consortium of Middle Tennessee........................................................... 22 Federally Qualified Health Care Organizations............................................................. 23 Share of Uncompensated Inpatient Care............................................................................... 25 Indigent Care Stakeholder Work Team................................................................................... 27 Major Themes of Study...................................................................................................... 28 Community Engagement......................................................................................................... 31 Key Themes of Community Listening Sessions............................................................... 34 Models of Care Committee...................................................................................................... 35 Consensus Workshop........................................................................................................ 35 Summary of Potential Enhancements.................................................................... 38 Researched Indigent Care Models................................................................................. 41 Hillsborough County Health Care Plan.................................................................. 41 Congregational Health Network............................................................................. 41 Central Health Medical Access Program............................................................... 44 Live Well San Diego................................................................................................... 44 Arizona Health Care Cost Containment System................................................... 44 Boston Health Care for the Homeless Program..................................................... 46 Funding Model Committee...................................................................................................... 47 Tax-Based Funding............................................................................................................. 47 Gaming-Based Funding.................................................................................................... 50 Other Sources of Revenue................................................................................................ 50 Indigent Care Trust Fund................................................................................................... 51 Budget Management........................................................................................................ 51 Findings and Recommendations............................................................................................. 53 A Collaborative Network of Safety Net Providers........................................................... 56 BetterHealth Nashville® – A New Indigent Care Management Program.................... 60 Reimbursement Structure......................................................................................... 60 The Role of Data Science......................................................................................... 63 Implementation......................................................................................................................... 65 Structure of Network Implementation Team................................................................... 65 Infrastructure of Nashville General Hospital................................................................... 65 Proposed Implementation................................................................................................ 68 Conclusion................................................................................................................................. 69 Acknowledgments ................................................................................................................... 72 What does it mean to be indigent? The medically indigent are among Nashville’s most vulnerable citizens. They are uninsured or do not have adequate insurance More than 100,000 people in the city of Nashville are considered medically underserved. Members of this group are diverse in age, race, education, occupation, and where they live in Davidson County. Many have jobs; still, they cannot afford comprehensive health insurance. If they get sick, they cannot pay their medical bills. Nashville relies on their contributions to the economy, and they rely on Nashville’s safety net system for their health care. The health care safety net system consists of numerous organizations in the Nashville area: to cover the cost of their • Nashville General Hospital at Meharry, the city-funded hospital medical expenses and • Private hospital systems and providers often sacrifice food and • Federally Qualified Health Centers (FQHC) other necessities to make • Meharry Medical College clinics • Community and faith-based clinics ends meet. Sources: Tennessee Community Catalyst, Hospital Charity Care and Financial Assistance Policy and Procedures. What is a safety net? The Institute of Medicine defines the safety net as those providers that organize and deliver a significant level of health care and other needed services to uninsured, Medicaid and other vulnerable patients. Source: The Institute of Medicine 1 Executive Summary The safety net is vital to the greater health of our community; however, it is deeply fragmented, and its effectiveness and efficiency have been increasingly called into question. In November 2017, then-Mayor Megan Barry brought the issue to a head when she announced inpatient services would close at Nashville General Hospital. The decision increased uncertainty and instability in the community. In response, Dr. James E.K. Hildreth, President and CEO of Meharry Medical College, volunteered to form an Indigent Care Stakeholder Work Team to look more deeply at the safety net system in Nashville, and formulate a vision for the future. Because of the college’s long-established mission to serve the underserved, Meharry felt a duty – and was uniquely qualified – to lead the conversation about the future of indigent care. THE STATED PURPOSE OF THE STAKEHOLDER WORK TEAM WAS TO CONCEPTUALIZE AND RECOMMEND A NEW SYSTEM OF INDIGENT CARE THAT LEAVES NO ONE BEHIND. To ensure that all perspectives were brought to the table, Dr. Hildreth invited representatives of health care and community organizations to join the Stakeholder Work Team. By design, each member of the team approached indigent care from a unique perspective, yet all shared the same goal: to deliver the best possible care to those in our city who need it most. Charged by our purpose, the Stakeholder Work Team met for the first time on December 18, 2017. Our work has been bolstered by the overwhelming support of the people of Nashville, who voiced in a Vanderbilt University poll in March 2018 the opinion that the city has a responsibility to care for its most vulnerable residents. For 14 months, the Stakeholder Work Team met in both public and private sessions to study the best options for indigent care in Nashville. Our work included: • Researching indigent care models and best practices from across the nation; • Inviting input from local, regional and national experts in the field of indigent care delivery; and • Hearing testimony from community and civic leaders who value the safety net for health care services. BASED ON OUR FINDINGS, WE BELIEVE: • • Nashville must become a healthy city for all who live and work here if we are to maintain our vitality, growth and national profile. Every resident of Nashville deserves quality health care delivered in an environment that is conducive to healing, regardless of zip code or ability to pay. • The patient – not the provider – must be the priority and center of the safety net system. • To truly be effective, the safety net system must address nutrition, transportation, housing, and other social determinants of health that impact a patient’s ability to access treatment and heal. • Nashville’s entire health care community must be involved in the system to maximize care for our vulnerable residents, minimize costs, and eliminate duplication of services. • Nashville’s position as a health care capital creates the unique opportunity to tap into the best minds in health care and make our safety net system a model for the nation. The Purpose of the Stakeholder Work Team: to conceptualize and recommend a new system of indigent care that leaves no one behind. TO THIS END, THE STAKEHOLDER WORK TEAM RECOMMENDS THAT NASHVILLE CREATE AN INTEGRATED SAFETY NET SYSTEM THAT PLACES PATIENTS AT ITS CENTER AND ACTIVELY INVOLVES THE CITY’S ENTIRE HEALTH CARE NETWORK IN THEIR CARE. 2 WHY THIS MATTERS Cost of indigent care at Nashville’s three major hospital systems is calculated at $153,500,000 annually. There were an estimated 270,333 emergency room visits in 2017 for the uninsured. There is no tracking system for uninsured patients, resulting in inconsistent and uncoordinated care. Fragmentation in the current system focuses on acute care rather than preventive medicine and wellness. INDIGENT CARE NASHVILLE : A MODEL FOR THE NATION High-quality, cost efficient, and patient-centered system. Rooted in imagination, innovation, collaboration, community spirit and service. Empowered patients who are partners in health care decision making. Information transparency that is accessible to patients and providers. 3 WE RECOMMEND THAT THE SYSTEM BE COMPRISED OF TWO CORE ELEMENTS: A collaborative network of hospitals and health care providers across the city of Nashville that will deliver integrated, quality, patient-centered care to the uninsured and underinsured, according to their areas of specialty. 1 • • Nashville General Hospital will serve as the hub of the network, coordinating care with the city’s private hospital systems, community-based clinics and social service agencies. AS THE NEXT STEP IN THE PROCESS, WE RECOMMEND THE CREATION OF A NEW NETWORK IMPLEMENTATION TEAM THAT WILL DETERMINE A FISCAL AND OPERATIONAL STRUCTURE TO MAKE THE SAFETY NET SYSTEM VIABLE, SUSTAINABLE, AND SUCCESSFUL. THE ROLE OF THE PLANNING TEAM WILL BE TO: • Conduct a detailed gap analysis of the current system to gather and assess current data on who is in need, where they live and work, and the services required. • Recommend the most effective funding mechanism for the new system by studying best practices, identifying available resources, and testing various financial models. • Determine the ideal management structure for the new system by examining best practices and testing various management scenarios. • Assess the infrastructural needs of Nashville General Hospital and recommend a capital improvement program that involves either renovating the existing structure or constructing a new one. Patients can enter the network through any provider within the system and will be directed to the best care options based on their specific medical needs. An indigent care management program called BetterHealth Nashville®, which will coordinate the care of Nashville’s most vulnerable residents, ensuring that their services are adequately funded, their treatment is tracked and integrated, and their social needs are addressed. 2 • BetterHealth Nashville® will be managed by Meharry Medical College, which will coordinate care for eligible patients and engage the Data Science Institute at Meharry to track and manage their medical and social needs wherever they receive care within the network. • Patient care will be reimbursed through a newly-formed indigent care fund. Funds will follow the patient wherever they receive care in the network. 4 The safety net is one for people who don’t have other kinds of access. It’s also absolutely a source of high quality, affordable care for everybody in this community. COMMUNITY MEMBER AT STAKEHOLDER WORK TEAM LISTENING SESSION 5 Nashville’s Health Care Infrastructure Nashville, Tennessee is the capital for health care services in the U.S. and is often referred to as the “Silicon Valley” for start-up health care companies. Its rich history in health care began in the mid-1870s with the founding of the Medical Department of Central Tennessee College (Meharry Medical College) and Vanderbilt University Medical Center (Vanderbilt School of Medicine). Today, Nashville is home to more than 500 health care companies, including 17 publicly-traded corporations, which work locally, nationally and globally, and generate over $92 billion in revenue and 570,000 jobs. Nashville is also home to nearly 400 professional service firms that provide expertise to the health care industry. Despite this purchasing power and health care intellectual capital, comprehensive and efficient indigent care in the city is a pernicious, unresolved issue. If we are to maintain our growth and national profile, we must become a healthy city for all who live and work here. 17 publicly traded health care companies 570,000 global jobs created by the health care industry $92 Billion in annual revenue Source: Nashville Health Care Council 7 1890 1876 9 Meharry Medical College founded City Hospital opens; later named Metro General Hospital 1915 Meharry’s Hubbard Hospital built; moves to North Nashville in 1930 History of Nashville General Hospital Nashville General Hospital at Meharry has cared for the people of the Nashville community for more than 128 years. When it first opened as City Hospital on April 23, 1890, with one physician, seven nurses and 60 beds, the hospital’s mission was to provide health care services to the desperately ill or those persons unable to care for themselves. It has carried that mission forward to this day. A decade later, Meharry’s 8th president and future U.S. Surgeon General, Dr. David Satcher, introduced a plan to merge Hubbard Hospital and the city’s hospital, then called Metro General Hospital. The plan benefited both institutions. Meharry was considering closing Hubbard Hospital and Metro General Hospital was faced with renovating its 100-year-old facility or building a new hospital. The history of Nashville General is intricately linked with Meharry Medical College, which was founded in 1876 to train black doctors to treat freed slaves. Meharry was named to honor the Meharry family, which gave more than $30,000 in cash and real estate to fund the school in thanks for a kindness received from a family of former slaves. Since its founding, Meharry has pursued a singular mission: to serve the underserved. Today it is one of the top five producers of primary care physicians in the nation. In 1992, the Metropolitan Council approved the plan. A year later, Meharry Medical College began providing medical services at Metro General Hospital. On January 11, 1998, following renovations to the building, the new Metropolitan Nashville General Hospital at Meharry was dedicated. In 1915, the year Meharry Medical College obtained its own granted charter, area citizens raised enough money to erect a hospital honoring the college’s first dean and president, Dr. George W. Hubbard. First erected in South Nashville, the George W. Hubbard Hospital moved to North Nashville in 1930. With nowhere else to go for health care, most black people in Nashville turned to Hubbard Hospital until the 1960s. For a quarter century, Nashville General Hospital has served as the principle teaching hospital for Meharry’s clinical training, with Meharry residents and students providing care to the patients there. Meharry students and residents train in family medicine, internal medicine, occupational medicine, preventive medicine, OB/GYN, and psychiatry at Nashville General Hospital. The hospital represents a unique public-private alliance between Meharry and the Metropolitan Government of Davidson County to care for the most vulnerable citizens of Nashville. In the late 1970s, Meharry constructed a new Hubbard Hospital, featuring an 11-story tower and 400 bed facility. 1992 1970s New Hubbard Hospital constructed on Meharry’s campus Metro Council approves plan to merge Hubbard Hospital and Metro General Hospital on Meharry’s campus 1998 Metropolitan Nashville General Hospital at Meharry dedicated 10 The significance of Meharry Medical College and Nashville General Hospital to the City of Nashville Nashville General Hospital is a primary safety net provider in the city. Meharry and Nashville General Hospital provide over $83 million in uncompensated care to the medically underserved of Nashville. Meharry Medical College’s core mission is to serve the underserved. 4 of 5 medical and dental Meharry alumni practice in underserved rural and urban communities. 70% of Meharry medical graduates pursue primary care specialties. 11 12 100,000+ residenTs of Nashville are uninsured or underinsured. Current State of Indigent Care in Nashville According to the Institute of Medicine, a safety net system is made up of “those providers that organize and deliver a significant level of health care and other needed services to uninsured, Medicaid and other vulnerable patients.” Nashville’s safety net system includes one public and three private hospital systems, three Federally Qualified Health Centers (FQHC), and multiple community and faith-based providers. Thirty-five sites in Middle Tennessee provide outpatient care to the medically underserved. More than 100,000 residents rely on this system for their health care. Yet Nashville’s safety net is overwhelmingly fragmented, relies heavily on inpatient versus outpatient care, lacks significant capital investment, and is currently undergoing political scrutiny. There is no process in place to track the services that hospitals and clinics provide to vulnerable Source: Institute of Medicine patients, leaving them with inconsistent and uncoordinated care. Nashville General Hospital and Meharry Medical College provide $83 million in uncompensated care to the uninsured or underinsured each year. Additionally, Nashville’s three hospital systems – HCA Healthcare, Ascension Saint Thomas Health, and Vanderbilt University Medical Center – provided more than $153 million in uncompensated care to the uninsured or underinsured in 2016 alone. Such expenses tax both the city of Nashville and the hospitals that must carry the load. Over the years, it has become increasingly clear that Nashville needs a newly designed indigent care system that is more centralized and seamless. However, discussions on the care and financing for the medically underserved in Nashville have been contentious. 14 We are questioning whether or not we should be doing indigent care, which seems so backwards. If you have people who are your own, you take care of your own. COMMUNITY MEMBER AT STAKEHOLDER WORK TEAM LISTENING SESSION 15 MARKET CONDITIONS $ Over 100,000 residents of Nashville – or 15% of the population – are uninsured or underinsured. According to Perception Health, the three major hospital systems in Nashville provided over $150M of uncompensated inpatient care in 2016. In 2016, the 35 safety net organizations in Nashville/ Davidson County provided care to 109,448 patients in 339,451 visits. The population at risk of being classified as indigent and thus requiring free or subsidized care: Homeless..................................................................................................2,365 <$15,000: ...............................................................................................36,553 $15-24,999: ............................................................................................30,446 $25-34,999: ............................................................................................31,069 Total Indigent Population...................................................... 109,448 Population of Davidson County........................................................697,945 Total Indigent Population as Percent of Total..................................... 15.6% Source: Perception Health 1616 NASHVILLE GENERAL HOSPITAL The uncertain status of Nashville General Hospital is a constant theme in the discussions about indigent care in Nashville. Nashville General maintains 114 licensed beds and 546 employees. It reported 26,410 ER visits, 2,454 inpatient admissions, and 40,621 outpatient visits in 2018. In partnership with Meharry Medical College, Nashville General provides approximately $83 million in uncompensated care each year. Meharry Medical College alone provides over $26 million of that. Three of Davidson County’s top ten zip codes for uninsured residents receiving inpatient and emergency services in Davidson County are adjacent to Nashville General Hospital. Nashville General Hospital provides the bulk of uninsured care for specialty populations as well, including patients from the Tennessee Prison for Women, Riverbend Maximum Security Institution, and the Turney Center Industrial Complex. Metro Government provides a subsidy of approximately $35 million per year to Nashville General Hospital to defray the cost of caring for the high number of medically underserved patients who visit the hospital. Yet in recent years, this level of city funding has not been sufficient to cover expenses at the hospital. Consequently, Metro has had to approve emergency funding to stabilize Nashville General Hospital. In the meantime, the patient volumes at the hospital have fallen, threatening Meharry residents’ training in certain service lines. In November 2017, then-Mayor Megan Barry proposed cutting costs by closing inpatient care at the hospital. Rather than stabilizing the situation, the proposal created further uncertainty and concern in the community served by Nashville General Hospital. NASHVILLE GENERAL HOSPITAL PAYER MIX MEDICAID/ TENNCARE 18% MEDICARE 15% SELF PAY 56% OTHER THIRD PARTY 11% Source(s): Nashville General Hospital, June 30, 2017 Audit Report 17 AVERAGE CHARGE PER PATIENT CHAMPUS COMMERCIAL MANAGED CARE MEDICAID MEDICARE MEDICARE HMO METRO PRISONERS NASHVILLE INDIGENT OTHER GOVERMENT SELF PAY SELF PAY AFTER INSURANCE TENNCARE $- $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 Source(s): Data from 2017 Medicare Cost Reported in October 2017, Perception Health 2018 20 NASHVILLE’S THREE MAJOR HOSPITAL SYSTEMS Number of licensed beds at top Nashville area hospitals ASCENSION SAINT THOMAS MIDTOWN 683 TRI- STAR CENTENNIAL 686 VANDERBILT 1025 Three major health systems – HCA Healthcare, Ascension Saint Thomas Health, and Vanderbilt University Medical Center—play an important role in caring for the medically underserved. Critical Nashville area hospitals in these systems include: ASCENSION SAINT THOMAS MIDTOWN HOSPITAL, a nonprofit, has more than 36 service areas, including general wellness centers, emergency care, wound care, obstetrics and gynecology, behavioral health, cardiology, pulmonology, gastroenterology, nephrology, endocrinology, neurology, rheumatology, orthopedics, radiology and pharmacology. As of 2017, Ascension Saint Thomas Midtown maintained 683 licensed beds, 2,901 associates and affiliated physicians, 47,146 ER visits, 15,163 surgeries, and 195,183 outpatient visits. TRI-STAR CENTENNIAL MEDICAL CENTER, a for-profit HCA Healthcare hospital, offers medical and surgical programs including behavioral health, 24-hour emergency care, cardiology and vascular care, radiology, neurology, oncology, orthopedics, pediatrics, rehabilitation, sleep disorder care, and women’s services. As of 2017, Centennial maintained 686 licensed beds, 4,100 staff and physicians, 32,500 patient admissions, and 87,500 ER visits each year. VANDERBILT UNIVERSITY MEDICAL CENTER (VUMC), a nonprofit, is the only Level 1 trauma center in the Nashville Metropolitan Area. Its service lines include neurology, ophthalmology, otolaryngology, cardiology, pulmonology, gastroenterology, urology, oncology, obstetrics & gynecology, pediatrics, orthopedics, transplants (hepatic, general, trauma, vascular), and anesthesiology. As of 2016, VUMC maintained 1025 licensed beds, 20,235 employees, 123,632 ER visits, 57,421 surgeries, 1,903,548 outpatient visits. 21 THE SAFETY NET CONSORTIUM OF MIDDLE TENNESSEE The Safety Net Consortium of Middle Tennessee, a nonprofit, was founded in 2000 to help the medically underserved of Nashville access the services of the safety net system. The Consortium brings together clinics, providers, academicians, consumers, and community leaders to integrate knowledge and skills supporting the safety net and improve patient care. The Consortium’s “Project Access Nashville” and “Project Access Nashville – Specialty Care” programs have led to more than 62,000 individuals finding a medical home and over 4,700 accessing specialty care. MEMBERS OF THE SAFETY NET CONSORTIUM ASCENSION SAINT THOMAS HEALTH MEHARRY MEDICAL COLLEGE NASHVILLE ACADEMY OF MEDICINE CENTERSTONE MEHARRY VANDERBILT NASHVILLE GENERAL HOSPITAL CHARIS HEALTH CENTER CONNECTUS HEALTH FAITH FAMILY MEDICAL CENTER HOPE CLINIC INTERFAITH DENTAL CLINIC MATTHEW WALKER MEDICAL CLINIC ALLIANCE MENTAL HEALTH AMERICA OF MIDDLE TENNESSEE MERCY COMMUNITY HEALTHCARE METRO PUBLIC HEALTH DEPARTMENT MIDDLE TENNESSEE ORAL HEALTH COALITION Project Access Nashville Project Access Nashville Specialty Care = 62,000 individuals finding a medical home NEIGHBORHOOD HEALTH SALVUS CENTER SILOAM HEALTH NEIGHBORHOOD HEALTH TENNESSEE DISABILITY COALITION 22 FEDERALLY QUALIFIED HEALTH CARE ORGANIZATIONS MATTHEW WALKER COMPREHENSIVE HEALTH CENTER Provides primary medical care, behavioral health services, dental care and health education to approximately 17,000 people annually in Nashville, Clarksville and Smyrna, Tennessee. NEIGHBORHOOD HEALTH Described as “Nashville’s Family Doctor”; provides family medical care, a 24-hour call-line, preventive, urgent and chronic care, lab tests, and prescriptions. CONNECTUS HEALTH A nonprofit community health care organization that helps manage the health care of the entire family and community, including individuals who are underinsured or lack insurance. 23 Share of Uncompensated Inpatient Care Though the three private hospital systems have created programs to assist patients who have difficulty paying for care, Nashville General Hospital provides the highest percentage of charitable care in the city. According to the 2016 Annual Report of the Tennessee Hospital Association, Ascension Saint Thomas Midtown contributed 3.8% of its total inpatient care in a charitable capacity, Centennial contributed 0.3%, and Vanderbilt University Medical Center contributed 3.5%. In the same year, Nashville General Hospital topped all Davidson County hospitals with 18.4% charitable care. Vanderbilt Stallworth Rehab St. Thomas Specialty Surgery Centennial Medical Center Summit Southern Hills Skyline Vanderbilt St. Thomas West St. Thomas Midtown Nashville General Hospital 0% 20% 40% Uncompensated Care 60% Total Net Revenue Source(s): Data from 2017 Medicare Cost Reported in October 2017, Perception Health 2018 25 80% 100% TOTAL UNCOMPENSATED COST OF INPATIENT HOSPITAL CARE Vanderbilt Stallworth Rehab St. Thomas Specialty Surgery $13,699 $178,404 Southern Hills $2,128,518 Summit $2,834,187 Skyline $7,483,036 Centennial Medical Center $7,500,952 St. Thomas West St. Thomas Midtown $14,392,262 $24,079,083 Nashville General Hospital Vanderbilt $38,722,734 $56,721,370 Source(s): Data from 2017 Medicare Cost Reported in October 2017, Perception Health 2018 26 Indigent Care Stakeholder Work Team OVERVIEW In response to community concern about then-Mayor Megan Barry’s 2017 announcement to close inpatient care at Nashville General Hospital, Meharry President and CEO Dr. James E.K. Hildreth volunteered to form an Indigent Care Stakeholder Work Team to look more deeply at the system in Nashville. Because of the college’s long-established mission to serve the underserved, Meharry felt a duty – and was uniquely qualified – to lead the conversation about the future of indigent care. To ensure that all perspectives were brought to the table, Dr. Hildreth invited representatives of health care and community organizations to join the Stakeholder Work Team. By design, each member of the team approached indigent care from a unique perspective, yet all shared the same goal: to deliver the best possible care to those in our city who need it most. The Stakeholder Work Team convened to identify strengths and gaps in the safety net system in Nashville. Since December 2017, the Stakeholder Work Team has met in public and private sessions to assess the current system and research other models for indigent care delivery. Members of the full Work Team met monthly in executive session to define parameters of their assignment, report on research and progress, and deliberate recommendations. Additionally, the Work Team engaged in the following activities: • Community Engagement: The Work Team ensured transparency and community input with an outreach plan that included: A dedicated website: www.home.mmc.edu/stakeholder-mission where the Work Team posted its findings and solicited community feedback. Six community listening sessions at locations throughout the city where members of the greater community provided input about their concerns and desires surrounding health care. A case competition in which graduate students at the Milken School of Public Health at George Washington University were invited to study the system and present their insights and recommendations on the future of indigent care in Nashville. • Models of Care Committee – The Work Team tasked this committee with assessing Nashville’s current Safety Net System and examining exemplary models of indigent care delivery in other cities to inform the creation of a system in Nashville. • Funding Models Committee – The Work Team tasked this committee with exploring national funding models. The following are major themes that arose throughout the year of Stakeholder Work Team study: 27 1 CUSTOMER SEGMENTS Who needs to be served? (Insured? Uninsured? Residents? Other?) F E E D BAC K Everyone Homeless, students, working poor, immigrants, incarcerated Start broadly to include everyone and then narrow it down to set parameters on geographic boundaries 2 VALUE PROPOSITION What are the customer needs to be satisfied? What is most important to you about this process? F E E D BAC K Seamless integration regardless of ability to pay Stable source of care connected to social determinants of health Systems approach to electronic medical records (EMR) Adequate communication at the level patients can understand Improved health education/lifestyle habits Preventive care/wellness Management of chronic conditions Emergency, primary, and specialty care Convenient and timely access to care 28 3 KEY ACTIVITIES What should be the core, fundamental activities provided? What are the service gaps? F E E D BAC K Transportation, access, care coordination, primary ambulatory care that is culturally competent, planning and resource allocation process Communication to patients about where to go to access care and costs of health care Electronic Medical Record/shared health data among providers Service gaps: interpreters, health literacy, mental health, linkage to service, access to specialists, continuity of care, language barriers, chronic and preventive care 4 PARTNERS Who are the key strategic partners? What will these partners bring to the table? F E E D BAC K Nashville General Hospital Health Science Physicians Educators City government FQHCs Insurers State/Federal/CMS Community Patients (educational institutions, religious 29 Meharry Employees organizations, etc.) Prisoners Three major Mental health hospital systems organizations Community advocates that provide direct services Faith-based clinics Business community Medical schools Nashville Technology Council Metropolitan Transit Authority 5 DELIVERY How should we deliver services and interact with stakeholders? (pre-service, point-of-service, and after-service?) F E E D BAC K Technology driven Messaging Community leaders Tech, data, brain power Clinic, acute care, Service standards: chronic care language, hours, Inclusion of hours of Clinic, virtual, operation app, palliative Services should be integrated care, ongoing communication Media K E Y R E S O U R C E S What key resources does our value proposition require? Technology Interoperability Infrastructure Providers Funding Data and modeling expertise Information systems Political will (political buy-in from city and state leaders) R E V E N U E What are the sources of funds that will make a sustainable system and how do we capture these funds? Leaders from like- TennCare/Private models that have Insurance succeeded Funding Payers Community Community buy-in Foundation of and advertising of Middle Tennessee services Up-to-date equipment S T R E A M S Grants Commonwealth Group Foundation CMS Innovation Fund City/State Government Beta testers Centennial Vanderbilt Ascension Saint Thomas Metro Employee Health Plan Dedicated Local Tax Charitable gifts Appropriate metro funds to fill gaps Business/ Entertainment Industry 30 Community Engagement THE IMPORTANCE OF NASHVILLE GENERAL HOSPITAL AND MEHARRY The Stakeholder Work Team developed an outreach plan for the community and other stakeholders to ensure that members of the public were regularly and fully informed about the progress of its work, and to provide ample opportunity for them to give their perspectives and input on the discussions. The plan aided in the intentional inclusion of community members amidst a low-trust social and political climate. “Not only is Meharry an important part of taking care of the most important people, which are indigent patients, but they train doctors who do the same thing.” A key component of the outreach plan was a series of six community listening sessions, allowing Davidson County residents an opportunity to provide feedback about then-Mayor Barry’s announcement, as well as input on ways to move forward. “This is about the people in our community who are generally overlooked, but Meharry has always been there for them.” The following are the dates and locations of the listening sessions and major themes that emerged: DATE January 24, 2018 February 15, 2018 February 15, 2018 March 3, 2018 April 21, 2018 June 19, 2018 31 LOCATION First Baptist Church Capitol Hill Meharry/Vanderbilt Alliance Safety Net Consortium Olive Branch Church Salahadeen Center and Mosque of Nashville Coleman Park Community Center First Baptist Church Capitol Hill “There is not another hospital in the state of Tennessee that can do what Meharry Medical College or Nashville General will do – not can do, but will do.” “General Hospital, in the past they give great service to the Kurdish community. They give good service to people who don’t have insurance. I can’t pay my bill, but monthly, I pay. They saw my income was low. So, they found the resources to cover my bills. They did.” CITY OF NASHVILLE’S ROLE “What we’re dealing with is the by-product of a systematic failure on the part of the leadership of this city to address the issue of General Hospital and the issue of Meharry Medical College.” “This is [a]… defining issue that will give this community an opportunity to deal forthrightly with the things that have systematically undermined and hurt us and kept us from being the city that we have the opportunity to be.” “The word on the street is also that we pay taxes but our taxes are not equitably given to health care and particularly for indigent individuals in our community.” “We are questioning whether or not we should be doing indigent care, which seems so backwards. If you have people who are your own, you take care of your own.” Not only is Meharry an important part of taking care of the most important people, which are indigent patients, but they train doctors who do the same thing. COMMUNITY MEMBER AT STAKEHOLDER WORK TEAM LISTENING SESSION 32 NASHVILLE GENERAL HOSPITAL BUDGET “Historically, what the mayor submits to the Metro Council is lower than what the hospital has said they needed. So, when that happens over a period of time, then in my humble opinion, you have set this entity up to fail.” “It’s just that every budget is a matter of priorities and the priorities are set by politics and typically, in the city of Nashville at the local level, health has not been a major political priority.” “Our problem is that we don’t have money to market. We don’t have money to buy the most comfortable beds. We have been given around the same money since 1998. We are working in 2018 with a 1998 budget.” “You are looking at Nashville General like it has the financial capabilities of an HCA or an Ascension Hospital, and we don’t. We haven’t been properly funded for years.” “Health care services is probably less than 5% of the total Metro budget.” CARE FOR THE POOR “I think people have a sense when you see these uncompensated care numbers presented, that these other hospitals are doing all of this free care. They are, but 99.9% of it is coming from patients who present in the Emergency Department. So, they are not walking into Centennial or Ascension Saint Thomas and saying, ‘I have cancer. Can you give me chemotherapy?’ [That’s] going to be a short conversation.” “Lots of times we think that people are indigent because they did something wrong, but I didn’t do anything wrong. I just got sick.” “What’s really important in a lot of the talk that goes on these days, is to remember that two thirds of people who are living in poverty in this community are working.” “The safety net is a safety net for people who don’t have other kinds of access. It is also absolutely a source of high quality, affordable care for everybody in this community.” CONTINUITY OF CARE “Every hospital—public, private, nonprofit—has a responsibility under EMTALA to take care of patients who present in the emergency department, but once that patient’s crisis or medical condition is stable, they no longer have an obligation, they can discharge that patient.” 33 “It really goes back to all those social determinants of health. When you are discharging somebody to a place that’s not healthy or safe, then it doesn’t work.” “One of the pieces that has really fallen to the wayside for our patients is that follow-up care that they desperately need.” “We must streamline processes for our patients to figure out how to allow for admission/ discharge and transfer (ADT) of information.” “I want to echo what the doctor said about continuity of care. That’s very important. I work in the clinics and we cannot do what we do without the hospital.” “We kill a lot of trees in this town because we have no common eligibility process.” INTEGRATED CARE “From the perspective of oral health in our city, it’s still grossly under-funded. It is still in the top 2 or 3 of top needs when people are asked about their overall health.” “It’s not just primary care. It is primary care, with behavioral health; with oral health; with a nutritionist; with the pharmacy; with all of that integrated together that makes the work that we do work.” “The most expensive people served by Metro General, by Saint Thomas, by Vanderbilt, they’ve got mental illness on top of diabetes or some other chronic health condition.” “There is a 300% increase in costs when caring for a patient that has a co-morbidity [hypertension, diabetes, and alcoholism] along with some other kind of issue in addition to behavioral health.” “There is no health without mental health. People are not well and cannot be healthy without good mental health.” KEY THEMES OF COMMUNITY LISTENING SESSIONS Nashville General Hospital and Meharry are important and valued. Nashville has an obligation to care for vulnerable citizens. Nashville General Hospital’s budget is inadequate to care for the poor. Coordination of care is important to health outcomes. Integrated care is imperative. 34 Models of Care Committee CONSENSUS WORKSHOP • Importance of a dedicated funding source The Models of Care Committee examined the systems of care in Nashville, explored successful models in other communities, and made recommendations to the Stakeholder Work Team. The committee held a consensus workshop to define key goals, assess the current system, and look at sustainable models around the country. • Plan that integrates hospitals, Federally Qualified Health Centers and public health • Incentives for the entire system to work together • Amount of TennCare dollars received The facilitated consensus workshop focused conversations on the current and ideal state of Nashville’s safety net system. The committee sought to answer the following question: • Population Health approach and inclusion of social determinants of health • Broadened specialty care • Implication of Medicaid Expansion • How might Nashville create a system of care in Davidson County that leaves no one behind? The conversations emphasized current assets, challenges, and opportunities within Nashville’s safety net system, and how to develop a more coordinated and integrated system. The framework involved participating in a collective, integrated thinking process to create a shared vision for indigent care. In preparation for the meeting, several items were sent to the group to review, including models of care from other municipalities and the John Snow, Inc. report, which was commissioned in 2010 by Metro Nashville and Davidson County Government to assess care alternatives for Nashville’s medically underserved residents. The group provided feedback on its initial assessment of these items. Seven primary points of interest emerged: 35 The committee agreed to change its task from “How might Nashville create a system of care that leaves no one behind?” to “What incremental changes/enhancements to the current system of care would set in motion a system that leaves no one behind?” The facilitator asked each of the seven participants to write down 10-15 essential incremental changes to the current system. The participants were then separated into two groups, to discuss essential elements and identify the most salient. A summary of potential enhancements to the current system by Models of Care Committee: 1 OPTIMIZE ACCESS Increase access to sub-specialty care. Increase utilization of sub-specialty Advanced Practice Professionals in Federally Qualified Health Centers. Increase utilization of telemedicine to improve access to care. Integrate behavioral health into care. 2 GO UPSTREAM Ensure community-wide health education, including how patients can access care. Incentivize investment in social determinants of health. Improve patient access to transportation. 3 CARE COORDINATION Utilize community health workers/navigators. Coordinate between acute care and public health professionals. Create community-wide database of resources for uninsured and underinsured. Triage to most appropriate provider type. 38 4 CONNECTED CARE Establish tech-enabled shared standards for medical homes. Create shared “core” Electronic Health Record-lite. Admission/Discharge/Transfer (ADT) system. 5 COMMON ELIGIBILITY Create shared process determining eligibility for enrollment. Establish universal qualifying system. 6 FOCUSED COLLABORATIVE SOLUTIONS Ensure focused collaboration on high-spend conditions. Pilot program/defined by service and diagnosis. Further define “highest and best use” of existing assets. 39 7 PLANNING & STRUCTURE Create centralized leading and planning entity that is integrated and involves key stakeholders. Establish an authority/body to facilitate forward progress. Implement “standing” structure to coordinate inter-system continued collaboration. Establish shared plan to address community-identified needs. Create partnerships to train a more culturally-competent workforce. Encourage investment and engagement of private industry. 40 RESEARCHED INDIGENT CARE MODELS OUTCOMES FROM HCHCP HAVE BEEN POSITIVE : The Models of Care Committee also researched safety net systems that have been identified as providing exemplary care to the uninsured and underinsured. The following is an overview of the programs the committee reviewed. • From 2006 to 2016, HCHCP served more than 260,000 residents with an estimated positive economic impact of over $1 billion. • HCHCP experiences an annual $23 million savings in ER costs due to community partnerships. • HCHCP serves approximately 18,000 unduplicated members per year and has an average monthly enrollment of 13,000. • There has been a 5% average annual growth in pharmacy claims since 2013 and 89% average HCHCP utilization by enrolled HCHCP members. HILLSBOROUGH COUNTY HEALTH CARE PLAN (HCHCP) Tampa, Florida OVERVIEW: The Hillsborough County Board of County Commissioners created the Hillsborough County Health Care Plan (HCHCP) in 1991 to provide a reliable source of funding for the delivery of health care to low-income, uninsured residents. • • Funding: a ½ cent sales tax, deposited into a Health Care Trust Fund. Eligibility: Residents who do not qualify for the Affordable Care Act, Medicaid, or any other insurance, and with incomes at or below 125% of the poverty level, qualify. A resident must also be a U.S. citizen or documented legal representative of the U.S. CONGREGATIONAL HEALTH NETWORK (CHN) Memphis, Tennessee OVERVIEW: The Congregational Health Network (CHN) is a partnership established in 2006 between Methodist Le Bonheur Health and nearly 400 churches in Memphis, Tennessee to improve health education of local parishioners and help them seek proper care through the Methodist Health System. THE HCHCP IS IMPORTANT TO THE HILLSBOROUGH COUNTY ECONOMY: THE NETWORK INVOLVES BOTH HEALTH SYSTEM EMPLOYEES AND VOLUNTEERS: • In FY 2016, HCHCP provided approximately $90 million to community health care providers. • • HCHCP has 12 hospitals, 31 primary care clinics, over 3,000 participating medical specialists, and a host of ancillary services. Navigators employed by Methodist Le Bonheur Healthcare train at least two volunteer liaisons per congregation on the basic services provided by the health system. • These liaisons connect the patient to health resources. • Navigators work with each patient from admission to post-discharge. THE HCHCP IS OVERSEEN BY THE HILLSBOROUGH COUNTY HOSPITAL AUTHORITY BOARD THAT HAS RESPONSIBILITY FOR: • • • 41 Monitoring the lease permitting Florida Health Sciences Center, Inc. to occupy the Authority’s Davis Island property, and transferring ownership and operation of Tampa General Hospital. OUTCOM ES OF CHN HAVE BEEN POSITIVE : • More than 12,000 congregants are enrolled in the program. • Monitoring the hospital’s overall condition, indigent and charity care reports, and minority business enterprise (MBE) contract participation. A recent study found that the mortality rate of CHN members was nearly half the rate of non-enrolled patients with similar characteristics. • Reviewing grievances by citizens who feel they were denied care due to the inability to pay. The same analysis showed CHN members had lower health care costs than non-participants. • CHN members had a lower inpatient utilization and a higher satisfaction level with the Methodist Health Care system. CENTRAL HEALTH MEDICAL ACCESS PROGRAM Austin, Texas • MAP enrollment reached 44,397 in FY 2017, an increase of 2,743 from the previous year. • MAP provider network expanded to 20 new locations throughout Central Texas in 2017. OVERVIEW : Established in 2005, the Medical Access Program (MAP) by Central Health in Austin, Texas covers primary care, prescriptions, specialty care, and hospital care for low income Travis County residents. THE PROGRAM INVOLVES A HOSPITAL HUB THAT IS SUPPORTED BY OTHER PROVIDERS: • Medical care is provided at CommUnityCare Health Centers and other contracted providers in the community. • Hospital care is provided at Dell Seton Medical Center at the University of Texas. • MAP services include in-network physician services, hospital care, outpatient care (including specialty care), x-rays, lab services, emergency care, home health care, durable medical equipment, prescription drugs, dental services, and emergency transportation. Some services require pre-authorization. • Enrolled individuals receive a MAP ID Card for health care services through any participating clinics or doctors. LIVE WELL SAN DIEGO San Diego, California OVERVIEW: Live Well San Diego was adopted by the San Diego Board of Supervisors in 2010 to work with over 300 “recognized partners” to build a better service delivery system, support positive choices, pursue policy and environmental changes, and improve the overall culture of health in San Diego. THOUGH THIS MODEL DOES NOT DIRECTLY ADDRESS THE INDIGENT POPULATION, OUTCOMES HAVE BEEN POSITIVE: • The program’s partners are comprised of business, government, faith-based, and education organizations. • The number of partners increased to 124 in FY2015, compared to 51 the previous year. • More than one million San Diegans were added to the Live Well San Diego network with the addition of two hospital systems, increasing the total participating hospitals and medical facilities to 21. PUBLIC-PRIVATE PARTNERSHIP IS ESSENTIAL TO MAP: Dell Seton Medical Center is a privately-owned hospital on public land. Dell Seton Medical Center is owned and operated by the Seton Healthcare Family. The University of Texas leases the property to Central Health, Travis County’s health care district, which subleases it to Seton. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM (AHCCCS) State of Arizona The region’s newest hospital, Dell Seton is the primary teaching hospital for UT’s Dell Medical School. It is a Level 1 trauma center with 42 trauma beds, 13 operating rooms, 211 patient rooms (with capacity to add up to 135), 517,000 square feet, and a $310 million price tag for design and construction. The Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid agency, contracts with several health plans to provide covered services. 2017 OUTCOMES: • 150,800 people received health care services (+7,800 year-over-year). • 75,737 people received screening and assistance for coverage (+5,061 year-over-year). • 1,524 people received health insurance premium assistance. • Annual safety net primary care visits have more than doubled since inception (2005). OVERVIEW: THE HEALTH PLAN FUNCTIONS LIKE AN HMO: • An AHCCCS health plan works with doctors, hospitals, pharmacies, and specialists to provide care. • AHCCCS helps citizens schedule provider appointments, physical exams, immunizations, prenatal care, hospital care, and prescriptions. AHCCCS IS DRIVEN BY INNOVATION: AHCCCS operates under a Section 1115 Research and Demonstration waiver, which allows it to experiment with coverage and care delivery. 44 AHCCCS lists several initiatives targeting the reduction of fragmentation of health care services across Arizona. These include care coordination and integration, payment modernization, health information technology for communications, developing private sector partners, targeted investments incentivizing providers, and electronic visit verification. OUTCOMES HAVE BEEN POSITIVE: AHCCCS reported 2,827,495 unduplicated enrollees for FY 2017, an increase of 109,681 from the previous year. BOSTON HEALTH CARE FOR THE HOMELESS PROGRAM (BHCHP) Boston, Massachusetts OVERVIEW: The Boston Health Care for the Homeless Program (BHCHP) started in 1985 with a grant from the Robert Wood Johnson Foundation and the Pew Charitable Trust. The program began as a four-year pilot program and developed into a cost-effective, national model of providing comprehensive health care to more than 11,000 vulnerable men, women, and children each year. BOSTON HOSPITALS RELY ON THE PROGRAM: • Through BHCHP, vulnerable patients are kept alive and get help for chronic diseases like diabetes, hypertension, and cancer. • Boston’s hospitals depend on BHCHP as an alternative to the emergency room as well as a safe discharge location for medically vulnerable patients. • Services provided by BHCHP include adult primary care, behavioral health, family services, medical respite care, oral health services, and specialized services (which includes HIV care, Hepatitis C services, substance abuse disorders services, and transgender services). OUTCOMES HAVE BEEN POSITIVE: • Started as a four-year pilot program, BHCHP has developed into a national model providing comprehensive care to more than 11,000 men, women, and children each year. • Total revenue in FY2016 reached $56,596,611, compared to $49,476,332 in the previous year. • Since 2003, BCHCP has had a more than 110% increase in patients accessing oral health services. SUMMARY The programs reviewed by the Models of Care Committee have several features in common: • All systems had member agreement on the definition of the safety net with a common vision and goals as part of multi-year strategic plans. 
 • Performance and accountability of the systems were aligned with the overall safety net system goals. • All systems had organized, cohesive systems of care. • All systems provided or arranged for primary care services for their target populations. 
 • Most systems had created their own niches for specialty services in their communities. 
 • All systems had strong community-based constituencies. 
 • Most systems had made significant investments in information system technology. THE PROGRAM HAS DIVERSE FUNDING AND PARTNERS: • BHCHP’s budget is approximately $50 million; about 75% of that comes from third party reimbursements from MassHealth, Medicare, and Health Safety Net. • The remainder of the funding comes from grants and philanthropy. • BHCHP’s partnerships include members of the hospital, shelter, government, and nonprofit communities. 46 Funding Model Committee The Funding Model Committee analyzed Nashville’s indigent care funding structure, researched best practices in other cities and states, and made final recommendations to the Stakeholder Work Team. Several models inform how the city of Nashville could fund indigent care. • Participants may also incur a fee based on their income level, determined by a sliding scale. • Participants receive comprehensive health services including primary, specialty, mental health, emergency care, hospital care, prescription drugs and substance abuse treatment. TAX-BASED FUNDING • Each participant receives an enrollment card and selects a medical home for primary and preventive services. • Specialty care is provided by San Francisco’s public hospital and private nonprofit hospitals. Proponents of tax-based funding generally view access to health care as a right that should not be constrained by income or health status. Nashville General Hospital has historically served low-income populations, especially those people who cannot afford health insurance. A dedicated tax funding model would create a consistent revenue stream for the hospital. If pursued, a surcharge or tax could be incorporated into growing sectors of Nashville’s economy, including tourism, restaurant service, and utility bills; or on unhealthy items such as soda. Cities across the country have benefited greatly from a tax-based funding system. In just four months after the Philadelphia City Council approved a 1.5-cents-per-ounce soda tax on artificially sweetened beverages, it collected $25.6 million to fund health initiatives in the city. Soda taxes have also been enacted in Oakland, California; Boulder, Colorado; and Portland, Oregon. THE PROGRAM IS FUNDED THROUGH A MIX OF SOURCES: • The city’s general fund ($38 million in fiscal year 2016-17) • Contributions from private hospitals and medical homes ($8 million) • Participant sliding scale fees ($2 million) • Employers’ payments under the San Francisco City Option Program ($3 million) San Francisco, California The program also allows employers to add a “Healthy San Francisco Surcharge” to their goods and services to help pay for their employees’ access to the program. Restaurants, for example, can add a surcharge of around 4% to a patron’s check. OVERVIEW: In FY2016-17, an estimated $50.63 million was spent on Healthy San Francisco: HEALTHY SAN FRANCISCO Operated by the San Francisco Department of Public Health, the Healthy San Francisco program helps make health care services affordable to uninsured residents of the city. The program is broad and robust: • The program is available to all San Francisco residents regardless of immigration status, employment status, or pre-existing health conditions. • Participants must show proof of residency; be uninsured for at least 90 days; be ineligible for public insurance programs; be living on a combined family income at or below 500% of the Federal Poverty Level; and be over the age of 18. DER 47 • The San Francisco Department of Public Health spent approximately $43.1 million. • Additional funding of $38.27 million was provided by a City and County of San Francisco General Fund subsidy. Private community providers reported an estimated $7.55 million in net expenditures. • $4.8 million of this was generated in revenue from Healthy San Francisco. RESEARCHED FUNDING MODELS STATE DESCRIPTION Tampa, FL 0.5% county sales tax is dedicated to the Hillsborough County Health Care Plan. San Francisco, CA 0.4% Health San Francisco Surcharge is charged to local restaurant patrons. Boston, MA Annual $50 million budget is comprised of grants, private donations, and third-party billing, especially Medicaid. Austin, TX Medical Access Program is supported by a dedicated local property tax. New York, NY NYC Care is funded by a $100 million/year increase to the NYC Health + Hospitals budget, coming directly from the city budget and not requiring any new taxes. Miami, FL The operation, maintenance and administration of The Public Health Trust of Miami-Dade County hospitals and clinics are funded by a voter-approved 0.5% sales tax. 48 49 THE OUTCOMES OF HEALTHY SAN FRANCISCO HAVE BEEN POSITIVE: Despite ongoing changes in health care, the Healthy San Francisco program has continued to positively impact the health of its participants. According to the most recent annual report in 2016-2017: • The percentage of respondents who reported visiting an emergency room in a 12-month period declined since 2008. • The percentage of respondents who reported delays with receiving care declined since 2008, and the percentage of participants who reported good to excellent health increased. • The number of uninsured adults aged 18-64 in San Francisco declined from 90,000 in 2010 to 30,000 in 2016. Enrollees in HSF peaked at 55,000 in 2013 and decreased to 20,000 in 2016, due to citizens gaining access to Medi-Cal under ACA expansion. However, HSF continues to be a major source of access to care for the city’s estimated 35,000 undocumented residents. In light of the political landscape, the success of the Healthy San Francisco program has continued to evolve and meet the changing needs of the city’s most vulnerable population for ten years. GAMING -BASED FUNDING : “LOTTERY TAX” Education systems in the United States have benefited from supplemental funding through state lotteries. Indigent care could similarly benefit. Viewed as a “voluntary tax,” many state lotteries allocate funds to K-12 public educational programs or scholarships for higher education. However, eight states direct their lottery revenue to a general fund. The money from the general fund is then redistributed to other areas of the state, including health care. The lottery presents a steady stream of revenue that is consistently growing. The average American spends more money on lottery tickets than reading materials or movie tickets. In Tennessee, the Tennessee Education Lottery Corporation (TEL) closed the last fiscal year with gross total sales of $1.73 billion. Due to the growth of the lottery, TEL was able to increase funding to education by 9.1 percent in FY18. This growth has great implications for how beneficial the lottery for Nashville’s indigent care system could be if a portion of revenue were redirected towards health care. be partially diverted to a city health care system. Additionally, this approach would run the risk of pitting education against health care funding. OTHER SOURCES OF REVENUE HOSPITAL SYSTEM FOUNDATION Establishment of a private, nonprofit foundation to support indigent care could provide additional support and strength to a stable funding source, such as a tax. Many safety net hospitals across the country operate a foundation within their organizational structures, allowing individual citizens and community organizations to support the hospital financially. Effective foundations have been able to raise millions of dollars that contribute to the care of a hospital’s indigent populations. THE HENRY W. GRADY HEALTH FOUNDATION Atlanta, Georgia OVERVIEW: The Henry W. Grady Health Foundation works with donors, corporations and civic activists to raise money for Grady Memorial Hospital and provide underserved patients with excellent medical care. The foundation is a thriving example of philanthropic efforts that support a safety net hospital: • In 2017, gifts from annual donors, campaign donors, employees, and sponsors raised $19.4 million. Gifts came from 150+ organizations and 1500+ individuals. • The foundation collaborates with other organizations to renovate outdated areas of the hospital and provides naming rights to new programs. For example, The Marcus Foundation, Inc., gave $20 million to expand the Marcus Trauma and Emergency Center and $10 million for the Marcus Stroke and Neuroscience Center Multidisciplinary Outpatient Center. • Projects are also funded through public provisions. Grady Memorial Hospital is building the Center for Advanced Surgical Services funded as a 50/50 public-private partnership by bonds issued from Fulton and DeKalb counties and philanthropic partnerships. In theory, a lottery general fund or specified allocation for health care could support indigent care in Nashville. However, the concept creates obvious complications. It would be difficult to gain approval for state-wide lottery funds to 50 INDIGENT CARE TRUST FUND (ICTF) An Indigent Care Trust Fund (ICTF) expands Medicaid eligibility and services, supporting rural and other health care providers, primarily hospitals that serve the medically indigent. An ICTF funds primary health care programs for the medically indigent. INDIGENT CARE TRUST FUND (ICTF) State of Georgia OVERVIEW: Georgia Department of Community Health established the Indigent Care Trust Fund (ICTF) in 1990 to expand Medicaid eligibility and services; support rural and other health care providers, primarily hospitals which serve the medically indigent; and fund primary health care programs for medically indigent Georgians. THE ICTF IS AN UMBRELLA PROGRAM ICTF includes the Disproportionate Share Hospital (DSH) program; nursing home provider fees; Care Management Organization (CMO) Quality Assessment Fees; breast cancer tag fees, ambulance rates, and other initiatives. ICTF funding allows uninsured people who do not qualify for Medicaid to receive health care from participating hospitals. BUDGET MANAGEMENT The Casemix or Activity-Based Funding (ABF) model has proven effective for indigent care. It allocates funding based on the number and types of patients treated and the average cost of treating patients. The purpose of the model is to promote transparency, accountability, and efficiency in government funding. Casemix or ABF was popularized by the State Government of Victoria, Australia. Victoria uses this model to monitor, manage, and administer the funding of health care provided by public hospitals. It has proven beneficial in focusing on patient care and improving treatment outcomes. THE PRINCIPLES OF CASEMIX OR ABF: Equitable Access • Allocate services in accordance with need for services • Provide patient choice • Promote the delivery of appropriate care at the appropriate time 51 • Facility setting to maximize quantity and quality of health care • Patient health needs are treated alike (horizontal access equity) • Patients with greatest needs are treated preferentially (vertical access equity) • Patient, not provider, focused Effectiveness • Increases health care outputs and/or improves health outcomes • Evidence-based • Integrated technical efficiency • Delivers highest quality care for the resources used • Transparency and accountability • Auditable sustainability • Reduces long-term health expenditures THE STEPS FOR CASEMIX OR ABF INCLUDE: • Step 1: Classify the patients • • Step 2: Count patients • • Patients are grouped to Diagnostic Related Group (DRG) All admitted patient activity is reported through a hospital dataset Step 3: Cost of patients • Measure and report costs for each episode of care • Step 4: Calculate Weighted Inlier Equivalent Separation (WIES) DRG cost (adjusted for patient’s length of stay) + co-payment (adjusted for patients with higher costs, such as ICU patients) • Step 5: Patient care funding=WIES x Price This calculation provides the total per patient funding need from the government. In order to implement this plan, Nashville would need to examine each service and identify the dollar amount to treat the patient with a specific illness. A history of past patients treated can provide an estimate of how much would need to be allocated for upcoming budget years. PRINCIPLES OF CASEMIX OR ABF ALLOCATES SERVICES ACCORDING TO NEED PROVIDES PATIENT CHOICE PROMOTES DELIVERY OF THE RIGHT CARE AT THE RIGHT TIME PATIENT HEALTH NEEDS ARE TREATED ALIKE (HORIZONTAL ACCESS EQUITY) PATIENTS WITH GREATEST NEED ARE TREATED PREFERENTIALLY (VERTICAL ACCESS EQUITY) CASEMIX OR ABF PROCESS CLASSIFY PATIENTS PATIENT CARE FUNDING = WIES X PRICE CALCULATE WIES COUNT PATIENTS COST OF PATIENTS 52 Findings and Recommendations of the Indigent Care Stakeholder Work Team Today, Nashville’s safety net includes nearly three dozen health centers and hospitals that all provide care to the city’s medically underserved. There is no “majority stakeholder.” Though Nashville General Hospital carries a significant share of the care as the city’s only public hospital, no single organization provides the majority of safety net services. More importantly, no single organization oversees the system as a whole. There is no coordinating entity assessing performance, mobilizing resources to fill gaps, or guiding strategic investments by Metro, payers, and health care systems. THE GOALS OF THE SYSTEM : • Optimize access for medically underserved patients (technology, providers) • Go upstream (incentivize work on social determinants, education, prevention) • Coordinate care (navigators, resources, methods, standards) • Connect care (records, sharing appropriately) Public debate and ambivalence about Metro’s funding for Nashville General Hospital often monopolizes conversations about the city’s safety net system. Unpredictable funding for Nashville General Hospital has a ripple effect on the stability of health care providers. Previous assessments of the funding mechanism focused on Nashville General Hospital rather than the larger safety net system. • Create a common/shared eligibility process • Develop focused, collaborative solutions (e.g., strategies for patient categories where lowering cost or improving outcomes is a shared priority) • Streamline structure and planning (establish a leading entity; create a diverse and competent workforce) There is, however, a track record of collaboration. The many stakeholders of the Safety Net Consortium of Middle Tennessee have worked consistently over the last 15 years to enhance coordination, streamline systems, fill gaps, and improve outcomes. This new safety net system should reflect the vested interest of all stakeholders and build upon the best practices of the most successful indigent care models in the country. It should be viewed as a whole – a shared community investment, not a charity or isolated Metro obligation. At its core, the new system should be rooted in the belief that better health for all Nashvillians will improve the well-being of the whole city. The Stakeholder Work Team believes Nashville can build on this foundation to transform and elevate the care that the city of Nashville provides to our medically underserved. WE RECOMMEND THAT NASHVILLE CREATE A SAFETY NET SYSTEM THAT PLACES PATIENTS AT ITS CENTER AND ACTIVELY INVOLVES THE CITY’S ENTIRE HEALTH CARE INFRASTRUCTURE IN THEIR CARE. 53 THE MEMBERS OF THE STAKEHOLDER WORK TEAM BELIEVE : Nashville must become a healthy city for all who live and work here if we are to maintain our vitality, growth and national profile. Every resident of Nashville deserves quality health care delivered in an environment that is conducive to wellness, regardless of zip code or ability to pay. Health care for all must be viewed as a strategic, shared community asset, not as an isolated city investment. The patient—not the provider— must be the priority and center of care. To truly be effective, the system must address nutrition, transportation, housing and other social determinants of health that impact a patient’s quality of life. Nashville’s entire health care community must be involved in the system to maximize care to our vulnerable residents, leverage resources and eliminate duplication of services. Nashville’s position as a health care capital creates the unique opportunity to optimize the best minds in health care and make our safety net system a model for the nation. 55 WE RECOMMEND A NEW SAFETY NET SYSTEM THAT IS COMPRISED OF TWO CORE ELEMENTS : 1 THE THREE MAJOR HOSPITAL SYSTEMS A COLLABORATIVE NETWORK OF SAFETY NET PROVIDERS A collaborative network of hospitals and health care providers across the city of Nashville will deliver integrated, quality, patient-centered care to the uninsured and underinsured, according to their areas of specialty. • Nashville General Hospital will serve as the hub of the network and focus on delivery of care in three Centers of Excellence: Oral and Systemic Health, Diabetes, and Hypertension. • The three hospital systems – HCA Healthcare, Ascension Saint Thomas Health, and Vanderbilt University Medical Center – will provide patients with specialty services that are outside of Nashville General Hospital’s areas of expertise, such as transplants, certain surgical subspecialties, cardiothoracic surgery, certain subspecialty cardiology, and radiation oncology. • FQHC and community clinics throughout Nashville will continue to provide safety net services and refer patients for inpatient services to Nashville General Hospital for additional treatment. • Nashville General Hospital and the city’s three major hospital systems should consider the feasibility of a mutually-beneficial agreement under which the private hospitals transfer their low acuity patients to Nashville General. 56 Safety Net System Provider Network Nashville General Hospital will be the hub where patients receive emergency and primary care services. It will develop three Centers of Excellence in Oral and Systemic Health, Diabetes and Hypertension. INDIGENT CARE NETWORK STRUCTURE Nashville General Hospital will send its patients who need specialized treatment—surgical subspecialties, radiation oncology, etc.—to Nashville’s three major hospital systems. The network will be supported by public and social service agencies (MTA, MDHA, senior centers) that can assist with the social issues that impact patient health, such as insufficient food services, lack of transportation, or homelessness. Nashville General Hospital and the city’s three major hospital systems should consider the feasibility of a mutually-beneficial agreement under which the private hospitals transfer their low acuity patients to Nashville General. 57 SPECIALTY CARE PATIENTS LOW ACUITY PATIENTS LOW ACUITY PATIENTS LOW ACUITY PATIENTS NGH SPECIALTY CARE PATIENTS Saint Thomas Midtown SPECIALTY CARE PATIENTS TriStar Centennial Medical Center LOW ACUITY PATIENTS FQHCs, Meharry Clinics and Other Safety Net Clinics Vanderbilt University Medical Center 58 DETERMINANTS OF HEALTH Genes & Biology Social/Societal Characteristics Health Behaviors Total Ecology Medical Care • Genes and biology: sex and age • Health behaviors: alcohol use and smoking • Social environment or social characteristics: income and gender • Physical environment or total ecology: neighborhood and population characteristics • Health services or medical care: access to quality health care and insurance 59 2 BETTERHEALTH NASHVILLE ® – A NEW INDIGENT CARE MANAGEMENT PROGRAM BetterHealth Nashville® – an indigent care management program – will be formed to coordinate the care of Nashville’s most vulnerable residents, ensuring that their services are adequately funded, treatment is tracked and integrated, and their social needs are addressed. • The program will be developed and managed by Meharry Medical College, which has been treating the underserved of Nashville for 142 years and has the necessary expertise in medical and oral health care disparities and social determinants of health. • Patient care will be reimbursed through a newly-formed indigent care fund. Funds will follow the individual patients throughout the network so that their care is covered wherever they receive treatment. • The new indigent care fund will be created from public and private dollars. It will not tap into the funding already allocated by the city of Nashville to operate Nashville General Hospital. • Patients will qualify for the system based on predetermined eligibility criteria, including income and insurance status, and can access care from any provider in the network based on their medical needs. • Patients in the program will be assigned a care coordinator who will help navigate the safety net system, identify the most suitable providers, and manage their ongoing treatment. • The care coordinators also will help patients identify and address the social challenges that impact their health, including inadequate housing and nutrition, and lack of transportation to and from doctors’ appointments. • The Data Science Institute at Meharry will create risk profiles for patients and track their treatment throughout the network to decrease redundancy and waste, pinpoint trends, and produce better outcomes. BETTERHEALTH NASHVILLE ® REIMBURSEMENT STRUCTURE Traditionally, in the city of Nashville, public funding for hospital-based indigent care has been distributed to Nashville General Hospital to treat uninsured and underinsured patients. This funding approach was implemented decades ago because, as the city’s dedicated safety net hospital, Nashville General provides the highest percentage of indigent care to the residents of the city. However, it has not been ideal for Nashville General, other area providers, underserved patients, or taxpayers. Under the current funding structure: • Nashville General must be a one-stop health care provider to all its patients, offering a broad range of health care services even if those same services are offered by other hospital providers just a few miles away. • Other hospitals and clinics must write-off millions of dollars each year that they spend treating uninsured and underinsured patients • Patients who live far from Nashville General Hospital and do not have access to adequate transportation often choose to forgo treatment and fall through the cracks. The Stakeholder Work Team recommends the creation of a new indigent care fund that will cover the cost of care for patients who are eligible for BetterHealth Nashville®. We envision that both public and private dollars will be allocated to create the fund, and that it will be separate from the funding the city already provides to operate Nashville General Hospital. Patients who are eligible for BetterHealth Nashville® can pursue care at any provider within the safety net system, and their treatment will be reimbursed out of the new indigent care fund. This new funding structure creates maximum efficiency for the system. Nashville General Hospital will no longer have to be all things to all people. It can concentrate on the services at which it excels, such as emergency care, primary care, and treatment for diabetes and hypertension; and refer patients with high acuity issues, such as specialized oncology or transplant, to other area providers, whose services will be covered. The patient becomes the center of the safety net system and all the providers collaborate to deliver the highest quality personalized care. 60 BetterHealth Nashville ® Patient is enrolled in BetterHealth Nashville® program. • Program will be facilitated by Meharry Medical College. Patient qualifies based on income level, insurance coverage and other factors. • Patient will be assigned a care coordinator who will help navigate the network and access proper treatment. • The Data Science Institute at Meharry will create a profile for each patient that includes medical needs, family history, and social determinants of health, including nutrition and transportation. • Profile will be included in BetterHealth Nashville® database. 61 Safety Net providers will have access to BetterHealth Nashville® database and can track patient outcomes. • Database eliminates need for patients to detail their history every time they visit a provider. Patient can access care at any safety net provider in the network. • Patient information will be tracked through the database. • Consistent data and tracking lead to seamless experience for the patient and better health outcomes. • Funding will follow the patient rather than be allocated to any single provider. 62 THE ROLE OF DATA SCIENCE Interoperability between organizations in the safety net system will be essential to ensuring that patients receive consistent and effective care while leveraging resources and eliminating duplication of efforts. The power of data science provides a comprehensive view of a system and makes interoperability attainable as never before in health care. Doctors and health plans need a complete, holistic understanding of their patients’ issues in and out of the health care setting. This information leads to optimal outcomes and appropriate payment. Currently, providers who attempt to exchange information about patients navigate a complex web of technology systems filled with latent data, which captures mere snippets of information about patients at each individual treatment episode. What arises is an incomplete picture of each patient’s status. Meharry Medical College has made a capital investment of $1 million over the past two years to establish a Data Science Institute to inform student training, patient care, and biomedical research. This initial investment built the technical infrastructure and data ecosystem architecture to establish a “data lake” of clinical data from Nashville General Hospital, Meharry Medical Group, and Meharry’s School of Dentistry. Built on open source technology and hosted in a secure cloud, the data lake includes environmental health data (the “exposome”), social determinants of health, and publiclyavailable behavioral data from social media. This Nashville General Hospital-Meharry health data ecosystem has proved a foundation for clinical interoperability between Nashville General Hospital and Meharry electronic medical records, enabling the systematic combination of multiple data sets for analysis, reporting, and visualization. The goal is to make evidence-based decisions answering real-world problems. It makes it possible for multiple providers to track patient progress and predict outcomes, leading to more efficiencies and better care. The Stakeholder Work Team recommends that the city of Nashville partner with the Data Science Institute at Meharry to leverage data-driven information for actionable insights on the continuum of care of our most vulnerable citizens. The Coordinated Care Project would provide efficient care coordination and communication with multiple organizations across the city. The Data Science Institute will establish a central “viewing platform” where summaries of patient history with both the health care system and other city agencies (homeless shelters, social services, etc.) can be accessed by relevant stakeholders. The Data Science Institute at Meharry currently has two tools for leveraging the data lake: the Discover Tool and the Alteryx Tool. The Discover Tool allows users to manage patient cohorts for clinical quality care and inform shared risk with health insurance plans. It is used by academic health science researchers in facilitating clinical translational research from bench to bedside. The Alteryx Tool allows data scientists to look across multi-factorial, structured and non-structured data to develop new predictive models for various disease states. Meharry continues its institutional investment in the Data Science Institute. The next 12 months will deepen use of the Discover Tool by the Meharry-Nashville General Hospital Health Network for developing predictive models on hypertension, cardiovascular disease, obesity, and type-2 diabetes. THE COORDINATED CARE PROJECT 63 Central “viewing platform” summarizes patient engagement with both the health care system and other city agencies (homeless shelters, social services, etc.) Provides efficient coordination and communication of patient information with multiple agencies throughout Nashville Provides city of Nashville a crucial asset from Meharry Health to assist in influencing outcomes pursuant to a person’s health long before interaction with a care provider during an episode of care Enables differentiated “views” according to stakeholder need DISTRIBUTED ACCESS CONTROL AGILITY CENTRALIZED CONTENT SCALABILITY DATA LAKE KNOWLEDGE DISCOVERY WITH DISCOVER & ALTERYX TOOLS Health Care Exposome Social Determinants Social Media 64 Implementation AS THE NEXT STEP IN THE PROCESS, THE STAKEHOLDER WORK TEAM RECOMMENDS THE CREATION OF A NEW NETWORK IMPLEMENTATION TEAM THAT WILL DETERMINE A FISCAL AND OPERATIONAL STRUCTURE TO MAKE THE SAFETY NET SYSTEM VIABLE, SUSTAINABLE, AND SUC CESSFUL. Creating and sustaining the proposed safety net system will require thoughtful, thorough implementation and follow-through. There are multiple important considerations: management of the system, funding, reimbursement structure, distribution of responsibility among partners, coordination of care, and capital needs. Currently, Nashville does not have a central body in place to build the infrastructure for the new system and implement the necessary systemic changes. The Stakeholder Work Team recommends the creation of such an entity. The new, independent implementation team will determine the best financial and operational structure that ensures patients receive the highest quality care at a manageable cost with measurable outcomes. It will analyze gaps in the current system and initiate improvements. This entity will ensure public accountability and be charged with catalyzing changes that support an integrated health system for Nashville’s medically underserved population. STRUCTURE OF NETWORK IMPLEMENTATION TEAM The Stakeholder Work Team recommends launching the new Network Implementation Team by May 1, 2019. Meharry Medical College will consult with the city of Nashville and other health care partners to determine the overall funding structure of the team and a timeline for implementation and delivery. The new Network Implementation Team should be an outgrowth of the Stakeholder Work Team and include the following elements: • A governing board carefully composed to represent health system, philanthropy, business, government, and consumer perspectives; • An operating board substantially based on the current Safety Net Consortium; 65 • A staff (initially 1-2 positions) that reports to the operating board and is responsible for: • Conducting the necessary assessments of the current system; • Recommending, coordinating and overseeing system improvements; and • Facilitating and mediating solutions across the organizations participating in the system. Central to the work of the new Network Implementation Team will be the following: • Conduct a gap analysis of the current system to gather and assess current data on who is in need, where they live and work, and the services required. • Recommend the most effective funding mechanism for the new system by studying best practices, identifying available resources, and testing various financial models. • Determine the ideal management structure for the new system by examining best practices and testing various management scenarios. • Assess the feasibility of bringing on a strategic partner to oversee the consolidation of services at Nashville General Hospital and Meharry Health Clinics to increase efficiency and reduce duplication of services. • Assess the infrastructural needs of Nashville General Hospital and recommend a capital improvement program that involves either renovating the existing structure or constructing a new one. INFRASTRUCTURE OF NASHVILLE GENERAL HOSPITAL A critical topic in the conversation surrounding Nashville General Hospital is the quality of its services and infrastructure, and whether they meet the needs of today’s patients of all income levels. As part of its work, the new Network Implementation Team should assess the level of capital commitment needed to raise the hospital’s standards by renovating the existing structure or constructing a new one. The following are specific points for consideration regarding the hospital infrastructure: • • A new design should meet the needs of today’s patient, with an emphasis on emergency and ambulatory services and a smaller inpatient unit. • An updated facility could bolster use of Nashville General by Metro employees who can gain incentives for receiving medical treatment at the hospital. • The city should consider contracting with a strategic partner with expertise in hospital management to help oversee the facility, identify new revenue streams, and share the risk. The design should support the establishment of three Centers of Excellence at Nashville General Hospital in Systemic and Oral Health, Diabetes, and Hypertension. NEXT STEPS: PROPOSED IMPLEMENTATION PHASE 1 ASSESSMENT OF MMC SERVICE LINES AT NGH Addictive Medicine / Behavioral Health Cardiology Endocrinology Gastroenterology Nephrology Obstetrics & Gynecology Ophthalmology Oral Health & Systemic Health Disparities Orthopedic Surgery Podiatry Urgent Care PHASE 2 PHASE 3 AGREEMENTS AND FUNDING ADDITIONAL CONSIDERATIONS Potential joint enterprise with Meharry Medical College & Nashville General Hospital Establish Level 2 Trauma Affiliation agreements with FQHCs Petition the State to increase payment from Public Hospitals Supplemental Pool Fund Develop patient transfer center Establish a system-wide referral network Hospital investment via Opportunity Fund or other funding source Continuity clinics for resident training in Internal Medicine, Family Medicine, Obstetrics in the FQHC Physical and Oral Health Care integration in multiple locations serving the medically underserved Partner with community health workers providing patient-centered medical home models Urology Vascular Surgery Surgery 68 Conclusion The safety net system in Nashville is not sustainable nor coordinated in its current state. However, the demonstrated strength of the providers and their vested interest in delivering optimal care for the medically underserved illustrates potential for the successful implementation of dynamic system-wide change. Nashville has the commitment, expertise, and motivation to be a model for indigent care throughout the nation. 69 Achieving this objective will require a long-term approach, leveraging the will and the creativity of the entire city of Nashville. The Indigent Care Stakeholder Work Team believes such commitment is achievable and looks forward to working toward a new safety net system that will provide the highest quality care to the medically underserved, while ensuring that resources are maximized and costs contained. A MODEL OF PERSONALIZED CARE FOR ALL Better health outcomes Cost effective Reduced waste Increased and seamless efficiency Patient-centered compassionate care for all Increased cost savings city-wide Value-based Reduced use of ER Increased opportunity to achieve health equity Work across the city to reduce costs for high-spend diagnoses 70 IIHHIIH ACKNOWLEDGEMENTS The Stakeholder team would like to acknowledge those who contributed to the development of this report over the last year. We owe a great deal of gratitude for their investment of time and talent in formulating the set of recommendations for Nashville’s indigent care system. KIT ABNEY- SPELCE MARK BROWN PAULETT DAVIS Senior Director of Eligibility Services Chief Operating Officer Special Projects Coordinator Central Health Nashville General Hospital AMY ANDRADE PERLA CAVAZOS Hillsborough County Florida Health Care Services Assistant Vice President of Research Vice President of Government Affairs GENE EARLEY Meharry Medical College Data Science Institute Central Health Department Director NANCY ANNESS, M.S.N., A.P.N., F.N.P.- B.C. THEODORE (TED) CHAN, M.D., F.A.C.E.P., F.A.A.E.M. Hillsborough County Florida Health Care Services Emergency Medicine Physician, Chair of Emergency Medicine ANTHONY ESCOBIO Ascension Saint Thomas Health UC San Diego Health Tampa General Hospital NICHOLAS ARLEDGE, M.B.A. JOHN CLARK Executive Director of Clinical Operations Chief Information Officer MARQUETTA L . FAULKNER, M.D., M.B.A., F.A.C.P., F.A.S.N. Chief Advocacy Officer University of Texas at Austin Dell Medical School KIMBERLY AVANT Program Manager Meharry-Vanderbilt Alliance KATINA BEARD, M.S.P.H. Chief Executive Officer Vice President of Revenue Cycle MARIAH COLE, J.D. Former Dean of the School of Medicine and Professor, Internal Medicine Director, Program Management Meharry Medical College Center for Health Policy at Meharry Medical College TOD FETHERLING MILLARD D. COLLINS, M.D. Perception Health Central Health Associate Professor & Chair, Family & Community Medicine CEO STEVE FREEDMAN, Ph.D., F.A.A.P, N.A.S.I. Matthew Walker Comprehensive Health Center, Inc Meharry Medical College REGINALD COOPWOOD, M.D. Adj. Professor of Health Policy & Pediatrics TERENCE A. BECK, C.H.C., C.I.C.A. CEOr University of South Florida Chief Operations Officer Regional One Health Tampa Family Health Centers MONICA CROWLEY LEONARD HOWARD FREIDMAN, Ph.D., M.P.H., F.A.C.H.E. Professor and Program Director CRAIG BECKER Chief Strategy & Planning Officer President and CEO Central Health George Washington University DR. JOHN CURRAN NIELS FRENCH Tennessee Hospital Association JOHANNE BELIZAIRE, M.D. Residency in Internal Medicine at the Teaching Hospital of Peace Port-au-Prince, Haiti George Washington University Retired Professor of Pediatrics & Associate Vice President, USF Health Hillsborough County Florida Health Care Services APRIL CURRY- ROBERTS, Ed.M. PATRICIA BLANTON Director of Admissions Manager, Records & Recovery Meharry Medical College Hillsborough County Florida Health Care Services Director of Operations & International Ministries Methodist Healthcare ASHLEY SUSAN FROST, LEIGH ANNE LEGARE, KATELYN LEE, AMANDA ANNE MEEKINS, AND BROOKE MICHELLE HOPKINS SUMNER Milken Institute School of Public Health George Washington University 72 SCOTT FULLER DEAN JESSUP, J.D. JONATHAN MORGAN Vice President of Joint Ventures & Alliances Manager, Fiscal & Contracts Compliance CEO & Interim Executive Director Ascension Texas Hillsborough County Florida Health Care Services MIKE GEESLIN Community Care Collaborative DR. ALBERT MOSLEY Senior Vice President, Faith & Health President & CEO PAM JONES, D.N.P, R.N., N.E.A.- B.C. Central Health Senior Associate Dean/ Associate Professor DONNA GRIGGS Vanderbilt University School of Nursing County Commissioner, District 1 ROLAND JONES Hillsborough County Florida Board of County Commissioners CEO E3 Performance Group Methodist Health SANDRA L . MURMAN EDDIE HAMILTON, M.D. Assoc. Dean of Business & Finance, School of Medicine Physician Meharry Medical College Icon Pediatrics JEFF KNODEL , C.P.A. Tampa Family Health Centers PATRICIA M. HAMMOCK, M.Ed. Chief Financial Officer MARC OVERLOCK, J.D., M.D.I.V. Program Specialists Central Health Meharry Medical College DEVIN LAWRENCE, M.B.A. Nashville General Hospital C. MARTIN HARRIS, M.D., M.B.A. Assoc. Director, Practice Administrator CAROLINE PORTIS - JENKINS, F.N.P. Associate Vice President of the Health Enterprise & Chief Business Officer of Business Affairs Community Care Health Centers JANET LESTER Connect Us Health University of Texas at Austin Dell Medical School Administrative Assistant to the Chief Nursing Office BILL PURCELL FONDA HARRIS, Ph.D Director of Health Access Nashville General Hospital DR. WENDY LONG ESTELLA NEIZER-ASHUN Chief Clinical Officer General Counsel Co-Chief Executive Officer Former Mayor of Nashville Founding Partner Farmer Purcell White & Lassiter, PLLC Metropolitan Government of Nashville and Davidson County Deputy Commissioner GREG HARTMAN KAREN LOWERY Chief of External & Academic Affairs Director of Business Development Ascension Texas HCA Healthcare Kingwood Medical Center DR. MONICA R. RIDER ELIZABETH MARRERO, M.S.S.W. Tampa Family Health Centers LORENS A. HELMCHEN, PH.D. Associate Professor of Health Policy & Management, Milken Institute School of Public Health Department of TennCare Program Director Central Health SHANNON RHODES Project Manager, Contracting Hillsborough County Florida Health Care Services Chief Medical Officer JILL RISSI, Ph.D., M.P.A. MIKE MERRILL Associate Professor, Associate Dean for Academic Affairs Administrator Portland State University Chief Executive Officer Hillsborough County Florida Health Care Services HEATHER ROHAN, F.A.C.H.E. Suncoast Community Health Centers, Inc KAREN MINYARD, Ph.D. George Washington University BRADLEY P. HERREMANS, M.B.A., F.A.C.H.E. SUZANNE HURLEY, F.N.P. Co-Chief Executive Officer Connect Us Health DANIEL JACKSON Vice President of Administration Well- Star 73 Executive Director Georgia State University President TriStar Division of Hospital Corporation of America MICHELLE ROBERTSON CATRINA L . MELTON Chief Operating Officer Public Relations Specialist Ascension Saint Thomas Health WellStar MARGARET ROBINSON Executive Assistant, School of Medicine Dean Meharry Medical College STEVEN G. ULLMANN, Ph.D. Executive Assistant, School of Medicine Dean Professor and Chair of the Department of Health Sector Management and Policy in the School of Business Administration Meharry Medical College University of Miami MEGAN M. ROGERS TAMA VAN DECAR, M.D., A.C.P.E. Program Coordinator, Assistant to Pam Jones Chief Medical Officer MARGARET ROBINSON TriStar Centennial Medical Center Nursing Clinical and Community Service Units at KEVIN WAGNER Vanderbilt University Principal Business Analyst AMY SEIGENTHALER Hillsborough County Florida Health Care Services Managing Partner Finn Partners, Inc. THOMAS SHARP Policy Director Metropolitan Nashville Public Health Department BONNIE SLOVIS, M.D., M.S.H.S. Professor of Medicine, Associate Division Director for Clinical Affairs Medical Director, Adult Cystic Fibrosis Center Vanderbilt University Medical Center STEPHEN J. SMITH, M.Ed. Program Manager Center for Health Policy at Meharry Medical College DUANE SMOOT, M.D., F.A.C.P., F.A.C.G., A.G.A.F Sr. Associate Dean for Clinical Affairs & Professor LARRY WALLACE Executive Vice President & COO Central Health JOSEPH WEBB, D.S.C., F.A.C.H.E. Chief Executive Officer Nashville General Hospital SHERI WEINER Councilwoman Metropolitan Nashville & Davidson County JOEL F. WEST Managing Partner Capgenus CONSUELO H. WILKINS, M.D., M.S.C.I. Executive Director, MeharryVanderbilt Alliance, Associate Professor of Medicine Meharry Medical College Vanderbilt University Medical Center and Meharry Medical College TOM STARLING CAROLINE YOUNG CEO, President Executive Director Mental Health America of Middle Tennessee NashvilleHealth MOLLY SUDDERTH Director of Community Engagement NashvilleHealth DR. RHONDA SWITZER- NADASDI’S, D.M.D. Chief Executive Officer Interfaith Dental Clinic 74