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Using Text Messages to Help People Find Primary Care

How can text messages encourage people to see a doctor? Lessons from New Orleans

Joseph Boskovski and Owen Phillips

If you haven’t seen a doctor in a long time, the thought of picking up the phone to schedule an appointment can be terrifying. Sometimes it’s easier to adopt an “out of sight out of mind” mentality.However, the people who haven’t seen a doctor in years are the ones most likely to benefit from a check-up.

The and (a non-profit member association of New Orleans health clinics serving the poor and uninsured) is currently experimenting with innovative ways to encourage take-up rates of primary health care. Their focus is on patients qualifying for the Greater New Orleans Community Health Connection (GNOCHC), a Medicaid waiver program with similar eligibility requirements of the expanded Medicaid program available in many states (but until recently, not Louisiana) thanks to the Affordable Care Act. Community health leaders found that while the GNOCHC program provides critical primary and behavioral healthcare coverage, only about half of covered patients had utilized the free care available to them in the past 24 months.

In a project supported by program, the City of New Orleans and 504HealthNet engaged patients in the GNOCHC program through phone interviews, cohort convenings, and a day-long “design day” to understand their challenges in accessing care and to generate ideas for improving health care utilization.

One of the recurring themes that came out of that six-month long engagement was the need for better and more direct communication regarding the free health care available in a network of clinics established after Hurricane Katrina when the iconic Charity Hospital shut its doors for good.

With this feedback from patients, the New Orleans team asked the Behavioral Insights Team to design and conduct a randomized control trial to test different SMS text messages that encourage recipients to schedule a free check up. This trial was supported by Bloomberg Philanthropies’ initiative and is part of the City’s initiative, aimed at leveraging data science to improve City services in New Orleans.

Text messages were sent to over 21,000 low income adults (aged 19-64) in the GNOCHC program. Importantly, none of the recipients had seen a primary care physician in the past two years.

Those eligible were randomly allocated into three groups; the Simplicity group, the Ego group, and the Social Motivation group.

Every message included three parts. First, a warm greeting followed by instructions to text “YES” to be contacted by a healthcare representative to set up a free appointment, and an option to text “STOP” to unsubscribe.

But each message differed slightly in what was emphasized.

For example, the Simplicity group just received straightforward instructions to “Txt YES to be contacted to set up a FREE doctor’s appt.”

Meanwhile, the messages sent to the Ego group included an additional line that said, “You have been selected for a FREE doctor’s appt.”

And in the Social Motivation group recipients received, “Take care of yourself so you can care for the ones you love.”

texts_simp_ego_s.mot

 

 

 

 

 

 

 

 

Five days after the messages were sent we tallied up the number of “Yes” responses. The proportion of recipients who replied “Yes” in each group are displayed in the graph below:

Address Update_Final

Many of the people we polled in advance (ourselves included) were certain that the Social Motivation message would be most effective. But we were surprised to learn that it actually performed significantly worse than the Simplicity text.

It turns out, recipients in the Ego group were the most likely to respond “Yes”. Indeed, twice as many people responded “Yes” in the Ego group than in the Social Motivation group.

All differences are statistically significant at the 95% confidence level, meaning we can be very confident the results are not due to chance.

In the coming months we will follow up with the recipients to find out if these texts convert into actual appointments. But the results are clear: simple, low cost interventions, like the use of text messages, continue to prove to be a promising method for improving the lives of underserved populations.

There's Still Time To Get Health Insurance

Sign up during the Marketplace Special Enrollment Period March 15-April 30 and avoid paying a fine in 2016.

Visit one of these events and get in person assistance with enrollment.

To qualify for the special enrollment, all of the following should apply:

You are not currently enrolled in a health insurance plan
You did not have health insurance last year
You are filing taxes for 2014
You were not aware until after February 15, 2015 that there is a fine for not having health insurance

If you qualify, follow these steps by April 30, 2015

  1. Gather Social Security Numbers, employer and income information for everyone in your household who needs insurance.
  2. Choose how you want to apply:
    • Online at HealthCare.gov
    • Call the Marketplace at 1-800-318-2596 (open 24/7)
    • Locate the nearest in-person assistance by calling 504HealthNet at 504-206-6275

The Successes of Medicaid Expansion

The Louisiana Department of Health’s (LDH) innovative enrollment strategies along with the energetic outreach efforts of community organizations, like 504HealthNet, have resulted in the impressive enrollment of 225,900 people in Healthy Louisiana, which is Louisiana’s newly expanded Medicaid program. LDH is receiving nationwide attention for pioneering clever enrollment strategies, such as using enrollment in the Supplemental Nutrition Assistance Program (SNAP), or food stamps, to determine Medicaid eligibility, thereby expediting the application process for SNAP beneficiaries. Susan Todd, 504HealthNet’s executive director, emphasized, “This has truly been a collaborative effort by those working locally, state-wide, and nationally.” She also spoke of how, “Medicaid expansion will have an overwhelmingly positive impact on Louisiana’s budget and economy and is a critical step in ensuring access to health care services for everyone in the community.”

Through Medicaid expansion, over 100,000 people in the GNO area will have access to medications, treatment and preventive medicine, to help them manage chronic conditions like diabetes, or seek care when sick with the flu. This will not only strengthen the workforce in our community, but it will prevent people from going into bankruptcy and poverty due to medical bills they cannot pay. Ensuring everyone has medical insurance and access to care is an essential component to improving the health, stability and prosperity of our community.

In addition to providing health care services to Louisianans, Medicaid expansion is projected to increase Louisiana’s economic activity by $1.8 billion. This growth is projected to result in 15,600 new jobs, 30% of which will be outside of the healthcare industry. It will also positively impact Louisiana’s budget by dramatically reducing state spending on uninsured care, generating revenue through existing health plans and provider taxes as revenue increases, and accepting additional federal funding to pay for certain health services that would typically be paid for by the state budget. The tremendous economic benefits coupled with the drastic increase in access to care will lead to a better Louisiana. This is truly a historic moment for our state.

 

The House Passes a Shameful ACA Replacement Plan

Susan Todd, Executive Director, 504HealthNet                                                   5/4/17

The American Health Care Act (AHCA), the GOP-sponsored ACA replacement plan, passed through the House of Representatives today. This bill cuts $800 billion to the Medicaid program, eliminating benefits for people on Medicaid; decrease subsidies that help people pay for their health insurance; and effectively eliminates Medicaid expansion. In March, the CBO estimated that 24 million Americans would lose health insurance under this bill. Recent amendments to the AHCA made it even worse by allowing states to waive protections for people with pre-existing conditions, meaning that they could be charged much more for health insurance. The high-risk pools that will be implemented to cover people with pre-existing conditions are drastically underfunded, and are subsequently unable to fill the gap. As such, we believe that 24 million is a conservative estimate, as health insurance will certainly be unaffordable for many Americans with pre-existing conditions under this bill.

The AHCA shifts $10 billion in Medicaid costs to Louisiana. With a radical decrease in Federal support, our resource constrained state will be forced to end Medicaid expansion. Over 420,000 low-income Louisianans who recently gained coverage under Medicaid expansion will lose it. Huge cuts to Federal Medicaid funding plus per-capita caps will also lead to reduced coverage and services for 1.28 million Louisiana residents, many elderly or disabled, who rely on Medicaid for health care

Source: The Center on Budget Policies and Priorities

Furthermore, decreased subsidies for insurance will raise costs for Louisianans with Marketplace coverage, on average, by $4,823 annually. Finally, the AHCA will deepen Louisiana’s budget crisis. In the midst of this mess, the wealthiest Louisianans will get a big tax break.

This bill now moves to the Senate, and we ask Senators Kennedy and Cassidy to vote against it. We commend Senator Cassidy for his public opposition to the AHCA over the past few weeks, and urge him to stand by his commitment to prevent anyone from losing coverage, protect those with pre-existing conditions, and to design a system that puts patients first. As Senator Cassidy says, “it is better to give patients adequate coverage.” The alternative is costly, episodic, emergency care for the uninsured.

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504HealthNet is a non-profit coalition of 23 independent community health service providers who represent the primary care and behavioral health safety net for Southeastern Louisiana. Together, this network of community health centers is working collaboratively to improved access to services and better meet the primary care and behavioral health needs of low-income, uninsured, and underinsured residents in the Greater New Orleans area.

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Stand Up and Get Care: A Healthcare Campaign in New Orleans

Stand Up and Get Care: A Healthcare Campaign in New Orleans

Ariel White (former City Accelerator New Orleans project lead with 504 HealthNet)

After Hurricane Katrina hit New Orleans in August of 2005, the city was fundamentally changed. As the community came back to rebuild a devastated city health care organizations and local leaders used this as an opportunity to transform the previous system. For years care delivery for the uninsured was through Big Charity, a public hospital located in down town New Orleans. A visit to Big Charity was familiar to many people because they had been going through the giant concrete building for years with their grandparents, parents and their own children. Patients always knew that they would be taken care of at Charity, even if they had to wait.

Charity was closed following the storm forcing people to receive health care in other locations that were not there previously. Out of this need for primary and preventative care to be delivered across a city still rebuilding sprang a network of clinics. They took on the task of putting the health and wellness of the community at the forefront of their work.

504HealthNet consists of 22 non-profit and governmental organizations in the Greater New Orleans area who are committed to supporting primary care or behavioral health services with a special focus on low-income, uninsured populations.

 

This network is still in place ten years later, and built more robustly than ever. In the Greater New Orleans area there are 11 Federally Qualified Health Centers and 11 more service providers that accept patients regardless of their ability to pay. With more than 60 locations scattered across the region they have created opportunities for the community to manage their health in their own neighborhood. The Greater New Orleans area also has received a Medicaid waiver which grants free primary care and behavioral health visits to people living below 105 percent of the Federal Poverty Level. This means that the most vulnerable citizens have the ability to take care of their physical and mental wellbeing. This program, called the Greater New Orleans Community Health Connection (GNOCHC), provides coverage to more than 60,000 people in the region.

In 2014 the Department of Health and Human Services Medicaid Office realized that close to half of the individuals enrolled in the GNOCHC program had not seen their doctor in the last two years. This number is concerning on its own, but especially for New Orleans where there is a history of some of the worst health care outcomes in the nation. In the city 12% of babies are low birthweight, compared to 8% nationally, 12% of residents are diabetic, compared to 9% nationally and Orleans is consistently in the top five among US cities for HIV, and syphilis case rates. Since many of these cases can be addressed, prevented or mitigated in a primary care setting, getting people into care is more important than ever.

Stand Up and Get Care

As a result of the number of people who have not had a primary care visit in the last two years, the City’s Office of Performance and Accountability, the Office of Neighborhood Engagement, the New Orleans Health Department and 504HealthNet partnered to find out why so many people have not seen their doctor recently. Getting people to talk about their health is hard — it is a personal issue that is typically dealt with in a private setting.

Stand Up and Get Care was established to answer two questions: why are people not going to the doctor, and what can the City and their partners do to help. In order to get to those answers, small group meetings, and a larger Design Day event were held to ask participants to define and design their own solutions to the problems they see in the health care system.

Medicaid Expansion Kick-Off Press Release

FOR IMMEDIATE RELEASE

Medicaid Expansion Kicks Off in Louisiana as Enrollment Begins Today

New Orleans, LA (June 1, 2016)—

Governor John Bell Edwards, Secretary Rebekah Gee and Ruth Kennedy will host a press conference today, June 1st, at University Medical Center to kick off Medicaid expansion in Louisiana. The expanded Medicaid program is called Healthy Louisiana and an estimated 300,000 people will be eligible for coverage. “This will have an enormous impact on our community by increasing access to comprehensive health insurance coverage allowing families to get the care they need,” said Susan Todd, Executive Director of 504HealthNet. “We want to encourage everyone in our community to get covered.”

Eligibility is based on household size and income with citizenship or resident requirements. A household income level below 138% of the federal poverty line will qualify for coverage under expansion. This translates to $16,395 annually for one person or $33,534 annually for a household of four. More in depth eligibility information and how to apply can be found online at healthy.la.gov. Applications can be submitted June 1st with Medicaid benefits beginning on July 1st. Individuals can apply online at healthy.la.gov, by phone at 1-888-342-6207 or in person at various clinics throughout the city. Calling 504-658-2053 will help locate the closest location for in-person assistance in the New Oceans area.

DHH is striving to make the enrollment process run as smoothly and efficiently as possible. Take Charge Plus and the Greater New Orleans Community Health Connection (GNOCHC) beneficiaries will automatically be enrolled in Healthy Louisiana providing they had up to date mailing addresses. Letters were mailed to beneficiaries in May, informing them of their increase in benefits. Supplemental Nutrition Assistance Program (SNAP) beneficiaries will not have to fill out an application, but rather respond to letters mailed by DHH to be enrolled in Medicaid by calling 1-888-342-6207. In addition to bringing much needed coverage to many people across Louisiana, Medicaid expansion is also estimated to result in 15,600 new jobs and $1.8 billion in economic activity.

504HealthNet is a non-profit organization comprised of 23 community health service providers representing the primary care safety net for Orleans, Jefferson, St. Bernard, and Plaquemines Parishes. Together, this network of community health centers is working collaboratively to better meet the primary care and behavioral health needs of low-income, uninsured, and underinsured residents in the Greater New Orleans area.

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LOUISIANANS COME TOGETHER TO DEMAND “NO REPEAL WITHOUT REPLACEMENT”

Community Forum to Discuss Implications of Possible Affordable Care Act Repeal

January 5, 2017 – 6:00 – 8:00 pm
Corpus Christi-Epiphany Community Resource Center (2022 St. Bernard Ave., New Orleans)


NEW ORLEANS, LA
– Over half a million Louisianans are expected to lose health insurance coverage if Republican Congress members act on their promise to repeal the Affordable Care Act in early 2017.

Republicans have claimed they will delay the repeal for two years in order to develop a replacement to President Obama’s healthcare plan.

That’s not a viable option for the people of Louisiana, according to organizers of a community forum on the ACA repeal, scheduled for January 5th at 6:00 pm at 2022 St. Bernard Avenue in New Orleans.

“Repealing the ACA without having a well-developed replacement in effect is dangerous to the people of Louisiana and the future of our state,” said Susan Todd of 504HealthNet and one of the speakers at the upcoming event.

4.3 million people across the country are expected to lose health coverage immediately, even if the repeal is delayed, because of uncertainty and disruptions in the health system. Studies predict that those hardest hit by the repeal will be working families with low and moderate incomes.

But the effects of a repeal will be felt by everyone across Louisiana, as the state is expected to lose $26.7 billion in federal funding between 2019, when the repeal would take effect, and 2028. That will be “devastating,” according to the Louisiana Budget Project, as the state is mired in an economic downturn, faces persistent midyear deficits, and must overcome a looming $1.5 billion “fiscal cliff” in 2018.

The purpose of the January 5th forum is to arm community members with information about what an ACA repeal might mean for the state budget and, more personally, their families Panel members and the audience will also discuss ways to take action against the threatened repeal. All are welcome to attend.

Speakers at the forum will include Jan Moller from the Louisiana Budget Project, Susan Todd from 504HealthNet, and Dr. Anjali Niyogi, Clinical Assistant Professor of General Internal Medicine at Tulane University. Locals will also give testimony about the effects a repeal, without a viable replacement, will have on their lives and businesses.

The event is sponsored by the Louisiana Budget Project, 504HealthNet, Jesuit Social Research Institute, the Advocacy Center, and Voices of the Experienced (VOTE).

It's about community health

Last month we celebrated National Health Center Week, which brings attention to health centers nestled in every neighborhood throughout New Orleans. These health centers are community based, patient directed organizations that serve all of our residents. At New Orleans East, LA (NOELA) Community Health Center we work to make sure that everyone—regardless of their ability to pay—has access to health care.

As a member of 504HealthNet we are one of 21 organizations that follow that mission through our 55 sites throughout the Greater New Orleans Area. These organizations are dedicated to treating the whole patient, and providing the frontline of health care—primary care—to everyone around us. Together we are working to build a system of care that is accessible for everyone from those who have private insurance, are uninsured or underinsured, to those who are on a public health care plan.

Establishing a primary care physician is one of the most important steps a person can take in order to ensure their long-term health. Primary care physicians treat the entire patient for their entire life–from allergies to flu shots, from physicals to chronic conditions. It is important to have a doctor that you can go to for any and all health needs. Creating that history with a doctor helps manage your health, and makes it easier to get care when you do end up getting the flu, or need a prescription refilled.

In addition to the health benefits, community health centers also make an economic impact for more than $47 million in our region. These health centers also create more than 500 jobs in the GNO area alone, both within and outside of the health care industry. However, most importantly 1 in 15 people in the US have used a community health center.

Health centers are a proven model that has delivered multiple returns on the investment for the past 50 years—better access to health care, cost-savings, and even jobs. This is why it is so important to support health centers. But don’t just take my word for it—visit a health center near you and experience for yourself how we work to keep everyone in our community healthy.

–Keith L. Winfrey, MD, MPH
Chief Medical Officer
NOELA Community Health Center

Guidelines for the Use of Daily Aspirin for the Primary Prevention of Myocardial Infarction in Men and Cerebral Vascular Disease in Women

By Farah Kaiksow

The following information is summarized from the USPSTF March 2009 publication. Please note, the USPSTF is currently in the process of updating this publication.

  • Daily low-dose aspirin decreases the risk of myocardial infarction in men aged 45-79 years, but not in women.

  • Daily low-dose aspirin decreases the risk of ischemic cerebrovascular disease in women aged 55 to 79 years, but not in men.

  • Primary Care Physicians should recommend daily aspirin for men and women in the above age groups if their calculated risk of MI or ischemic CVD, respectively, outweighs their risk of gastrointestinal hemorrhage.

Population

Men
Age 45-79 Years

Women
Age 55-79 Years

Women
Age 55-79 Years

Women
Age 55-79 Years

Men and Women Over 80 Years

Recommendation

Encourage aspirin use when potential CVD benefit (MIs prevented) outweighs potential harm of GI hemorrhage.

Encourage aspirin use when potential CVD benefit (strokes prevented) outweighs potential harm of GI hemorrhage.

Do not encourage aspirin use for MI prevention.

Do not encourage aspirin use for stroke prevention.

No Recommendation

Grade

A

(High certainty that the net benefit is substantial.)

D

(Moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.)

I

(Insufficient Evidence)

For patients who do not take NSAIDs regularly and do not have a history of GI bleed or ulcers, the table below should be used to determine if the benefits of aspirin outweigh the risks of GI side effects.

10-year CHD risk for Men

10-year stroke risk for Women

Age 45-59 years

≥4%

Age 45-59 years

≥3%

Age 60-69 years

≥9%

Age 60-69 years

≥8%

Age 70-79 years

≥12%

Age 70-79 years

≥11%

Primary Care Physicians should use the following calculators to determine their patients’ 10-year risk of CHD or ischemic stroke:

  • Men (CHD)

  • Women (stroke)

Please note, the original stroke risk calculator (Western States Consortium) cited by the USPSTF is no longer available.

For patients who do take NSAIDs regularly or have a history of GI bleed or ulcers, Primary Care Physicians should carefully weigh the risks and benefits of daily aspirin as it more than doubles a patient’s risk of GI bleed or ulcer.

Guidelines for Diagnosis and Treatment of Diabetic Neuropathy

diabetes stock image cdc
A summary of the American Diabetes Association Standards of Medical Care in Diabetes 2015

by Sarah G. Candler, MD, MPH

The following is a summary of the American Diabetes Association Standards of Medical Care in Diabetes 2015.

Neuropathy is one of the most common complications of uncontrolled diabetes. Its incidence increases with the duration of diabetes so that by 25 years, about half of diabetic patients will develop diabetic polyneuropathy (DPN). This type of neuropathy is characterized by decreased sensation of the feet or decreased or absent ankle reflexes. Additionally, an estimated one in three diabetic patients will have painful neuropathy—with or without the loss of sensation. Diabetic patients are also at risk of cardiovascular autonomic neuropathy, which may nor may not be symptomatic, but which can be associated with significant morbidity and mortality.

It is important to screen for both sensorineural neuropathy as well as signs and symptoms of autonomic neuropathy at the time of diagnosis of Type 2 diabetes and 5 years after diagnosis of Type 1 diabetes, then annually. If patients have painful diabetic polyneuropathy (DPN), it is important to treat, as amelioration of pain has been shown to improve patients’ quality of life.

Evidence supporting pharmacologic treatment for DPN is weak, and the only medications FDA approved for this diagnosis are Pregabalin, Duloxetine, and Tapentadol. However, Venlafaxine, Gabapentin, and other medications have also been shown to assist with some DPN-related pain.

Diabetic Neuropathy Checklist
Prevent development or progression of neuropathy in ALL diabetic patients:

  • Monitor Hemoglobin A1c and promote glycemic control with goal <7%

    • If controlled: A1c at least every 6 months

    • If uncontrolled: A1c at least every 3 months

  • Recommend smoking cessation

  • Perform annual comprehensive foot exam and provide self-care education

  • Inspection, pulses, neuropathy evaluation (as below)

  • Refer to podiatry if patients smoke, have high-risk feet, or have ulcers

  • Perform annual dilated eye exam (impaired vision increases risk of foot trauma)

  • If diabetes is severe and uncontrolled, screen for cardiovascular / autonomic neuropathy (as below)

  • Treat symptoms related to painful DPN and autonomic neuropathy to improve quality of life (will not reverse the pathology)

Validated Screening Tools for the Diabetic Foot Exam
Use at least 2 methods for >87% sensitivity in detecting DPN:

  • Pinprick sensation

  • Vibration perception with 128-Hz tuning fork

  • 10-g monofilament pressure sensation at distal plantar aspect of both great toes and metatarsal joints
    assessment of ankle reflexes

Screening tests for Cardiovascular Autonomic Neuropathy: for patient with severe, uncontrolled disease

  • Resting tachycardia

  • Exercise intolerance

  • Orthostatic hypotension

  • Constipation

  • Gastroparesis

  • Erectile dysfunction

Other Causes of Neuropathy: rule these out when diagnosing DPN

  • Neurotoxic medications

  • Heavy metal poisoning

  • Alcohol abuse

  • Vitamin B12 deficiency (especially if taking Metformin)

  • Renal disease

  • Chronic inflammatory demyelinating neuropathy

  • Inherited neuropathies

  • Vasculitis or vascular insufficiency (particularly if smoker)

Recommended Treatments of Painful Diabetic Polyneuropathy (DPN)

  • FDA approved for DPN, likely effective: Pregabalin, Duloxetine, Tapentadol

  • Possibly effective but off-label use: Venlafaxine, Amitriptyline, Gabapentin, Valproate, opioids

  • N.B. Head-to-head trials are rare and evidence is poor, so management should be tailored to the patient