The Total Care Clinic at UF&Shands Jacksonville

“Improved health care at lower cost.” That is the holy grail of health care delivery. And that is what is being achieved at UF&Shands Jacksonville in the Total Care Clinic, or TCC, which opened in September 2012.

The motto of the TCC is: “Providing Total Care to manage and maintain good health.” This innovative approach to health care delivery was designed to create a comprehensive, unified and patient-centered approach to meet the growing needs of the approximately 10,000 underserved and uninsured citizens of Jacksonville who qualify for the City Contract program, while at the same time reducing the costs of providing care to this population.

This newsletter tells the story of the TCC — some historical background, a call to action, its initial implementation and early successes, and future goals.

Historical Perspective Approximately 40 million Americans do not have health insurance. Typically, they work at a low-paying job for a company that does not provide health insurance. Or they may be unemployed. Or they may be self-employed but have chosen not to purchase health insurance because of high premium costs. Most of these individuals do not qualify for Medicaid because they may not have dependent children, and are not pregnant, elderly or disabled. They are caught in the gap between Medicaid and employer-provided insurance.

About 4 million Floridians do not currently have health insurance, and about 180,000 of these individuals live in Jacksonville. Hopefully, as of Jan. 1, 2014, many of these individuals will be covered under the Affordable Care Act, either through their purchase of a private health plan through health insurance “exchanges,” or through the Medicaid expansion program.

In 1982, what is now Shands Jacksonville entered into a contract with the city of Jacksonville to provide health care for a subset of uninsured individuals who met specific criteria, such as residency in Duval County, financial assistance requirements (i.e., the family unit may not exceed 200% of the Federal Poverty Guidelines), a lack of health insurance and ineligibility for Medicaid. About 10,000 individuals qualify at any given time, and since 2001 the city has provided $23.8 million annually for the care of these individuals, which also includes the city and county prison population. While the costs of health care have increased over the past decade, at a rate greater than that of general inflation, the City Contract has been constant at $23.8 million.

At a contract amount of $23.8 million, the average yearly amount available to provide health care for these 10,000 individuals is about $2,380. Contrast this to the annual premium for individual health insurance coverage under the UF plan: $9,300. Thus, it’s no surprise that UF&Shands Jacksonville has been funding this program at a deficit — and increasingly so — over the years. Of the $23.8 million, $17 million is allocated for hospital services to this population, but the cost of providing these services last year was $50 million. Similarly, $6 million is allocated for physician services, but the cost of providing these services last year was $15 million. In total, UF&Shands Jacksonville lost $42 million last year on the City Contract.

At the same time, the health care provided was fragmented. City Contract patients could obtain health care by making appointments at any site in the system, or by presenting at the emergency room. There was little continuity, fragmented counseling, complexity in the follow-up of test results and home-care needs, and many other problems.

Call to Action At a strategic planning session of UF&Shands Jacksonville in April 2012, it was recognized that we were not providing optimal care for the City Contract patients and that the financial model was not sustainable. As a call to action, the idea of a single site for primary and specialty care for City Contract patients was brought forward as a way to improve care at lower cost. This idea, dubbed the “Total Care Clinic,” was refined over the subsequent several months. Many decisions were made in a short space of time about a variety of issues: location, space renovation, care delivery model, personnel, scheduling, IT, etc. Moving quickly from concept to reality, the TCC opened in September 2012, focusing initially on primary care services. Specialty services were added beginning in December 2012.

Initial Implementation and Early Successes The TCC houses primary care providers, specialists, nurses, pharmacists, case managers, mental health providers, phlebotomy services, call center personnel and patient assistant programs all under the same roof, to provide truly “Total Care.” Some innovations that are being implemented are group visits, telemedicine, home visits, population health, transition care, medication refill clinics and community services such as job placement.

Under the leadership of Judella Haddad, M.D., medical director; Nipa Shah, M.D., chair of the Department of Community Health and Family Medicine at Jacksonville; Gail Gullison, administrator; as well as many others, several important steps have been accomplished. First, an excellent location was identified — the fifth floor of the outpatient clinical facility vacated by the V.A., which is located just behind the Pavilion building on the UF&Shands Jacksonville campus. This space was redesigned in a highly functional, yet cost-effective manner. New hardwood floors, paint and lighting make a big difference! The space is now welcoming to patients and their families, and staff simply feel better about the care they can provide.

Second, a mix of physicians, nurses and other staff was coordinated such that there were fewer physicians and more support staff than at most primary care offices. Very often, the things our patients need do not necessarily require a physician visit and can be addressed effectively by staff. For example, if a patient just needs refills for stable medications, and has had no change in health status, these refills can now be provided by a pharmacist working in conjunction with a physician. Often, a patient is asked to make a separate visit to a specialist for assistance in clinical management, when a professional opinion is all that is really needed. Whenever possible, care at the TCC is coordinated between the family medicine provider and the specialist so that unnecessary referral visits to specialists are not required.

And third, specialty clinics have begun in Neurology, Neurosurgery, Cardiology, Psychiatry, Pharmacy, Orthopedics and Podiatry. In the next few months, Gastroenterology, Nephrology, Endocrinology and Rheumatology will be added. These specialty clinics occur at the same facility as the primary care practice, and at the same time, greatly facilitate prompt consultation and adding to patient convenience. One recent example was a patient who was referred from Orthopedics for cardiac clearance prior to a procedure. At the Total Care Clinic, he was scheduled to be seen on the same day that the cardiologist routinely sees patients. An EKG and cardiac evaluation was initiated by the family medicine physician, who then walked over to ask the cardiologist his opinion. The cardiologist agreed with the recommendations, and documented them in the chart, thus saving the patient an extra visit and possible further delay for his surgery. The patient was truly appreciative. Thus, the goals of collaborative care, improved patient satisfaction, reduced cost within a capitated system and efficient delivery of care are simultaneously being accomplished at the TCC.

One of the unique aspects of providing ‘total care’ is the avoidance of segmentation. Recently a 47-year-old woman who had a number of medical problems was surprised and incredibly grateful when her doctor at the TCC treated her for a gynecological concern, adjusted her blood pressure medications, assessed and treated her back pain, and spent even more time diagnosing and treating her underlying depression. At the TCC, whenever possible, all the patients’ health issues are addressed at the time of the visit, since no one benefits when a patient has to make another appointment to discuss his or her remaining health issues.

Future Goals An important immediate goal for the TCC is to increase the number of family medicine providers in order to accommodate more visits, since every patient who receives preventive care and/or treatment in a competent and timely manner is less likely to require an ED visit or hospital admission. An additional goal is to include more specialists on the team at the TCC, to promote even more collaboration with minimal extra cost and more convenience for the patient. Telemedicine, group visits, communication via email and texting are other projects in the works. Finally, recognizing that good health is influenced by the patient’s social and economic environment, we have started to provide job placement services and other community resources. To accomplish these goals and more, the Total Care Clinic welcomes philanthropic interest, will respond to pertinent grant funding opportunities and will pursue greater collaboration with the city of Jacksonville.

Across time, the future of health care is clear: Our patients will increasingly be covered in capitated arrangements, whether through Medicaid managed care, Medicare managed care or self-insurance. Although the TCC was conceptualized and implemented for patients enrolled in the City Contract, it is an innovative model that can be generalized to other capitated health plans. By generalizing the TCC model as capitation expands, and tailoring it as necessary to newly capitated populations, the holy grail of improved health care at lower cost will increasingly be achieved at UF&Shands.

Forward Together,

David S. Guzick, MD, PhD Senior Vice President, Health Affairs President, UF&Shands Health System