HealthyCal.org

By Leslie Griffy
California Health Report

Monterey County wants to revolutionize health care for one of the most difficult to reach groups, the mentally ill.

Its new program will create one-stop health care shopping for people whose main interaction with doctors is through the county’s behavioral health centers.

That means primary care, like regular doctor’s visits, flu shots or diabetes management, will be housed in the same building patients already visit for therapy or drug rehabilitation. And, all patient care will be coordinated on site.

“We think we can provide a wrap-around to help people really succeed,” said Amie Miller, Monterey County Department of Behavioral Health’s project manager for the plan.

The planned three facilities won’t just provide mental and physical health care, Miller said. Patients there will also be able to tap into healthy life skills courses focused on cooking, exercise and more. The plan brings together the county’s public health nurses, clinics and other services to fill an important gap.

“Last year we looked at our severely mentally ill population and 39 percent didn’t see a physician at all,” she said.

On top that, studies show that the lifespan of a mentally ill person in the United States is 25 years shorter than that of the general population.

The deaths aren’t be caused directly by the mental illness either, said Trina Dutta, public health advisor with the Substance Abuse and Mental Health Services Administration.

“These aren’t suicides,” Dutta said. Rather the mentally ill may suffer from related physical ailments like obesity or diabetes. Most often, she said, it is simply more difficult for them to get the health care they need.

Short visits that may not allow a patient to express their concerns or understand instructions can keep the mentally ill away from health clinics. Other barriers include the difficulty of making and keeping appointments while battling mental illness, a lack of insurance or transportation and stigma or fear of it.

Dutta’s agency, part of the US Department of Health and Human Services, is kicking in $400,000 a year for the next four years in grant money to support Monterey County’s program.

In the past, national and Monterey County efforts focused on bringing mental health care services to primary care facilities. So that a family doctor may ask if a patient is feeling depressed and then be able to refer them to a therapist down the hall.

It’s one way to create a health care home for patients, a place where all of their needs are met.

But, that doesn’t serve the severely mentally ill patient as well, said Dr. Wayne Clark, director of Monterey County’s Behavioral Health Department.

“Other populations don’t have an existing chronic illness,” Clark said. “We have special clinics throughout the county that are the place they go to for health care. We need to allow them to have other health issues addressed there, too.”

Integrating all of the services in one location is part of what makes Monterey County’s plan so innovative, Dutta said. Of the 90 grants her agency awarded to bring primary care to mental health care settings, the one to Monterey County is one of the only to include complete health care coordination.

That also means a lot of work.

Project manager Miller is meeting the public health nurses and officials from the county’s health clinics to figure out how they will share patient documents and gauge outcomes.

But she believes that the plan will drop barriers to care while increasing the efficiency of behavioral and physical health care for the 1,800 patients expected to access the centers each year.

The first integrated behavioral health care center in Monterey County is scheduled to open in April. For now, locations are planned on the grounds of the former Fort Ord, at Natividad Medical Center and in King City.

The Rev. Chip Murray. Photo: Robert Fulton/California Health Report

The Rev. Cecil Chip Murray continues decades of service

By Robert Fulton
California Health Report

The Rev. Cecil L. “Chip” Murray sits in the small conference room of the center that bears his name. He is both humbled and amazed by the fact of the eponymous Cecil Murray Center for Community Engagement, part of the University of Southern California’s Center for Religion & Civic Culture.

The Murray Center uses resources at USC, including the schools of law, business, social work and public policy, to bring in speakers from across the country. The center promotes civic engagement and economic development, and has launched a Faith Leaders Institute that addresses organizing, leadership, community development, civic engagement and more.

“The genuine essence of religion is not God wants you to have it, but God wants you to share it,” Murray says in his slow, steady baritone. “You would take a portion of what you have and share it with those who don’t have to lift them. The same way you came from blue collar to white collar, they can come from blue collar to white collar. The same way you came from zero to hero, they can come.”

Murray’s energy masks his 83 years and belies the gray in his hair. His eyes still possess a youthful hopefulness for what’s good and what’s right. His commitment to social justice is also reflected in decades of service, first in the U.S. Air Force, then in the ministry, and more recently as chairman of this center dedicated to positive civic engagement, tucked against the 110 Freeway just a few blocks north of USC’s campus in Los Angeles.

Murray is perhaps best known for his role in the civil unrest in 1992 that followed the incendiary Rodney King case. As pastor of the First African Methodist Episcopal Church of Los Angeles, a role he held for 27 years, Murray struggled to keep the peace. Church members went out into the immediate community in an attempt to stop the violence, and when that didn’t work, they welcomed those displaced by fire into their house of worship. Murray went on television with talk show host Arsenio Hall to plead for people to “be constructive in your anger, not destructive, not self-destructive.”

The First AME Church has a storied history in South Los Angeles. Its membership peaked at 18,000 in the 1990s; today it stands at 19,000. Outreach efforts flourished under Murray’s long tenure, and church programs ranged from homeless assistance to a “lock in” program that steered young people away from drugs and gangs. “The black church,” Murray told the Los Angeles Times in 1990, “must be the salvation of black men and black boys.”

When asked about the 1992 riots, Murray looks off to the side and responds with a quote from author Langston Hughes about a dream deferred. The Murray Center’s mission, as well as that of its namesake, is organizing the nonprofit and faith-based community to try to ensure that some day no more dreams are deferred.

The center has added 500 organizations into its database since it opened in late 2011, Murray says, with an emphasis on South Los Angeles specifically and Southern California at large. Its focus is on issues such as education, housing, reentry, substance abuse and legal counseling.

“If people have access and if they have motivation, then the two will go together for success,” Murray says.

Major challenges face underserved and minority populations in modern America, Murray says. He draws upon Martin Luther King Jr.’s assertion that the three major threats to mankind are racism, war and poverty. In Murray’s opinion, poverty is society’s biggest threat, and he breaks it down into what he calls the Four P’s: poverty of family, poverty of pocket, poverty of education and poverty of image.

Murray sees poverty as more than empty pockets. He wants to get beyond discussions of poverty that use the old adage about being given a fish instead of being taught how to fish. He wants to go a step further—he wants to see more people owning the pond.

“You won’t last or linger without that component,” Murray says. “Teach them how to fish, yes, that’s fine. But it won’t work much for the next generation.”

Murray sums up poverty of family as too many missing fathers. For that he blames the disproportionate number of African American men in the U.S. prison system, for which he cites unfair sentencing practices relating to drug charges. Establishing reentry programs for prisoners coming out of the system is one of his priorities.

Murray sees the poverty of education as stemming from high dropout rates in poorer communities. Lack of an education leads to lower earning potential, which leads back to poverty of pocket. Too many young African Americans aren’t aware of or don’t take pride in accomplishments made by those who came before them—the cause of poverty of image.

When considering health care, Murray ties his Four P’s together. “When you’re poor in pocket, family, image and education, you’re going to be poor in health,” he says.

Murray’s current work reflects what he started as the pastor at First AME Church, where he stressed community engagement.

The Rev. Mark Whitlock met Murray in 1982, when his future wife took him to the First AME Church. Whitlock is now a pastor at Christ Our Redeemer AME Church in Irvine and executive director of the Murray Center.

“I think the Rev. Murray has a deep passion and compassion for people,” Whitlock says.

Murray sees more recent examples of dreams deferred, from Occupy Wall Street to the Arab Spring.

“The 99 percent are rebelling against the 1 percent,” he says. “It’s a difficult lesson to learn, because as Lord Acton says, power tends to corrupt, and absolute power corrupts absolutely.”

Murray recently sat on a blue-ribbon commission investigating jail violence at the Los Angeles County Jail. The commission found a “persistent pattern of unreasonable force.”

“There has to be monitoring of power,” Murray says during the interview at his center. “You have to have surveillance, monitoring, disciplinary rules, and you have to insist on the execution of these rules.”

Murray has been training for a job like this all his life. He grew up in Florida and has been married to his wife, Bernadine, for 54 years. The couple has one child, Drew, also a reverend. Murray’s mother died at a young age, and his father worked as a school principal. People said that the young Cecil, who had the same leadership qualities as his father, was a regular chip off the old block, hence the nickname.

Early on, Murray understood the importance of education and attended Florida A&M College (now university) in Tallahassee, where he majored in history. He repaid his $1,600 scholarship by enlisting in the Air Force.

It took a harrowing personal experience to turn him to the ministry. Though he had an interest in the ministry at an early age, an episode in the Air Force called Murray to service. As he tells the story in his memoir “Twice Tested by Fire,” during a failed takeoff attempt, the cockpit filled with flames, and he heard a voice telling him to use the escape hatch in the rear of the plane. Murray survived, eventually retired from the Air Force and entered the seminary.

Murray enrolled in the Claremont School of Theology. After he completed his education, his first pastoral assignment from the African Methodist Episcopal Church landed him in Pomona. That was followed by stints in Kansas City, Kan.; Seattle; and finally Los Angeles in 1977.

“I looked at pastors who were primarily for themselves instead of for the people, and I thought that they should be working to lift their communities and their people and not themselves,” Murray says. “So I shifted from being the critic to being the participant.”

He works from 9 a.m. to 4 p.m. at the center, followed by additional duties such as prison or hospital visits. Though he is at an age when most would retire, Murray continues his mission. He exercises five days a week and ends his days by reading and watching the occasional basketball or football game.

“We’re going to keep growing and keep the dream going,” Murray says, “and the rest is up to the boss.”

This story originally appeared in the California Health Report magazine’s Winter 2012/2013 issue. Read the rest of the magazine here.

Hosts Conference in Southern California

Former president Bill Clinton speaks at the Health Matters Conference in La Quinta.

By Suzanne Potter
California Health Report

Gary Mendell choked back the emotion as he stood before the crowd at the Clinton Health Matters Conference, held recently in La Quinta, California. He told the story of his 25-year-old son, Brian, who hung himself after years of battling ADD and drug addiction. “I wish I could tell you that the anguish dulls with time. But it doesn’t. Knowing that my son died of a disease that is preventable but we don’t prevent it. It’s treatable but we don’t treat.”

Mendell is now fighting in Brian’s honor – and announced the formation of a new national nonprofit to improve prevention and treatment of addiction. His commitment was one of 31 pledges made at the conference – aimed at getting individuals and communities to take action to improve health and bring down costs.

In his opening remarks, Former President Bill Clinton said his foundation has worked with dozens of companies and non-profits to make best-practices a reality. “Today there will be pledges that amount to 100 million dollars that will help more than 25 million people across America.”

Actress and singer Barbra Streisand announced a two million dollar donation to the Barbra Streisand Women’s Heart Center at Cedars-Sinai Medical Center. Walmart is rolling out a program to put a “healthier choice” icon on certain foods and they are working with suppliers to eliminate trans fats and cut excess sugar and sodium in packaged foods.

Health insurance giant Humana is launching a program called Humana Vitality that rewards people for losing weight, getting active and eating better.

General Electric is putting six million dollars into a “Healthymagination” private/public health program that gives people online tools to improve their health. GE has also pledged to take nationwide a program that they started in Cincinnati, Ohio. There, GE worked with hospitals, nonprofits and government to improve coordination in patient care and encourage hospitals to publish what they charge for various procedures. GE says the program has already saved the region 200 million in emergency room costs over the past two years.

Tenet Healthcare, which owns Desert Regional Medical Center in Palm Springs and JFK Hospital in Indio, is hiring more case workers to follow-up with patients after they are discharged, in an effort to keep them from being readmitted.

One overarching theme emerged again and again: regular people have the power to fix most of what ails the health-care system – and the economy – just by embracing a healthier lifestyle.

Former President Clinton opened the conference with a warning about obesity, heart disease and diabetes, “About 70 percent of adults have already developed a preventable chronic disease which contributes to rising health care costs and reduces workplace productivity and (leads to) premature death. He cited a Columbia University study that found the cost of treating preventable diseases will rise by $48-66 billion a year if current trends continue.

Dr. Donald Berwick, former Administrator for Medicare and Medicaid, said genetics determine 50 percent of a person’s overall health. Health care (or lack thereof) is only 10 percent, and a person’s lifestyle makes up the rest.

“Forty percent of our health depends on our choices: What we eat, how much we walk, the risks we take, the substance abuse, the unprotected sex, the guns and violence in our streets, the pollutants in our air, the seatbelts and and bike helmets that we use or don’t use,” Berwick said. “That is very good news. That means that we can do wrong and what we do well largely into our own hands.”

Renowned heart health expert Dr. Dean Ornish said three-quarters of U.S. health-care costs are related to chronic disease. Ornish said he’s pleased that Medicare now covers his nutrition program and emphasized the benefits of a better diet and more exercise. “These approaches can not only help combat most chronic diseases but it can actually reverse them,” Ornish said. “They can even turn on good genes that protect us, and turn off harmful genes.”

Ornish added, “We need to address the more fundamental causes of why people get sick. We will find that we can have better healthcare available for more people for lower costs.”

President Clinton said that we need to give people incentives to make healthier choices rather than continuing to pound home the message that overeating, a sedentary lifestyle, drugs and smoking can kill. “We have to create positive incentives,” Clinton said, “not just threats about death or injury.”

The discussion also centered on improving transparency in medical care while protecting privacy. President Clinton lauded a unique law in Pennsylvania that requires hospitals to make public the prices they charge for various procedures and their success rates. Dr. Berwick called for a similar, national database and said that the Affordable Care Act (ACA) gives the government the authority to set it up, but Congress needs to mandate that Medicaid participate.

The experts also lamented the massive shortage of primary care doctors. They suggested that the health care system be overhauled to make careers in family practice more attractive to medical students.

Dr. Ornish suggested a new approach, where multiple specialists treat patients as a team. “The managed care approach … is forcing doctors to see more patients, in less time for less income, driving the best doctors out of medicine. We can create a new paradigm which is based on the quality of care and not just more care.”

Dr. Berwick agreed that the current system encourages hospitals to over-treat patients. “They’ve been conditioned by decades by a broken volume-based healthcare payment system to maintain business plans that depend on doing more, not less.” He says the ACA is a step in the right direction. “There are new emphases on payment for chronic care, coordination and outcomes.”

Technology also figured in plans to improve health care outcomes.

Dr. Peter Tippett, chief medical officer and vice president of Verizon’s Innovation Incubator vowed to facilitate health care transformation with technology and mobile apps. For example, Verizon now makes a watch that works like On-Star – you push a button and it makes a call to a relative or to emergency services. The watch also has a GPS tracking device that helps find wandering Alzheimer’s patients. And it can measure an elderly person’s movements and send a message to family if he or she doesn’t move for an extended period of time and may have fallen.

ABC News Medical Director Dr. Nancy Snyderman challenged the group to help more seniors age in place – and be monitored in their homes so they spend less time in expensive hospitals and nursing homes. GE announced a joint venture with Intel to offer remote patient monitoring, so doctors can check on a patient without an office visit. GE is also working on a refrigerator that can dispense medicine in the correct amounts.

Many experts also called for hospitals, insurance companies and government agencies to make databases compatible. Tippett lamented, “Almost no sharing actually happens. If we could get health information technology in healthcare to be similar to what they use in banking, everybody would be dramatically healthier…700 billion dollars in savings are available if we could only leverage the kind of information that we already have in meaningful ways.”

Berwick noted that seniors in private Medicare programs get information every month on what drugs they take and what it costs. “When they know that, they are incredible buyers and seekers of value.
The broader we get that idea (of transparency) in the system the more powerful it’s going to be. “

The first Health Matters conference led to the creation of the Clinton Health Matters Initiative, which is a seven year effort to improve health in two regions: Little Rock, Arkansas and the Coachella Valley.
The Coachella Valley, which became a part of the Health Matters Initiative late last year, is already implementing plans to improve health.

Carolyn Caldwell, CEO of Desert Regional Medical Center in Palm Springs said the hospital is revamping their cafeteria food to offer more healthy choices. The medical center is also partnering with the city of Palm Springs on a $25,000 fundraiser for the Clinton Health Matters Initiative, Caldwell said.

The Desert Healthcare Foundation (DHF) has funded a new manager to work with all three local school districts to combat childhood obesity. DHF Vice President Kay Hazen said, “The realization that we were raising a generation of XL children and our kids were becoming the first generation who might not live as long as their parents spurred us into action.”

A panel of local leaders also discussed ways to optimize the environment to encourage people to exercise more and develop stronger social ties. That involves cleaning up graffiti, building more sidewalks and parks, and helping people form walking groups and neighborhood watch programs with social networks. The City of Coachella has incorporated health concerns into its general plan, so any future development will include more space for recreation.

In December the CHMI gathered local leaders to write a blueprint for further action in the Coachella Valley. The plan will be released in early February.

Note. This article was updated Feb. 8 to correct the identification of Dr. Peter Tippett.

Registered Dental Hygienist Ushma Patel, upper right and Dental Assistant Navigator Leslie Estrada, far left, take photos of three-year-old Christopher Chacon's teeth during a dental check-up and cleaning on site at Magnolia Head Start preschool in East Palo Alto. The preschool is participating in the Virtual Dental Home Demonstration Project.

By Lynn Graebner
California Health Report

Three-year old Christopher Chacon got his teeth cleaned, treated with fluoride and x-rayed in a corner of the administrative office at Magnolia Head Start Pre-School in Palo Alto.

Many children at the preschool may have a dentist, but they don’t go regularly. They show up when they have pain, said registered dental hygienist Ushma Patel. So she and dental assistant Leslie Estrada go to them to offer and encourage preventative care.

They visit six sites in the county and sometimes treat more than half the class.

Patel works for Ravenswood Family Dentistry, which serves low-income and uninsured residents in San Mateo County, and is one of 11 organizations taking part in a telehealth initiative called the Virtual Dental Home Demonstration Project.

The project provides dental care to more than 2,000 people in California, including low-income children at school, people with disabilities and elderly people at residential care facilities.

The Pacific Center for Special Care, part of the University of the Pacific’s school of dentistry in San Francisco, operates the project. They hope to eventually improve oral health for underserved people nationally.

The project is giving dental care their clients would not otherwise get, said Dr. Paul Glassman, director of the Pacific Center for Special Care and a professor of dental practice at UOP.

Registered dental hygienists and registered dental assistants go into schools, nursing homes and residential facilities for people with disabilities. They bring portable imaging equipment for x-rays and photographs, supplies to do temporary fillings and an internet-based dental record system. They upload images and dental and medical histories to a website where a dentist reviews them and creates a treatment plan or refers patients requiring more complex treatment to a dentist.

Yogita Thakur, Dental Director at Ravenswood, sees education as one of the major goals of the project.

“Perceived need is the number one reason people seek care or don’t seek care,” she said. If people believe dental caries is preventable, they will seek preventative care, if they think they’ll get cavities no matter what, they won’t seek care, she said. “It’s about educating the parents.”

Carmella Gutierrez, President of Californians for Patient Care, noted that more than a quarter of children ages two through five and half of children ages 12 to15 have had tooth decay, which can be linked to poor digestion and heart and respiratory disease.

“Having dental care is linked to overall health,” she said.

The CDC reports that tooth decay affects children in the U.S. more than any other chronic infectious disease. Yet in 2011, only 27 percent of children eligible for Medi-Cal received dental care, down from 34 percent in 2009. Those figures come from California Medicaid Management Information Services and are cited by Glassman and others in the July 2012 issue of the California Dental Association Journal.

The goal of the project is to show that hygienists and their assistants can keep many people healthy by providing education, assessments of dental disease risk, cleanings, fluoride varnishes and dental sealants.

Results from the project sites so far show that about 50 percent of participating patients can be kept healthy by a dental hygienist. The other half are being referred to dentists for more complex treatment, Glassman said.

“I think it’s a tremendous advance,” Glassman said. “You’re talking about a population that doesn’t get dental care.”

Even if all the research points to the prudency of moving virtual dental homes into mainstream dentistry, many challenges remain, Glassman said. The way we pay for dental care and the laws governing telehealth are designed for our current system, which pays for procedures and dental visits.

“Making the population healthier is not what our current compensation systems are based on,” he said.

That’s the next phase of the Virtual Dental Home Demonstration Project. In the next couple of months Glassman anticipates potential funding for designing a health outcomes-based payment system that the Medicaid program could use. Dental providers would be compensated based on the health of their patients, not the number of procedures they perform.

Glassman said the main goal of the project is the same as the overall healthcare reform movement in the U.S.: better patient experiences, better health and lower costs.

“We’re going after the same thing in dental care reform,” he said.