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Delivering Patient-Centered Outcomes Research to the Nation’s Free Clinics

Webcast Transcript, Wednesday, March 30, 2011

Operator: Good afternoon, and my name is (Stephanie) and I will be your conference operator today. Please note that today’s conference call is being recorded. If you do not comply with this request, you may disconnect at this time.
I would now like to turn the call over to Mr. Howard Holland to start the Webinar. Please go ahead, sir.

Howard Holland: Good afternoon and thank you. We appreciate very much all of you joining us for today’s Webinar, which is titled “How Patient-Centered Outcomes Research Can Support The Nation’s Free Clinic”. This Webinar is hosted by The Agency for Healthcare Research and Quality also known as A-H-R-Q or AHRQ, as well as the National Association of Free Clinic. [Title Slide]

As the operator mentioned, my name is Howard Holland, and I’m the acting director of Office of Communications and Knowledge Transfer here at the agency. And it’s my pleasure to serve as the moderator today for our call.

AHRQ is committed to improving the quality, safety, efficiency and effectiveness of healthcare for all Americans. This tremendous task can only be achieved through the development of evidence based research, the kind of research that we here at the agency conduct through our effective healthcare program as well as the development of critical partnership that can help us convey this knowledge to consumers and clinicians. But, equally important are partners, partners who are vital in working with us to implement the tools and the results of this research so that we can achieve the long term improvements in healthcare that help us in turn reach our agency’s mission.

[Agenda slide] Speaking of partners, today we are thrilled to be partnering with the National Association of Free Clinic, NAFC, on what we hope will become a series of Web conferences, about the role of Patient-Centered Outcomes Research in free clinic environment. In the near future, AHRQ in conjunction with NAFC will be offering a series of Webinars discussing Patient-Centered Outcomes Research as it relates to specific topics. Topics such as type 2 diabetes, hypertension, high cholesterol, depression and other chronic health conditions once often identified in the very populations that free clinic serve. These Webinars speaking of free will be free. And, they will be offered to free clinic clinician exclusively and continuing education credit will be awarded for them.

I want you to know that response to today’s session has been tremendous, with nearly 300 registered attendees. We will soon be getting to the meet of the Webinar, but before we do that, let me please turn back to our staff, who are helping for providing a few technical notes before we dig in.

Male: Thank you, Howard. If you’re currently logged into the Webinar, you should see – go to Webinar control panel on the right side of the screen. The show panel is docked, you can only see a narrow bar with an orange arrow button. Clicking the orange arrow button will expand the doc and allow you to access some of the additional software functionality. Just below the orange button is the fullscreen button, which essentially maximizes the presentation window to fit your screen. When you expand the doc, you’ll see a window marked question, which is an area where you should submit text questions during the Webinar if you have them. During specific intervals in this Webinar, we will address questions by both text and phone submission. However, please feel free to submit questions using the questions panel throughout the Webinar.

At this point, I’ll turn it back over to you, Howard to get it started.

Howard Holland: Thanks again, I once again appreciate that. At this time, we will get started, but what we would like to begin with is to ask you to please respond to the first of three poll questions that we are going to have as part of our program today. If you’re using a computer, you can respond right online and you will see that coming up now. What we would like to get everyone in the audience to do is this. We would like to ask if you would please rate your understanding of Patient-Centered Outcomes Research and we would like you to do this on a scale of five options from, as you see, excellent to no understanding of Patient-Centered Outcomes Research at all. So, from excellent to no understanding there. And what we’re going to do here in real time is watch as people poll and look together at the results as they come in.

We are awaiting the jeopardy music to come up here, which should happen in a moment, no, that actually won’t happen. But, as we are waiting for the poll results, let us just say again, how pleased we are to be joining with our partners in NAFC for this Web conference and that again, how much we look forward to potential future Webinars that we may have to join with them on.

Again, as the poll questions begin to come in let me just go ahead and take a moment to actually introduce Nicole Lamoureux, who is the Executive Director of NAFC. Over the past year, Nicole and the National Association of Free Clinic have become one of the most – one of the agency’s very valuable and visible partners, helping us to reach diverse and often underserved communities. When we approached to her to discuss AHRQ, the Effective Healthcare Program and Patient-Centered Outcomes Research, she immediately recognized the importance of evidence based research and this information and together we started thinking of ways that we might convey this information to clinicians and disseminate this information to patients. Nicole, we’re very appreciative of the partnership and the chance to work with you today.

And before Nicole, we go into your slides, we’ll just look together at the results again of the poll question that we just post and obviously as all of you who are in front of your computer can see, it appears that moderate understanding of what Patient-Centered Outcomes Research with a leading response and something of a bell curve looking at a smaller percentage of people who rated at that point, then good. And then, on the other side of moderate, poor or no understanding. I think this would generally reflect what we would expect the results should be.

We know that as the field of Patient-Centered Outcomes Research has been talked about more recently, we’ve seen gains and people who understand they know about it. But that there are still people who aren’t aware and as a result, most people seem to indicate that they have a pretty moderate understanding of where we are in terms of what that means and what is included as part of that research. Thank you again for responding, we will have two other questions during the balance of the call.

And at this point, Nicole, we again want to welcome you and thank you for joining us. And, we will turn it over to you for your presentation.

Nicole Lamoureux: [Slide 1] Thank you so much. Thank you, Howard. I just want to take time here at the National Association of Free Clinic to thank AHRQ for everything that you have done, you’ve been an amazing partner with us and we look forward to working with you continuously in the future.

[Slide 2] I think that one of the first questions that so many people ask me is what is a free clinic? I think that’s normally the first question that gets and I think the definition of what a free clinic is, its pretty easy for us to be able to understand, it’s on the next slide first. And we are volunteer based organizations; provide a range of medical, dental, pharmacy, behavioral health services to the disadvantage individuals, who are predominantly uninsured. Free clinics are 501C3 organizations or a program component of a 501C3 organization. And you know, entity is that otherwise meet this definition, but may charge small nominal fees, can still be considered a free clinic especially and particularly, if the services that they are delivering, they’re given regardless of the patient’s ability to pay. That is a really big important part of this definition. Why that this definition is so important? When I started with this organization a couple of years ago, my first question was, what is a free clinic? And the board and our membership agreed and used this definition as to what a free clinic is.

[Slide 3] So, if we can move on to the next slide, I think it’s important to know about the history of free clinic. And some people, it depends, if you and so many of you have been a part of free clinic for a long time, you know that since the 60s and in some communities, even earlier than that, free clinics have been serving Americans working poor for such a long time. There was an old saying in the free clinic world that used to say, that when you have seen one free clinic, you’ve seen one free clinic. However, one of the things as we started to really understand the critical nature free clinics service in their communities, we change that.

What we want to say is free clinics are the communities response to the healthcare need in that particular area. We really worked very hard to have the community be a part of the services that we provide, not just through the volunteer efforts, but also through the partnerships we have with other hospitals and the specialists. As well as understanding the different disease states that are common across the country, diabetes being one of them, hypertension being one of them. But, also recognizing that when a hurricane or an oil spill or a fire happens across the country, the free clinics are there to be able to answer some of those needs that are very specific to that particular community.

And I’m looking for the next slide, please. [Slide 4] What is the National Association of Free Clinics? People ask me that all the time. The easiest way to say that is, we are an organization that was founded in Washington DC. And, we are an advocate for the issues of our clinics. So, we are the only non-profit organization and we are 501C3 organization whose mission is to solely focus on the issues and needs of the more than 1,200 free clinics and the people that they serve in the United States.

Our mission is to provide research in education and resources to promote and strengthen and advocate for a member organization. But, if you really want my honest opinion, it’s truly our vision that changed so many volunteers and has our patients really believing in what we do. Our vision is to be a central partner in building a healthy America. When we came up with that vision our board and our members understood that that was one big area (inaudible), and that’s exactly what they wanted to do. They wanted to be in a central partner in building a healthy America. [Slide 5]

Some basic information about free clinics, I think it’s very interesting and that many people don’t know is that we serve millions of patients each year and we mobilize tens of thousands of volunteers and for every dollar donated to a free clinic, a minimum of $5 in service is given to a patient. I think the two things that really standout for me as we’ve been traveling around the country and our clinics are talking to people is that 63 percent of our patients come from some sort of a working household, it’s really important to remember that being uninsured does not equal being unemployed by any mean.

The other point that we really want to stress to so many people and those of you who are volunteer at the free clinic know that better than anyone else. We’ve seen a 40 to 50 percent increase in patient demand in the last three years. And yes, I’m going to say that that again, 40 to 50 percent increase in patient demand in free clinics. And, we’ve also seen a 20 percent decrease in donation that have come into the free clinic. I’m constantly amazed at how free clinics continuously service their community and they do so much more with so little. [Slide 6]

Our patient, I think it’s important for everyone to recognize that free clinic serve our patient populations with little to no state or federal support. We rely very strongly just as we do on volunteers, we rely very strongly on donations and (sports fund) and products, and then we rely on grants in united way help, and our free clinics are amazing at their ability to find ways to service their patients that is at no cost to our patient. Again, I want to address the fact that there are some clinics, they may target administrative fee, sliding fees scale for their patient, but in order to be a member of the National Association of Free Clinic, no patient is denied services if they can’t pay.

[Slide 7] I think one of the biggest things that we have found that people ask me all the time is that people think that free clinics are urgent care centers or there are places that people, the patients drops in and out. And as you can see from this slide, there is an ongoing care that is given to the patient, when I asked so many patients as I travel around the country and I stated them, tell me who your doctor is, many of them say to me, my doctor is the Common Ground Clinic or the West Virginia Health Right, or the Christian Charitable Clinic. They don’t say to me, my doctor is so and so, they recognize that the care that they are getting is on an ongoing basis at a free clinic. In fact, one of the free clinic executive director was telling me a story that she actually has a patient that now is being put on a role in one of the state programs and that patient was having a hard time for 10 years. They had gone that same clinic for care. They were looking forward to being placed on Medicare as where they were going, but they were little sad to be leaving that pay clinic behind.

[Slide 8] One of the things that AHRQ has been an amazing supporter with us on has been our care clinics. Care clinics stand for communities that are responding every single day and these clinics started in conjunction with Dr. Ross, we held the clinic, our clinic in Houston stepped up to the plate being the first one NAFC has ever done and we saw 1,800 patient in that day. After that clinic, we’ve been to Little Rock, Arkansas, Kansas City, Missouri for two days. We’ve been to New Orleans twice. We’ve been to Hartford, Connecticut. And we’ve been to Atlanta, Georgia. And we’re going to De Como Washington now, at this point in time. We’ve helped over 12,000 patients, and you can show the next slide as well, and we have activated about 11,000 volunteers. [Slide 9]

One of the most important parts of these care clinics is that they are not just a one day solution, but rather what we do is each of those patients as we connect them to locations that can provide them care on an ongoing basis afterwards. And, we work very closely with the clinicians at these clinics to make sure that they get the information that they need, that we hear some of the questions that they maybe having about issues that they are finding either on this day or at their clinic that they work with directly.

[Slide 10] And working with AHRQ has been great. We started partnership in 2010, and I think to say that we felt there was a real kindred spirit and things that we could both work on would be an understatement. We started talking about our care clinics and said this is an amazing opportunity to get some of the material that you have in the hands of clinicians, who really want to help and be a part of it. And, they have come to our care clinics and provided information and have been the way to work it, and they even came to the national summit, which is where we bring together all free clinic executive, directors, volunteers, clinicians to talk about issues that are important to free clinics in our patients population. And their presentation was very well attended and very well received and we would invite, we’re going to invite them back if that tells you how that goes for us. And currently, AHRQ is working with our NAFC, North Carolina Clinics on health outcomes project that they have going on there.

And that’s it, next slide. [Slide 11] At any point in time, any one on this call has any questions, I know you can outreach to AHRQ directly, and they will be happy to put you in contact with us. But, we did want to put our contact information, and my name is Nicole Lamoureux, Kerry Thompson is here with me on staff. And, you have our phone numbers and emails. Please feel free to drop us off a phone – leave us a message or drop us an email, we’ll be happy to answer any questions that you may have. And, thank you for joining us today on this call. We’re very excited that you are here with us.

Howard Holland: Nicole, thank you so much for your presentation. I appreciate it. And just once more, please know, how pleased we are to be able to be working with you. There were a number of things from your presentation that I’m sure stuck many of us, one of the phrases that you used building a healthy America. I think, it helps to underscore the important role, the work that you do has and getting care to people who wouldn’t otherwise need it. And so, we thank you very much that you are doing the work that you are doing. [Slide 12]

I’d now like to welcome AHRQ’s Director, Carolyn Clancy, who will be our next speaker. Yes, this is the very same Carolyn Clancy, who was on the faculty of the Medical School of Virginia, Commonwealth University and who has been unceasingly singing the praises of the Men’s Basketball team and their appearance in the final four. She is excited about that and all thing Richmond at the moment, but we’re very excited about her, as our Director here and the work that she does in leading our agency.

And Carolyn, I’ll turn it over to you now for your presentation. Carolyn herself too had some free clinic experience in her day about which she may speak either during her presentation or at some point later during the Q&A.

Carolyn Clancy: Well, thank you very much Howard, and I’m really thrilled that you all could join us today. Let me just say, working with the Free Clinic and actually serving on the board of that clinic was one of the reasons I remain such as, about Richmond. And I did go to quite a few basketball games back in the day, but they never played at this level. So I’ll just leave it there. [Slide 13]

As you just heard from Nicole, our partnership with the National Association of Free Clinics actually began in 2010. And, we were actually privileged to support three of the care clinics in Washington DC, in New Orleans, one of my favorite cities besides Richmond and Charlotte, North Carolina. In addition, we participated in the annual summit in Cleveland, Ohio and responsive session about the effective healthcare program here at AHRQ and the application of patient centered outcomes research in the free clinic.

[Slide 14] So, as you heard, Howard say earlier, but you can’t say it often and often in my view, our mission is to improve the quality, safety, efficiency and effectiveness of healthcare for all Americans, very, very consistent what you’ve heard from Nicole, building a healthier America. So, we’re a science agency, we don’t pay for care, we don’t provide it, we don’t regulate it. We support research that helps people make more informed decisions and improves the quality of healthcare that they get. About 80 percent of our budgets is invested in grants and contracts focused on improving healthcare. Because, we’re a science agency, but our aspiration and mission is to improve care. We recognize very clearly, that that means that we have to make sure that the work that we are supporting is translated as practical information and tools that can be put to use every single day in free clinics and elsewhere.

[Slide 15] So, at a glance big priority areas for ARHQ, in addition to the effective healthcare program, which is shown here on the slide, and I should just note that our authority requires that we make sure the information is available in understandable way to multiple audiences. The shortest versions by the way for policymakers, no comments on that. Clinicians in general want more of the needy gritty clinical details and actually working with individuals of varying levels of health literacy to help them think through with you as a clinician, which of multiple options is likely to be good fit for their needs and preferences.

It’s pretty complicated cognitive stuff, it’s kind of like looking through consumer reports to buy a product on steroids. Same issue of making effective comparisons, but the reality as you’re talking about decisions that effect how you feel everyday, whether you can get to work, how you’re going to do with your family and so forth.

In addition, two other big prime areas for us are research that helps to make care safer, helps all of us avoid potential harms that result from errors, from near misses, from poor communication and so forth. And, we support quite a bit of work in looking at how health IT can be part of that solution. Health IT doesn’t solve anything all by itself, but we recognize that it can be a very important part of the toolbox and we make a whole lot of data available, could be topic just for a Webinar on its own.

[Slide 16] So, the Effective Healthcare Program, just drilling down to today’s topic, the goal is to provide current and unbiased evidence on which treatments work for which patients under which circumstances. The great thing about being alive in 2011 is for many decisions whether that diagnosis treatment even prevention. There’s often two or more good options, that’s a real tribute to the biomedical research enterprise in this country, we have a global leadership position and so forth. What there’s not, however, it’s good information that clinicians and patients can access in real time when they’re struggling when trying to figure out, what’s the right choice for me.

So, our goal is to help consumers, providers and policymakers, make informed choices. Now, who defines informed choices are those people, this not a prescriptive program, we don’t make recommendations, what we try to do is present the information and touch away that it’s easier for individuals to make their own decision. The long term goal here is to improve healthcare quality and patients have outcomes, their end results to informed decision making by patients providers and policymakers.

[Slide 17] So that taking a queue from the calls very, very clear presentation, then what Patient Centered Outcomes Research? I’ve started to think about it as precision science, because it helps compare different intervention for common conditions by rigorously evaluating existing literature that is to say, what we know and generate new findings to scientific studies of different treatment and diagnostic interventions. So, we’ve got a lot to do because if you think about, there is usually a real gap between all kinds of knowledge and information out there and what you need right this minute to make a good decision.

[Slide 18] Now, the importance of this kind of work was explicitly recognized in the Patient Protection And Affordable Care Act by the creation of something called “The Patient Centered Outcomes Research Institute,” since we can shorten anything to an acronym here in Washington that is fondly known as (PCORI). Many people think this research is just fantastic, they’re a little worried about how it will be used, will the entity that’s sponsoring the research kind of make recommendations or present information in such a way that people are steered in one direction or not. So, the legislation actually says that this institute does not mandate anything, it doesn’t make practice guidelines, Medicare and other programs cannot deny coverage based on this information.

What we are excited about here at AHRQ is that 16 percent of the total budget, which will be up to a $150 million next year. So, 16 percent of that funding comes directly to AHRQ to disseminate research findings of the institute and similar research sponsored by other entities including those sponsored by the government. We also can use those resources to build capacity for this work. So, imagine that we have a perfect electronic health record and all of your clinics get it tomorrow, and it’s not only easy to work with it’s actually fun. And, there are no (pains) of bugs that’s just a fantasy, sorry. But, if you can imagine getting to that day, which I don’t see is all that far away, there’s a number of free clinics in a lot of community health centers for example that have these records now. We could actually be working with you to take advantage of the information that you collect taking care of patients, protecting their privacy, of course, to try to figure out more about this precision question, which treatments work the best for which patients and so forth.

[Slide 19] Now, there’s a lot of different ways you could think about doing this. If you think about interventions, well that is like one big bucket. We could be just looking at comparing drugs, or comparing surgical procedures, you know, instead, we’re working very collaboratively and getting a lot of input from public and private sector entities and as well as many individuals. Our work is framed by priorities that is to say conditions. Most of the time people don’t walk and say, jeez, what kind of pacemaker do I need, they say I’ve got a problem or you as a clinician working with the patient based on the lab test or something like that say, you know, high cholesterol is a problem that you and I are going to need to deal with. Here’s some of the options that are available for you and so forth. And I won’t read the list out loud except to just note that if you were trying to think about big ticket items that’s what really these conditions shown here as priority conditions represent.

[Slide 20] Now, OK. So, fast forward, you’ve got good information, we’re really excited about partnership thrice and flawless. How do you began to take that information and make it the basis of an informed conversation with the patient? Now, our research shows that most patients want to receive information about their treatment options directly from their doctor. We also know that many patients, some patients actually want to be in the driver’s seat and think of a clinician as kind of a consultant. This tends to be highly correlated with age, you won’t be surprised. So, people my parents’ age, quite a bit older than most of you, as I’m going to say about it. But, I mean getting up into the older ranks of Medicare folks in general want to know what the doctor recommends, period.

Middle aged baby boomers, you know, want to be a part of the decision making process, but even many of them will say, OK, this is really helpful, I’m glad you told me about all my choices. What would you recommend for your brother, sister or whatever? And younger people often act like a second opinion means, Google. So, you know, it’s kind of a broad specter or possibilities here. The reason we think this research is valuable and why we’re really excited about the opportunity is because it reviews alternative treatment options and presents them in an unbiased manner. We’re not saying buy this one or go this way, what we are saying is, here’s what the best research available tells you about the choices that you have to make. And what we firmly believe and there’s a growing amount evidence to support is that when both clinicians and consumer know and discuss the options the result is better care. And by the way even the folks who really want you as a clinician to make that recommendation, they really want to know what the choices are, many considered it a matter of respect, even if they’re waiting for you them to say, you could choose, A, B, C, D or E. And, I would recommend C, that’s OK. They still want to hear about all the options. So with that I’m really, really excited to introduce, turn this back to Howard, I’m sorry, I thought I was introducing, I was trying to take his job away.

Howard Holland: No problem Carolyn, that’s your purgative as executive director. Thank you very much for that overview. I think even for those of us who may have responded, we know in great deal about what Patient Centered Outcomes Research is or who may have something familiarity with AHRQ in the effective healthcare program that provides a terrific background and helps us to really focus on the fact that what we’re driving at is informed choices that patient get to make and helping them to have information together with their clinicians, they can use to make decisions about what the best care is for them based on their unique needs and situation.

[Slide 21] Thank you, again. I’d now like to introduce Dr. Karen Friday, from the Common Ground Free Clinic in New Orleans. Last year we had the pleasure as you heard, meeting Dr. Friday and some of her staff members when AHRQ participated in a National Association of Free Clinic two day citywide CARE clinic. It was the five year anniversary of Hurricane Katrina and we were not sure who we would meet and how valuable the information that we were planning to distribute the patient following their exams would be. The fact that the Dr. Friday is here today speaks to the question that we had about value and use of the materials in the affirmative and asserts we think about how useful the information from the effective healthcare program can be.

Needless to say, Dr. Friday has a story to tell and we are very pleased, Dr. Friday to have with us today to have tell that.

Karen Friday: Thank you, Howard. Welcome to everyone today and welcome to you Common Ground Health Clinic, in New Orleans. The picture you see in the upper right corner is the way the clinical looked for about five years and very recently we had it painted, its now currently yellow color with green trim, but it’s a very colorful place filled with very colorful volunteers and employees and patients and we would like to give you a little highlight on that.

I was asked to keep my slides rolled to the brief, so if you have other questions, afterwards I’d happy to answer them. [Slide 22] It has an incredibly unique history and is a strongly Type 2 Hurricane Katrina. The clinic was initially started on September 9th, just less about a week after Katrina in an unflooded section of New Orleans called, Algiers early location were varied.
The first location was in the Mosq