Let the Primary Care Roll

Close to eight years after Hurricane Katrina devastated New Orleans, the city has a renewed health care system, and Karen DeSalvo, M.D., has been a part of the rebuilding, as both New Orleans' current health commissioner and previously as a doctor and administrator in the city's health clinics. New Orleans' team approach to revitalizing health care put a big emphasis on boosting primary care. As a result of its work, the city was one of six winners of the 2013 Robert Wood Johnson Foundation's Roadmaps to Health Prize, which honors community partnerships that help people live healthier. | Interviewed by Paul Barr

What are some of the biggest ways health care has changed as a result of Hurricane Katrina?

DeSALVO: We made a very deliberate effort to change health care access in New Orleans after the hurricane to one where the door that patients could most easily get in was one of primary care and prevention. We wanted to make sure that it was the best place for the best quality care that was affordable to everybody in the neighborhood, so we built a network of what's now about 100 primary care sites across our region. There are within that about 20 robust community health centers where people can go not just for physical health, but also mental health, social services and other supports they need to be healthy.

Was it a matter of revamping primary care or did you have to start from scratch?

DeSALVO: It was not a matter of revamping primary care for us in this community; we had to build it from scratch. We had not had a track record of ever doing it. We had been reliant on hospitals and emergency rooms to support care for most people, especially for the uninsured, which is not a small number. The uninsured in our community make up about one in five people and we wanted to change that and give them the right place that they could go, where they would be able to call it a medical home. It also meant that we not only had to build the delivery model, but also we had to build the actual places of care. We've had to build a workforce. And we had to build our understanding about how to work together collaboratively as a community of providers.

What role did electronic health records play?

DeSALVO: It was really critical to us as we built this new system after Hurricane Katrina that we build it with the right tools in place so that providers could provide the right care for the patient at the right time. That, for us, meant to put into place electronic health records right away. Eighty-five percent of the system is using electronic health records.

In terms of public health, do you have any formal programs that you're working on?

DeSALVO: I am president of a group called 504 HealthNet, which is a coalition of community health providers. That group works together on quality of care, access to care and information flow through technology. For example, emergency preparedness is an area that we are working on. The clinics know these patients, they know who's most at risk during a power outage, high water or any other event. We are working together systematically to identify — using clinical information — those patients who are going to need the most help in the event of a disaster.

As a result of this emphasis on clinics, do you think that New Orleans has a higher proportion of care coming from clinics relative to hospitals than other cities do?

DeSALVO: We haven't looked at that recently, but we have gone from zero to 100, essentially, with access to services in the community. About 20 percent of our population is using outpatient services in this new safety net of health care centers and there was really nothing there before. If you think about the situation eight years ago, 200,000 people were not getting access to care and those services. We know there's been a big jump in the number of services; we know we have built back the rest of the continuum of care. What remains to be seen is what the outcomes will look like, if we'll be able to reduce unnecessary use of hospitals and ERs, improve the cost equation and improve quality and quality of life for our patients. We're beginning to track that now and we expect that the infrastructure we've built will lead to some much better outcomes for the population.

Is there any one group that takes the lead in terms of making decisions?

DeSALVO: I always say that New Orleans is more like jazz than symphony. By that I mean, in some communities there is an orchestra leader and a first chair, but in our community we tend to riff off each other and make beautiful music in that way. And so there have been many leaders in this process. Regarding the clinic collaboration of 20 different organizations, yes, we have a 504 HealthNet organization; yes, there is a leader of that group, but we all make decisions in consensus. That's the way we have moved forward as a community in the last eight years. I believe firmly that that is why it has stuck, why it is working. Because we are making decisions that we all buy into and believe in, and so we all own it, including patients in many circumstances.

You've described the effort as a social movement - What do you mean by that?

DeSALVO: It comes from the ground, it has a grassroots feeling to it, where everybody identifies a common enemy, an opportunity to make change and work in innovative ways across sectors in a very sustained way to redefine their culture, redefine their values and their priorities.

That's what's happened in New Orleans all across the board. In health care, we've shown that we can, with our sustained effort and our ability to be innovative and work together, decide that it's not good enough that we have poor quality and poor outcomes, that we deserve better as a community, and so we've worked to change that equation, re-engineer it. But we've also done that as a community in New Orleans, through civic engagement and a common purpose in education, in the criminal justice system, the levee system and a whole host of other areas where I think it's an exciting place to be, and is a good model for other communities who want to make change.

Really, what we're doing here has happened at other times in other communities on grand scales, it's just that it's happened so quickly and so visibly after this catastrophe that we've gotten a lot of attention for it.

The DESALVO File

CV: DeSalvo is an Austin, Texas, native but also an ardent supporter of New Orleans. She received her M.D. and master's in public health at Tulane University and a master's in clinical epidemiology from the Harvard School of Public Health.

PORCH CRASHER: DeSalvo enjoys running half-marathons. But much of her free time recently has been taken up by her 1940s cottage-style home. "We've essentially built out a large porch for entertaining, which turned into a massive overhaul."

MORE COWBELL: In a city teeming with great restaurants, DeSalvo singles out Oak Street's Cowbell. It anchors a once-rundown, but now thriving neighborhood. "I love going there because it gives you that great uplifting feeling — and the food's delicious.