Integrating Community Health Centers and Public Health: Moving Down the Pyramid. Lauren Smith, MD, MPH May 2013

Transcription

1 Integrating Community Health Centers and Public Health: Moving Down the Pyramid Lauren Smith, MD, MPH May 2013

2 Overview Rationale for evolving role Transition from programs to evidencebased policies and systems Community Transformation and Mass in Motion Substance abuse treatment

3 Smallest Impact CDC Health Impact Pyramid Shifting our Emphasis Counseling & Education Examples Eat healthy, be physically active Largest Impact Clinical Interventions Long-lasting Protective Interventions Changing the Context to make individuals default decisions healthy Socioeconomic Factors Rx for high blood pressure, high cholesterol, diabetes Immunizations, brief intervention, cessation treatment, colonoscopy Fluoridation, trans fat, smoke-free laws, tobacco tax Poverty, education, housing, inequality

4 Percent of Adults Social Stratification of Illness: Education and Diabetes Boston MA High School or less Some college College or more Source: MassCHIP, MA Department of Public Health

5 Describing Pathways of Impact Connect the dots for policymakers and the public between social determinants and health Help identify points of intervention

6 How does the social become biologic? Housing costs/ quality/location Food deserts Health care access Environmental exposure to toxins, pollution advertising Residential segregation Transportation Education quality Social support Neighborhood violence

7 Moving Down the Pyramid: Working with Massachusetts League of Community Health Centers Community Transformation Grants

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9 % Overweight or Obese Children Childhood Obesity is Not Randomly Distributed Among our Communities Childhood Obesity and Median Household Income, $0 $20,000 $40,000 $60,000 $80,000 $100,000 $120,000 $140,000 $160,000 $180,000 Median Household Income ( American Community Survey, US Census Bureau)

10 Percent MA Students who are Overweight/Obese by Grade & Gender, Grade 1 Grade 4 Grade 7 Grade 10 Male Female Source: MDPH, Bureau of Community Health, Access and Prevention, Division of Primary Care and Health Access, School Health Unit

11 Massachusetts s Obesity Burden: Are we out of balance? Nutritional Risks Protective Factors

12 Fast food restaurant density related to income and % black residents of neighborhood. Disparities in Fast Food Nation A 4% increase in proportion of black residents associated with 10% increase in fast food density Block JP et al, Am J Prev Med, 2004 Predominantly black neighborhoods 6 times more fast food restaurants 2.4 fast food restaurants/sq mile

13 The fun way for on-the-go kids to refuel Kids Meals Chicken McNuggets (6 pc), small French fries, 8 oz low-fat chocolate milk Double cheeseburger, small French fries, 8 oz low-fat chocolate milk Chicken McNuggets (4 pc), small French fries, 8 oz low-fat chocolate milk Cheeseburger, small French fries, 8 oz low-fat chocolate milk Calories Fat (g) Chol (g) Sodium (mg)

14 Where are the healthy options? Supermarkets have more heart healthy food vs. grocery & convenience stores Low income & minority neighborhoods Less likely to have supermarket More likely to have small grocery stores

15 Mass in Motion: Eat Better, Move More Multifaceted state initiative Call to Action report Public information campaigns Municipal wellness grants Website Info on physical activity and nutrition Calendars Blogs Links to state and local resources

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17 Municipal Wellness Grants: Evidenced Based Approaches Grantees using CDC recommended evidenced based strategies for community change Promote availability of affordable healthy food Support healthy food and beverage choices Create safe communities that support physical activity

18 Mass in Motion Municipal Wellness & Leadership Grants Promoting Healthy Eating and Active Living Initiating or expanding policy, systems, and environmental change through healthy community design to consider health in all policies Promote Health Equity Engage non-traditional & diverse stakeholders Multi-sector planning & work groups Using CDC recommended evidenced based assessments & strategies A public-private partnership supporting cities and towns

19 Community Transformation Grants Local policy and environmental change Tobacco-free living/smoke-free housing (Public) Healthy Eating/Active Living Clinical Interventions Three long-term outcomes Reduce death and disability due to tobacco use by 5% in the implementation area. Reduce the rate of obesity through nutrition and physical activity interventions by 5% in the implementation area. Reduce death and disability due to heart disease and stroke by 5% in the implementation area.

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22 Healthy Community Design Important characteristics of the built environment critical to promoting health include: walkable and bikeable neighborhoods public transit parks, recreation facilities, and open spaces healthy food environments safety

23 Community Planning: Healthy Eating Create incentive programs to attract supermarkets and grocery stores to underserved neighborhoods Use zoning regulations to enable healthy food providers to locate in underserved neighborhoods (e.g., as of right and conditional use permits ) to limit the density of fast food establishments Land use policies/zoning regulations to promote, expand, and protect potential sites for community gardens and farmers markets vacant city-owned land or unused parking lots

24 Community Planning: Active Living Adopt a pedestrian & bicycle master plan for long-term vision for walking/cycling. Plan, build and maintain a network of sidewalks and street crossings that safely connect schools, parks and other destinations. Build and maintain parks and playgrounds that are safe, attractive and close to residential areas. Adopt community policing strategies that improve safety and security for park use 24

25 Clinical Initiative & State Innovations Model: e-referral Program The Division of Prevention and Wellness and the Massachusetts League of CHCs have two projects that aim to integrate primary care and public health: 1) Community Transformation Grants: Clinical Initiative The CTG (8 county) is working with 2 CHCs (Brockton and Mid Outer Cape Hyannis) in a QI initiative to improve clinical measures for blood pressure control. 2) The CMS State Innovations Model Testing Grant: e-referral program In the 4-year funding period, we will link up to 9 CHCs to 4 community resources (i.e., tobacco quitline, YMCA, local senior centers, and VNAs). Since this program kicked off 4/1/2013, we are still working with the Massachusetts League of CHCs to identify the specific CHCs.

26 Community Transformation Grants: Clinical Initiative State Innovations Model: e-referral Program Activities EHR data transmission from CHCs to MDPH Create statewide primary care Quality Improvement collaborative Create Clinical- Community Linkages Outputs Data feedback reports for CHCs Learning Sessions, Best Practices Clinical- Community Linkages: SIM e- Referral Project Short-term Outcomes Increased rates of preventive care Improved health equity Systems change supported by primary care staff Lowered BP, lipids, HbA1C, tobacco use Increased connections to MiM community resources Long-term Outcomes Decrease in smoking prevalence Decrease in obesity prevalence Decrease in CHD and CHD-related diseases

27 Community Transformation Grants: Clinical Initiative Focus - implementing clinical systems change and enhancing community-clinical linkages The goals of the CTG clinical initiatives are to improve health outcomes reduce disparities for people with or at risk for chronic disease MDPH and the Massachusetts League of Community Health Centers have jointly worked to: identify outcome measures and survey tools develop a reporting structure to be used by local CHC recruit CHCs from Mass in Motion communities develop infrastructure for a Primary Care Quality Improvement (QI) Collaborative (PC-CORE).

28 Community Transformation Grants: Clinical Initiative Since October 2012, MDPH has: Conducted preliminary data analysis of ~ 90,000 deidentified unique patient encounters Developed feedback reports with actionable information for care teams at CHCs Drafted a Train-the-Trainer QI Coach curriculum Outlined a Culturally and Linguistically Appropriate Services (CLAS) training module for CHC staff Compiled community resources for asset mapping MDPH has also developed a bi-directional Community Rx that links patients, primary care providers and participating community agencies

29 Massachusetts State Innovation Model Testing Grant: e-referral program The Massachusetts League of Community Health Centers is primary clinical partner Bi-directional e-referral program enabling electronic communityclinical linkages $3.8 million over 4 years for IT support & clinical and community resource staff CHIA DRVS data system will allow evaluation of the impact on referrals to community resources & health outcomes E-Referral program estimated launch - Spring 2014 Initial pilot sites - 3 CHCs affiliated with Mass League with CHIA DRVS and 4 community resources: Tobacco Quitline, Councils on Aging, VNAs, YMCAs

30 State Innovations Model: e-referral Program Example of a bi-directional e-referral Outbound Transaction Clinical Setting Transmission from EMR Community Resource CHC Health care provider diagnoses Jane Smith with diabetes. Jane gives consent for referral to tobacco quitline and local CDSMP program. e-referrals from Provider to (1) Quitline & (2) Council on Aging Contact Information: Address, Phone Other Health Data: Current smoker and Type 2 Diabetes Tobacco Quitline & Local Council on Aging Jane is contacted by Quitline and starts counseling program to quit smoking. Jane is also contacted by Senior Center and begins 6 class CDSMP program. CHC Automatic updates of smoking and exercise program added to EMR. At next appointment, health care provider is able to see the update of Jane s progress in Jane s own electronic health record. Inbound Transaction Clinical Setting Transmission to EMR Community Resource Progress report from community resources to provider (Standardized HL7 Formatted Transaction) Jane Smith Smoking status at 6 months post referral, CDSMP sessions attended, and improvement in FV intake and exercise Tobacco Quitline & Local Council on Aging Quitline calls back 6-months post referral for update. Senior Center prepares final CDSMP report on Jane s progress. Updates transmitted to provider as requested.

31 Moving Down the Pyramid Office Based Substance Abuse Treatment

32 Integrating Office Based Opiate Treatment (OBOT) in CHCs: Why We Need it MA has a significant opioid abuse and addiction problem : 15% increase in clients with opiate use in Bureau of Substance Abuse Services treatment programs 51.7% of all clients in the last fiscal year : 2,300 fatal overdoses : 12,136 opioid overdoses 61.4 per 100,000 residents BSAS has piloted this model in 4 community health centers and 10 federally qualified health centers (FQHC) since August of 2008.

33 OBOT Integration Using Nurse Care Manager Model Developed by Boston Medical Center and adopted by SAMHSA as a promising practice BSAS and BMC received a SAMHSA Science to Service Award for this model in April 2012 Requires integration of primary health care and behavioral health services for opiate addicted patients Includes ongoing TA to FQHC s on implementing the model to ensure fidelity.

34 Value of Medication Assisted Treatment Decrease health disparities Non-whites patients who access MAT do so later in their illness. Develop workforce capacity to integrate the identification and treatment of patients with substance use disorders in a primary care setting.

35 OBOT Works 14 community health centers 6,503 patients enrolled Disparities reduced - improved retention among non-white patients compared to other MAT 77.8% achieved opiate abstinence based on objective drug screening results 28.3% have resumed their education 17.2% decrease in unemployment

36 Detox Admissions Notes: Hospital data is only available through 10/2010. Enrollments must have spanned the future timeframes (e.g. client must still be in treatment for admission to be counted). 5/10/2013 8:51 AM

37 ER Visits Notes: Hospital data is only available through 10/2010 Enrollments must have spanned the future timeframes (e.g. client must still be in treatment for admission to be counted). 5/10/2013 8:51 AM

38 ER Expenditures Notes: Hospital data is only available through 10/2010 Enrollments must have spanned the future timeframes (e.g. client must still be in treatment for admission to be counted). ER costs are estimated based on hospital charged amounts; Paid is currently calculated using 2/3 of the charged amount. These statistics have not yet been fully scrutinized. 5/10/2013 8:51 AM

39 Hospital Admissions Notes: Hospital data is only available through 10/2010 Enrollments must have spanned the future timeframes (e.g. client must still be in treatment for admission to be counted). 5/10/2013 8:51 AM

40 Hospital Admission Expenditures Notes: Hospital data is only available through 10/2010 Enrollments must have spanned the future timeframes (e.g. client must still be in treatment for admission to be counted). ER costs are estimated based on hospital charged amounts; Paid is currently calculated using 2/3 of the charged amount. These statistics have not yet been fully scrutinized. 5/10/2013 8:51 AM

41 CDC Health Impact Pyramid Getting Comfortable in a New Place Smallest Impact Largest Impact Counseling & Education Clinical Interventions Long-lasting Protective Interventions Changing the Context to make individuals default decisions healthy Socioeconomic Factors Eat healthy, be physically active Rxfor high blood pressure, high cholesterol, diabetes Immunizations, brief intervention, cessation treatment, colonoscopy Fluoridation, trans fat, smoke-free laws, tobacco tax Poverty, education, housing, inequality

42 Questions?